April 1, 2021
J15 Part A Postpayment Resumptive Review Status Update: 08.17.2020 – 12.31.2020
Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with postpayment reviews of items/services provided before March 1, 2020. Items and services are selected based upon high error rates and/or potential overutilization identified through data analysis.
CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.
Results for service-specific postpayment reviews are listed below.
Drugs/Biologicals – HCPCS Codes J2505, J9312, J9299 |
||
---|---|---|
Service-Specific Results |
Kentucky |
Ohio |
Reviews Completed |
33 |
29 |
Claims Allowed |
23 |
20 |
Claims Denied |
10 |
9 |
No Provider Response |
0 |
0 |
Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to the Social Security Act (SSA) § 1862 and the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, sections 3.6.2.1 and 3.6.2.2.
- The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
- Common Documentation Found Missing: orders, detailed history and physical, office visit notes, treatment plan supporting covered diagnosis, chemotherapy administration information, correct HCPCS coding for medication delivery, and Body Surface Area (BSA), if applicable.
Hyperbaric Oxygen Therapy (HBOT) – HCPCS Code G0277 |
||
---|---|---|
Service Specific Results |
Kentucky |
Ohio |
Reviews Completed |
5 |
44 |
Claims Allowed |
1 |
34 |
Claims Denied |
4 |
10 |
No Provider Response |
0 |
0 |
Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to the Social Security Act (SSA) § 1862 and the CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, sections 3.6.2.1 and 3.6.2.2.
- The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
- Common Documentation Found Missing: detailed history and physical, covered condition verified by pathology or imaging results, HBOT order (inclusive of time the physician desires the beneficiary to be under 100% oxygen and # of prescribed sessions), each HBOT session billed (treatment notes with dive times (ascent, descent, air breaks, treatment depth, etc., reason/rationale for all units billed.
Resources:
- Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
- National Coverage Determination for Hyperbaric Oxygen Therapy (NCD 20.29)
- CMS Medicare Program Integrity Manual (Pub. 100-08), chapter 3, section 3.3.2.4 - Signature Requirements
- CGS J15 Part A Medical Review Signatures Web page
- CGS J15 Part A MR Activities and Documentation Requirements Checklists
Provider inquiries and education requests may be sent to: J15AMREDUCATION@cgsadmin.com.
CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity log and by using tools such as Comparative Billing Reports (CBRs) offered through the myCGS Web portal.
To learn more about the postpayment resumptive process, please refer to the following: