Medical Review Part B has recently completed the results for Q4 of 2016 of the prepayment widespread targeted review for CPT 99223-Initial hospital care, per day, for the evaluation and management of a patient The denial rates for this widespread targeted review are listed below:
CPT 992230- Initial hospital care, per day, for the evaluation and managemetn of a patient
State
Number of Providers
Error Rate
Alabama
17
75.01%
Georgia
10
63.38%
Tennessee
11
87.56%
Based on the outcome of this review, Cahaba will continue the prepayment Widespread targeted review. Cahaba will continue to review CPT 99223-Initial hospital care, per day, for the evaluation and management of a patient. Claims meeting the parameters will be selected across the provider community. Once selected, the claims will be reviewed for medically necessity. The majority of denials for the widespread probe were due to one of the following reasons:
Lack of medical necessity to support providing the service for 99223 (Denial Reason 056): This denial reason was due to the documentation submitted did not support medical necessity for the billed service 99223. The information provided does not support the level of service as shown on the claim. This message indicates that the documentation supports a lower level of service than billed as performed based on non local coverage determination policy.
Lack of documentation (Denial Reason 234): This item or service was denied because information required to make payment was missing. This message indicates there was no valid or legible provider signature in the submitted documentation as performed based on non local coverage determination policy.
Lack of timely submission of requested documentation (Denial Reason 351): Claims were denied due to a lack of record submission in a timely manner. According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, 3.2.3.8b, “During prepayment… or post payment… review, if no response is received within 45 calendar days after the date of the ADR, the MACs, and ZPICs shall deny the claim.”
To eliminate 351 denials, please review the following elements to ensure appropriate and timely record processing
Attach a copy of the ADR to the front of the requested medical documentation
Send requested information by your preferred method: mail, fax, CD, ESMD, etc…
Include ALL requested documentation outlined in the ADR
Submit the above information in a reasonable timeframe to ensure the MAC receives the information by the 45th day after the date of the request.
The Medical Review decisions were based on:
American Medical Association Current Procedural Terminology (CPT ®) Standard Edition
Medicare Claims Processing Manual, Chapter 12, Section 30.6.9
1995/1997 Documentation Guidelines for Evaluation and Management Services
Please review the following information from:
The 1995 and 1997 Evaluation and Management Services Documentation Guidelines
Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6: Evaluation and Management Service Codes – General (Codes 99201 – 99499)
Indications:
The claims submitted for review lacked supporting documentation for the medical decision making of high complexity. Document entries for the billed service failed to meet 3 of the 3 components as required. The documentation did not present a comprehensive history and met moderate complexity in the decision making.
The claims submitted for review indicates there was no valid or legible provider signature in the submitted documentation as performed.
Claims were denied due to a lack of record submission in a timely manner. The number of claims requested with this denial exceeded all the denial reasons posted.
References:
American Medical Association Current Procedural Terminology (CPT ®) Standard Edition
Medicare Claims Processing Manual, Chapter 12, Section 30.6.9
1995/1997 Documentation Guidelines for Evaluation and Management Services
Medicare Program Integrity Manual, PUB 100-8, Chapter 3, 3.2.3.8b
Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6: Evaluation and Management Service Codes – General (Codes 99201 – 99499)
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