License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

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The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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May 22, 2017

Cataract Removal (HCPCS Codes 66984, 66983, 66982): Complex Medical Review – Kentucky and Ohio – Continue

The J15 Part A Medical Review department performed a service-specific complex review of claims for Cataract Removal (HCPCS Codes 66984, 66983, 66982) in Kentucky and Ohio from January through March 2017. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results:

	Charges	Claims
Reviewed	$2,935,165.91	593
Denied	$943,551.85	186
Charge Denial Rate	32.1%

Ohio Service-Specific Complex Edit Results:

	Charges	Claims
Reviewed	$4,558,231.44	1,055
Denied	$1,871,645.43	349
Charge Denial Rate	41.1%

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).
- A legible signature is required on all documentation necessary to support orders and medical necessity.
- Use the most appropriate ICD-10-CM codes to identify the beneficiary's medical diagnosis.
Additional tips:
- During this quarter of review, 461 claims were denied for no documentation of medical necessity.
- Missing documentation included biometry results, visual acuity exams, description of impairment of ADL's, and documentation to support cataracts as the primary cause of the beneficiary's decreased visual acuity.
- When responding to an ADR for this edit, please include office notes from the opthalmologist that support the medical necessity of cataract removal (see L33954 Cataract Extraction on the CMS website for clarification).
For more information, refer to:

5D169 – Services not documented

Reason for denial:
- This claim was partially or fully denied because the provider billed for services/items not documented in the submitted medical record.
How to prevent denials:
- Submit all documentation related to the services billed when responding to the Additional Documentation Request (ADR).
- Ensure that results submitted are for the dates of service billed, the correct beneficiary, and the specific service billed.
For more information, refer to:
- CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section 3.3.2.4
- Code of Federal Regulations: 42 CFR 410.32

56900 – Requested Records Not Submitted

Reason for denial:
- The medical records were not received in response to an Additional Documentation Request (ADR) in the required timeframe; therefore, we were unable to determine medical necessity.
How to prevent denials:
- Monitor your claim status in Direct Data Entry (DDE). Claims in status/location SB6001 have been selected for review and records must be submitted. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Zone Program Integrity Contractor (ZPIC), may also request records. Ensure the records are submitted to the appropriate entity.
- Ensure your mail room staff routes any mail you receive from CGS to the appropriate person/department for handling.
- Submit medical records as soon as the ADR is received, but not later than 45 days of the date in the upper left corner of the ADR letter.
- Gather all information and submit at one time.
- Attach a copy of the ADR to each individual claim.
- If you are responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
- Do not mail packages COD; we cannot accept them.
- Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

5C199 – Billing Error

Reason for denial:
- The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.
How to prevent denials:
- Check all claims for accuracy prior to submitting to Medicare.
- Ensure that the documentation submitted in response to the ADR corresponds with the date that the service/diagnostic test was rendered and the dates of service billed.

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.