Skip to main content
Corporate

November 21, 2014

Cataract Removal (HCPCS Codes 66984, 66983, 66982): Probe Medical Review,  Kentucky and Ohio – Advanced to Targeted Review

The J15 Part A Medical Review department performed a service-specific prove review on claims for cataract removal (CPT codes 66984, 66983, and 66982) in Kentucky and Ohio.  Based on the results summarized below, the probe edit review will be advanced to targeted medical review in Kentucky and Ohio.

Kentucky Service-Specific Probe Edit Results:  Cataract Removal

 

Charges

Claims

Reviewed

$381,665.53

91

Denied

$326,896.11

76

Charge Denial Rate

85.6%

 

Ohio Service-Specific Probe Edit Results:  Cataract Removal

 

Charges

Claims

Reviewed

$355,608.16

108

Denied

$315,453.76

97

Charge Denial Rate

88.7%

 

The top denial reasons associated with this review are:

5D164/5H164 –No documentation of medical necessity

Reason for denial:

  • This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to prevent denials:

  • Submit documentation to support all required components of the service when responding to the Additional Documentation Request (ADR).  CGS has a Local Coverage Determination (LCD) for Cataract Extraction, which describes specific indications and limitations of coverage for this procedure.  You should review and be familiar with this LCD, including indications and limitations of coverage, and provide documentation that the submitted service meets these requirements.
  • A legible signature is required on all documentation necessary to support orders and medical necessity.
  • Use the most appropriate ICD-9-CM codes to identify the beneficiary’s medical diagnosis.
  • Provide supporting documentation as to why the surgery is necessary (e.g., the maturity of the cataract, patient’s visual acuity and ability to carry out activities of daily living).  You may choose to contact the physician who has followed the patient for his/her cataract to request supporting information.

For more information, refer to:

5H169-Services not documented 

Reason for denial:

  • The claim was partially denied because the provider billed for services or items not documented in the medical record submitted.

How to prevent denials:

  • Submit all documentation related to the services billed.
  • Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed.

For more information refer to:

  • Code of Federal Regulations, 42 CFR – Sections 410.32External Website and 424.5External Website

If you receive an ADR from CGS, submit the requested medical record information within 30 days.  Before you send the requested records, we suggest you double-check the accuracy of your submitted claims. 

Completed review results will be posted on the CGS website.  Individual providers with significant denials will be contacted for one-on-one education.

If you have questions regarding this review, please call the CGS Part A Provider Contact Center at 866.590.6703.


26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved