99 - No response error No Medical records were received.

Transcription

1 1 May 2017 HCPCS Code Type Error Error Identified by CERT Anesthesia Services MISSING: 1) Signature attestation statement or signature log for the illegibly signed Pre-Anesthesia evaluation and illegibly signed Anesthesia Record; 2) Documentation supporting billing anesthesiologist provided post anesthesia care. SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information to determine whether payment is due), PUB Chapter (Payment for Anesthesiology Services), 50.B (Payment at Personally Performed Rate) and 50.I (Monitored Anesthesia Care). Diagnostic Services MISSING: 1) Treating physician/npp order or intent to order in the medical record for the MRI brain, 2) Clinical to support medical necessity. SSA 1833(e); 42 CFR 424.5(a)(6) (Sufficient information); 42 CFR (a) (Ordering diagnostic tests); LCD Radiology: Magnetic Resonance Imaging of the Brain (L34278) For services performed on or after 10/1/2015; PUB Chapter (Provider Retention of Health Insurance Records) and PUB Chapter (ADR), (Reasonable & Necessary Criteria) No was received, or no related to the claim line under review was received from the provider, after full process was pursued and exhausted, and there is no evidence to support another error code MISSING: 1) Order or intent to order in the medical record for the CT scan maxillofacial area, 2) Documentation to support the medical necessity of the CT scan, 3) CT scan report. SSA 1833(e); 42 CFR 424.5(a)(6) (Sufficient information); PUB Chapter (Provider Retention of Health Insurance Records) and NCD for Computed Tomography (220.1). MISSING: Physician's attestation for the unsigned mammogram report. SSA 1833(e); 42 CFR 424.5(a)(6) (Sufficient information); and PUB Chapter (Signature Requirements) , 72082, 76770, 74020, 72040, No response error No Medical records were received.

2 2 Diagnostic Services MISSING: 1) Clinical supporting medical necessity for billed EKG with interpretation and report; 2) Authenticated copy of the EKG interpretation and report. SSA 1833(e); 42 CFR 424.5(a)(6)(Sufficient Information); NCD 20.15(Electrocardiographic Services) ; PUB Chapter (Reasonable & Necessary Criteria) MISSING: 1) physician order/intent to order; 2) clinical supporting medical necessity of the billed ECG monitoring/report up to 48 hrs. SSA 1833(e), 42 CFR (a)(ordering diagnostic tests), Pub Chapter (Reasonable and Necessary), Pub Chapter (Definitions: Order), Local Coverage Determination (LCD): Medicine: Long-Term Wearable Electrocardiographic Monitoring (WEM) (L34264) Revision Effective Date 10/1/ /30/ ) Order or intent to order in the medical record for the cardiovascular stress test, 2) Physician attestation to support service billed. G0202 SSA1833(e); 42CFR (a) (Ordering diagnostic tests); PUB Chapter (Ordering & Following Orders for Diagnostic Tests) and PIM Chapter (Signature Requirements). MISSING: Physician's attestation for the unsigned mammogram report. SSA 1833(e); 42 CFR 424.5(a)(6) (Sufficient information); and PUB Chapter (Signature Requirements). Evaluation and Management Services No was received, or no related to the claim line under review was received from the provider, after full process was pursued and exhausted, and there is no evidence to support another error code MISSING: 1) initial inpatient progress note for billed date of service. SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information), PUB , Chapter 1, Section 110 (Provider Retention of Health Insurance Records).

3 3 Evaluation and Management Services No was received, or no related to the claim line under review was received from the provider, after full process was pursued and exhausted, and there is no evidence to support another error code MISSING: 1) of physician's office visit billed by Radiologist. SSA 1833(e); IOM Ch. 1 s 110 "Provider Retention of Health Insurance Records." MISSING: 1) billing provider's signature attestation statement for unsigned neurology office encounter. SSA 1833(e), PUB Chapter (Signature Requirements), C (Signature Attestation Statement), and (Reasonable and Necessary Criteria) Service incorrectly coded BILLED SERVICE IS INCORRECTLY CODED: Documentation submitted supports a code change from to 99304, with a D Hx, C Ex, MC - MDM. CPT 2016, 1995 E/M guidelines, and PUB Chapter (Selection of Level of Evaluation and Management Service) MISSING: 1) Treating physician signed and dated progress note for the billed subsequent hospital care visit. SSA 1833(e) (Insufficient Documentation), PUB , Chapter (Categories of Health Insurance Records to Be Retained) and 42 CFR 424.5(a) (6) (Conditions of Medicare Paymentsufficient information) Service incorrectly coded BILLED SERVICE IS INCORRECTLY CODED: Documentation supports a down code from to with a D Hx, EPF Exam and LC MDM based on the submitted E/M Guidelines, PUB , Chapter (Selection of Level of evaluation and Management), and CPT 2016.

4 4 Evaluation and Management Services 99223, 99232, 99233, 16 - No was received, or no related to the claim line under review was received from the provider, after full process was pursued and exhausted, and there is no evidence to support another error code Service incorrectly coded MISSING: Clinical to support billed inpatient initial and subsequent visit notes. SSA 1833(e)(insufficient ), PUB , Chapter 1, 110 (Provider Retention of Health Insurance Records). BILLED SERVICE IS INCORRECTLY CODED: Documentation supports down code from to with a C Hx, C Exam and MC MDM based on the submitted , 99232, 99238, 99223, Injection Services Service incorrectly coded CPT 2016, 1995 E/M guidelines, and PUB Chapter (Selection of Level of Evaluation and Management Service) No response error No Medical records were received. BILLED SERVICE IS INCORRECTLY CODED: Submitted supports 2 hours of infusion. Recode to 1 (UOS), from 2 (UOS). SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), CPT 2016, PUB Chapter (payment for chemotherapy administration), PUB Chapter15 50 (Drugs and Biologicals), and 50.3 (Incident to Requirements). J1071, MISSING: 1) the physician s order or intent to order the billed testosterone injection. J7050 SSA 1833(e), 42 CFR (a)(6), PUB Chapter (payment for codes for chemotherapy administration and nonchemotherapy injections and infusions), PUB Chapter (Incident To Requirements), 50.4 (R&N drugs), and 50 (Drugs and Biologicals). MISSING: 1) Treating physician's order for the normal saline infusion; 2) Documentation to support the performance of the normal saline infusion for date of service. SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), CPT 2016, and PUB Chapter C (Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy).

5 5 Injection Services-Vaccines 90732, No response error No Medical records were received. Laboratory and Pathology Services G0483 MISSING: 1) Treating physician s order for or clinical to support the plan/intent to order the billed laboratory test; and 2) Documentation to support the medical necessity of the billed test. SSA 1833(e), 42 CFR (a) (Physician s orders), PUB , Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests), PUB , Chapter (Reasonable and Necessary Criteria), and Local Coverage Determination (LCD): Pathology and Laboratory: Quantitative Drug Testing (L35920) revision effective 01/01/ Service incorrectly coded BILLED SERVICE IS INCORRECTLY CODED: Documentation supports code change from billed CBC with differential, to CBC. SSA 1833(e); CPT 2016; 42 CFR (a) (Physician's orders); NCD (Blood Counts); PUB Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests) MISSING: 1) Clinical to support medical necessity for serum ferritin monitoring more frequently than every three months for a beneficiary with anemia in chronic kidney disease. SSA 1833(e); 42 CFR 424.5(a)(6)(Sufficient Information); NCD ( Serum Iron Studies); PUB , Chapter (Clinical Laboratory Services and PUB Chapter (Reasonable and Necessary Criteria) MISSING: 1) Clinical supporting the medical necessity for testing at the frequency of 3x year for billed Vitamin D; 25 Hydroxy. SSA 1833(e); PUB Chapter (Reasonable and Necessary Criteria); LCD Pathology and Laboratory: Vitamin D Assay Testing (L34274), Rev. ending 9/30/ MISSING: 1) copy of physicians order or describing intent to obtain Pap smear, such as might be found in the physician's exam note; 2) copy of exam note describing medical necessity for Pap smear; claim is billed with ICD-10 CM code for screening for rectal neoplasm SSA 1833(e); IOM Pub ; Chap Screening Pap Smears; IOM Pub Chap Screening Pap Smears.

6 6 Laboratory and Pathology Services G0481, G0483, MISSING: 1) to support the need for quantitative urine drug testing , 80184, 80156, 80157, 80159, 80173, 80177, 80201, 80162, G0479, G0482, SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), 42 CFR (a)(Physician s orders), PUB , Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests) and LCD for Pathology and Laboratory: Quantitative Drug Testing (L35920) revision effective 10/01/ /01/ /18/2017 MISSING: 1) Treating physician's order or clinical to support the plan or intent to order the specific tests for DOS; 2) Treating physician's clinical to support the medical necessity for the tests SSA 1833(e), 42 CFR 424.5(a)(6)(sufficient information), 42 CFR (a)(Physician s orders), PUB , Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests) and 42 CFR (d)(2)(I)(medical necessity in the record). MISSING: 1) physician s clinical to support medical necessity for urine drug screen (UDS) for PCP, 2) physician s order or of intent of ordering UDS. SSA 1833(e), 42 CFR (a)(MD orders), LCD for Pathology and Laboratory: Quantitative Drug Testing (L35920)(Rev Eff 10/1/ /31/2015), and PUB Chapter (Reasonable and Necessary Criteria) MISSING: 1) the physician s order or intent to order the billed lipoprotein A lab; 2) clinical supporting the necessity for the billed lab , 81291, 81240, 81241, 81400, SSA 1833(e), 42 CFR (a)(6), PUB Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests), and PUB Chapter (Reasonable and Necessary Criteria). MISSING: 1) physician s order for or intent to order pharmacogenetic lab tests (Level 2 molecular pathology procedure, 2 units, MTHFR, F2, F5, and Level 1 molecular pathology procedure), 2) provider's progress notes to support medical necessity and improved clinical outcome performing specific genotyping. SSA 1833 (e), 42 CFR (a)(MD orders), LCD for Pathology and Laboratory: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L35660)(Rev Eff 1/1/2016), and PUB Chapter (Reasonable and Necessary Criteria).

7 7 Laboratory and Pathology Services 81225, MISSING: Treating physician's clinical (progress note) to support the medical necessity of CYP2C19 gene analysis, common variants and CYP2D6 gene analysis, common variants , 81241, 81291, 81400, 81401, SSA 1833(e); 42 CFR (d)(2)(i) (Medical necessity); LCD Pathology and Laboratory: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L35660)[rev eff 01/01/2016]; PUB Chapter (Clinical Lab Services) and PUB Chapter (Special Provisions for Lab ADR), (Reasonable & Necessary Criteria). MISSING: Treating physician's clinical (progress note) to support the medical necessity of F2 Variant, F5 Leiden variant, MTHFR gene analysis common variants and Molecular pathology procedures Levels 1 and SSA 1833(e); 42 CFR (d)(2)(i) (Medical necessity); PUB Chapter (Clinical Lab Services) and PUB Chapter (Special Provisions for Lab ADR), (Reasonable & Necessary Criteria). MISSING: 1) Copy of the results for UGT1A1 performed on the billed date of service; and 2) Treating physician s clinical to support the medical necessity of the genetic testing. SSA 1833(e), 42 CFR 424.5(a) (6) (sufficient information), and Local Coverage Determination (LCD): Pathology and Laboratory: CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (L35660) revision effective 01/01/ Medically unnecessary service or treatment BILLED SERVICES ARE NOT R & N: Missing clinical to support medical necessity and intent for labs performed on this claim, therefore the venipuncture is denied as not medically necessary. SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information) and IOM PUB Chapter (Services Related to and Required as a Result of Services Which are not Covered Under Medicare). MISSING: 1) Clinical supporting medical necessity for billed prothrombin time. SSA 1833(e), 42 CFR 424.5(a)(6) (Sufficient information), IOM PUB Chapter (Reasonable and Necessary Criteria), 42 CFR (a) (Physician's orders), PUB , Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests), IOM , Chapter 1, (Prothrombin Time).

8 8 Laboratory and Pathology Services G6053, G6031, G6042, G6043, G6044, MISSING: 1) Treating physician s order for or clinical to support the plan/intent to order each of the billed laboratory tests; and 2) Documentation to support the medical necessity of the billed tests. SSA 1833(e), 42 CFR (a) (Physician s orders), PUB , Chapter (Requirements for Ordering and Following Orders for Diagnostic Tests), PUB , Chapter (Reasonable and Necessary Criteria), and Local Coverage Determination (LCD): Pathology and Laboratory: Quantitative Drug Testing (L35920) revision effective 10/15/ /31/2015. G0483 MISSING: 1) describing medical necessity for definitive drug testing, 22 or more tests SSA 1833(e), Pathology and Laboratory: Quantitative Drug Testing, 1/1/2016; 42 CFR Part (b). Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions, IOM Pub Chap & 80.6 "Requirements for Ordering and Following Orders for Diagnostic Tests," and IOM Pub Chap Reasonable and Necessary Criteria. G0482, G0483, 81225, 81226, 81227, 81240, 81240, 81241, 81291, 81350, 81400, 81401, 81479, 81355, 81415, 82542, 84228, G0479, G0483, 85025, 36415, 81003, G0481, 80048, 82607, 84443, 85027, 84403, G No response error No Medical records were received Medical Care Services 1123F, 1033F, 1159F, 1160F, G0250, G0009, G0008, G8696, 99 - No response error No Medical records were received

9 9 Medical Care Services-Chronic Care Management MISSING: 1) copy of physician s visit note that is not part of chronic care management (CCM) to support beneficiary has two or more chronic conditions expected to last at least 12 months and includes of a discussion with beneficiary, and established need for CCM services, 2) copy of that supports provision of at least 20 minutes of CCM services for the month billed. SSA 1833(e), CPT 2016, MPFS 2016, PUB Chapter Supplementary Medical Insurance (SMI) Provisions, MLN (Medicare Learning Network) Fact Sheet on CCM services (ICN , May 2015) MISSING: 1) Copy of the physician s visit note that established the need for Chronic Care Management, with to support the beneficiary has two or more chronic conditions expected to last at least 12 months and includes of a discussion of Chronic Care Management with the beneficiary; 2) Copy of the electronic comprehensive care plan with that it was provided to the beneficiary or beneficiary s caregiver. SSA 1833(e), CPT 2016, MPFS 2016, PUB Chapter Supplementary Medical Insurance (SMI) Provisions, MLN (Medicare Learning Network) Fact Sheet on CCM services (ICN , May 2015) MISSING: 1) clinical supporting the electronic comprehensive care plan with that it was provided to the beneficiary or caregiver. Surgery Services-Integumentary System SSA 1833(e), 42 CFR (a)(6), CPT 2016, PUB Chapter Supplementary Medical Insurance (SMI) Provisions, and MLN (Medicare Learning Network) Fact Sheet on CCM services (ICN , May 2015) , No response error No Medical records were received. Surgery Services-Nervous System MISSING: 1) clinical supporting an initial exam supporting pain levels prior to and with oral medication, and also showing functional impairment of beneficiary; 2) the beneficiary s pre and post pain score. SSA 1833(e), 42 CFR (a)(6), and LCD: Surgery: Injections of the Spinal Canal (L34291), revision effective 10/01/2015, ending 01/02/2017.

10 10 Therapy Services MISSING: 1) Physician signed and dated PT certification. SSA 1862(a)(1)(A), 42 CFR 424.5(a)(6) (sufficient information), PUB , Chapter (Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services), (Certification and Recertification of Need for Treatment and Therapy Plans of Care), PUB , Chapter 5, 10.3.F (Identifying the Certifying Physician), and PUB Ch (Medical Review Documentation).