January 12, 2016
Progressive Corrective Action (PCA) Review: Assisted Living and Nursing Facility Visits
The J15 Part B Medical Review department performed Progressive Corrective Action (PCA) reviews on assisted living and nursing facility 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 did not support the minimum components required for the lowest level code
- The documentation did not support a face to face encounter
- Medical necessity issues
- Medical necessity was not supported
- The frequency in which services were billed was medically unnecessary
- Cloning
- Illegible documentation
- The guidelines for split/shared visits were not followed
- The guidelines the use of a scribe were not followed,
- Signature guidelines were not followed
- No signature was found on the medical record
- The documentation supported hospice patient visits
- Inappropriate use of CPT modifier 25
- Routine foot care - No documentation of a separately identifiable service above and beyond the debridement of nails Failure to provide medical records for the review
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
- 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
Nursing Facility Fact sheets:
Social Security Act