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October 23, 2014 - Updated 01.12.16

Progressive Corrective Action (PCA) Review: Hospital Visits

The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on hospital visits throughout the year. The findings of PCA reviews occurring over 2015 are as follows:

  • Reduction in level of service for not meeting the key component levels required by the code billed
  • The documentation did not support the minimum components required for the lowest level code
  • Medical necessity issues:
    • The documentation did not support the medical necessity for the visit.
    • The documentation did not support the medical necessity for the level of service billed.
    • The documentation did not support the frequency of visits.
    • Cloning/inappropriate templating
  • Date of service issues:
    • The date of service was not documented.
    • No documentation could be located for the date of service billed under review.
    • Wrong date of service
  • The documentation did not support a face-to-face encounter.
  • Billing for "incident to"- There is no Part B provision for "incident to" in the in-patient setting. Payment for nurse and ancillary staff services are included within the Part A stay.
  • Split/share guidelines were not followed.
  • Signature guidelines were not followed.
    • Late, missing, and illegible signatures
  • Late documentation
    • Guidelines for record addenda were not followed
  • Teaching guidelines were not met
  • An emergency room and an initial hospital visit were both billed on the same day by the same provider
  • Illegible documentation
  • No documentation was received in response to the request for medical records.

For more information on Medicare guidelines, including documentation required to process a claim, please refer to:

CMS 1995/1997 Documentation Guidelines for E/M Codes

CMS Internet Only Manual

Initial and Subsequent Hospital Fact sheets:

Social Security Act

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