October 23, 2014 - Updated 01.12.16
Progressive Corrective Action (PCA) Review: Office Visits
The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on office visits throughout the year. The findings from PCA reviews occurring over 2015 are as follows:
- Failure to meet the key component levels required for the code billed,
- The documentation failed to support a face-to-face encounter occurred,
- Medical necessity was not supported,
- Cloning of medical records
- Signature guidelines were not met
- Late and missing signatures
- "Incident to" guidelines were not met,
- Guidelines regarding the use of a scribe were not met,
- Inappropriate use of CPT modifier 25, and
- Failure to provide medical records.
For more information on Medicare guidelines, including documentation required to process a claim, please refer to:
CMS Internet Only Manual
- CMS Pub 100-4 Claims Processing Manual, Chapter 12, Sections 20.1, 20.3, 30.1, 40.1, 30.6.1 B and C
- CMS Pub 100-8 Medicare Program integrity Manual, Chapter 3, Section 3.3.2.4
Fact sheets:
Social Security Act