November 21, 2014
Cataract Removal (HCPCS Codes 66984, 66983, 66982): Probe Medical Review, Kentucky and Ohio – Advanced to Targeted Review
The J15 Part A Medical Review department performed a service-specific prove review on claims for cataract removal (CPT codes 66984, 66983, and 66982) in Kentucky and Ohio. Based on the results summarized below, the probe edit review will be advanced to targeted medical review in Kentucky and Ohio.
Kentucky Service-Specific Probe Edit Results: Cataract Removal
|
Charges |
Claims |
---|---|---|
Reviewed |
$381,665.53 |
91 |
Denied |
$326,896.11 |
76 |
Charge Denial Rate |
85.6% |
|
Ohio Service-Specific Probe Edit Results: Cataract Removal
|
Charges |
Claims |
---|---|---|
Reviewed |
$355,608.16 |
108 |
Denied |
$315,453.76 |
97 |
Charge Denial Rate |
88.7% |
|
The top denial reasons associated with this review are:
5D164/5H164 –No documentation of medical necessity
Reason for denial:
- This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.
How to prevent denials:
- Submit documentation to support all required components of the service when responding to the Additional Documentation Request (ADR). CGS has a Local Coverage Determination (LCD) for Cataract Extraction, which describes specific indications and limitations of coverage for this procedure. You should review and be familiar with this LCD, including indications and limitations of coverage, and provide documentation that the submitted service meets these requirements.
- A legible signature is required on all documentation necessary to support orders and medical necessity.
- Use the most appropriate ICD-9-CM codes to identify the beneficiary’s medical diagnosis.
- Provide supporting documentation as to why the surgery is necessary (e.g., the maturity of the cataract, patient’s visual acuity and ability to carry out activities of daily living). You may choose to contact the physician who has followed the patient for his/her cataract to request supporting information.
For more information, refer to:
- CGS LCD for cataract extraction
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4
- CMS MLN Matters article MM6698, “Signature Guidelines for Medical Review Purposes”
- Definition of “medically necessary”: Social Security Act (SSA), section 1862(a)(1)(A)
- Code of Federal Regulations: 42 CFR 410.32
5H169-Services not documented
Reason for denial:
- The claim was partially denied because the provider billed for services or items not documented in the medical record submitted.
How to prevent denials:
- Submit all documentation related to the services billed.
- Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.
For more information refer to:
If you receive an ADR from CGS, submit the requested medical record information within 30 days. Before you send the requested records, we suggest you double-check the accuracy of your submitted claims.
Completed review results will be posted on the CGS website. Individual providers with significant denials will be contacted for one-on-one education.
If you have questions regarding this review, please call the CGS Part A Provider Contact Center at 866.590.6703.