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CGS Administrators, LLC

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September 9, 2020

Widespread Post-Pay Service Specific Review Announcement – HCPCS Codes A4351; A4352; A4353; A4355; A4316

CGS's Medical Review staff will be conducting a complex post-pay service-specific medical review of HCPCS Codes A4351; A4352; A4353; A4355 and A4316 (Urological Supplies). This review will be conducted because data analysis revealed that Jurisdiction C's allowed dollars for HCPCS Codes A4351; A4352; A4353; A4355 and A4316 were significantly above expected amounts. Additionally, the Urological policy group ranked #11 in total CERT errors.

CGS would like to remind suppliers of the importance of responding to Additional Documentation Request (ADR) letters. Authorization for the collection of this information is included in Federal Law at SSA 1833 (e) and in Federal regulation at 42 CFR 424.5(a)(6).  Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC).

The ADR letter will contain the following information:

  1. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order);
  2. A valid order;
  3. The patient's medical records that may support the medical necessity for the items provided and the frequency of testing ordered;
  4. Itemized proof of delivery documentation
  5. Proof of beneficiary's or caregiver's request for refill
  6. Any other pertinent documentation
  7. Advance Beneficiary Notice (ABN) on file should be submitted with other requested documentation
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