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% |
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, 3.6.2.2
.
- 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 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% |
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, 3.6.2.2.
- 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, 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% |
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, 3.6.2.2.
- 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, 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% |
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, 3.6.2.2.
- 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, 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% |
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, 3.6.2.2.
- 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, 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:
- Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
- National Coverage Determination for Hyperbaric Oxygen Therapy (NCD 20.29)
- Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.3.2.4
- Signature Resources
- Code of Federal Regulations: Electronic Code of Federal Regulations
- CMS Medicare Learning Network website
- CMS Medicare Benefit Policy Manual
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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