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

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These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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April 21, 2022

J15 Part A Post Pay Resumptive Review Status Update 04/01/2021–7/31/2021

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with post payment reviews of items/services provided before March 1, 2020. Items and services were 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 post payment reviews are listed below.

Drugs/Biologicals – HCPCS J2505, J9312, J9299

Service Specific Results Kentucky Ohio
Sampled Claims 19 18
Reviews Completed 11 18
Claims Allowed 9 10
Claims Denied 2 8
No Provider Response 8 0
Overall Error Rates 52.6% 44.4%

Results for service specific post payment review

Top Findings: The requested documentation was not submitted within the 45-day time frame.

The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External pdf.

  • 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 HCPC coding for medication delivery, and Body Surface Area (BSA) if applicable.

Hyperbaric Oxygen Therapy (HBOT) – HCPCS G0277

Service Specific Results Kentucky Ohio
Sampled Claims 13 40
Reviews Completed 4 17
Claims Allowed 1 5
Claims Denied 3 12
No Provider Response 9 23
Overall Error Rates 92.3% 87.5%

Results for service specific post payment review

Top Findings: The requested documentation was not submitted within the 45-day time frame.

The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External pdf.

  • 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, decent, air breaks, treatment depth, etc., reason/rationale for all units billed.

Therapeutic Exercise – 97110

Service Specific Results Kentucky Ohio
Sampled Claims 21 137
Reviews Completed 21 137
Claims Allowed 14 68
Claims Denied 7 69
No Provider Response 0 0
Overall Error Rates 33.3% 50.4%

Results for service specific post payment review

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External pdf.

  • 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, total number of minutes for timed services, signature attestation for plan of care/certification/re-certification, prior functional level, therapy notes, reason for therapy, delayed certification/recertification with no explanation of the reason for delay

Pulmonary Rehabilitation – G0424

Service Specific Results Kentucky Ohio
Sampled Claims 60 107
Reviews Completed 51 82
Claims Allowed 18 33
Claims Denied 33 49
No Provider Response 9 25
Overall Error Rates 70.0% 69.2%

Results for service specific post payment review

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External pdf.

  • 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, pulmonary function test results, signatures on assessments, frequency of exercise, psychosocial assessment, individual treatment plan, physician-prescribed exercise with duration and frequency of sessions noted, evidence of moderate to severe COPD, outcomes assessment, session documents do not match billed claim, no records returned for review

Cardiac Rehabilitation – 93798

Service Specific Results Kentucky Ohio
Sampled Claims 0 172
Reviews Completed 0 135
Claims Allowed 0 69
Claims Denied 0 66
No Provider Response 0 37
Overall Error Rates 0.0% 59.9%

Results for service specific post payment review

Top Findings: The requested documentation was not submitted within the 45-day time frame.

The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2External pdf.

  • 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, physician order for Phase II Cardiac Rehab, signatures on assessments, psychosocial assessment, individual treatment plan, physician-prescribed exercise with duration and frequency of sessions noted, timed sessions, ITP not dated to support physician review/signature every 30 days, outcomes assessment, signed treatment plan

Resources:

CGS Part A MR Activities and Documentation Requirements Checklists are located here

Provider inquiries and education requests may be emailed 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 our web portal at myCGS.

To learn more about the post payment resumptive process, please refer to the following links:

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