October 23, 2014 - Updated 01.12.16
Progressive Corrective Action (PCA) Review: Emergency Room Visits
The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on emergency room visits throughout the year. The findings of PCA reviews occurring over 2015 are as follows:
- Reduction in level of service for not meeting the 3 key component levels required by the code
- Documentation failed to support the medical necessity of the service/level of service
- No documentation to support a face-to-face encounter
- Cloning/inappropriate templating
- Inappropriate use of CPT modifier 25
- Wrong/incorrect PTAN; the billing provider was not the performing provider of record
- Signature guidelines were not followed
- Missing signatures
- Guidelines regarding split/shared visits were not met
- Requirements concerning the use of a scribe were not met
- Teaching guidelines were not met
- Illegible documentation
- An emergency room and an initial hospital visit were both billed on the same day by the same provider, and
- Records were not received; records were not provided for the review.
For more information on Medicare guidelines, including documentation required to process a claim, please refer to:
Emergency Department Fact sheet:
CMS 1995/1997 Documentation Guidelines for E/M Codes
CMS Internet Only Manual
- CMS Pub 100-4 Claims Processing Manual, Chapter 12, Sections 20.1, 20.3, 30.1, 40.1, 30.6.1 B and C
- CMS Pub 100-8 Medicare Program integrity Manual, Chapter 3, Section 3.3.2.4
Social Security Act