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Spinal Injections (CPT Code 62311): Probe Medical Review – Kentucky and Ohio, Advance to Targeted Medical Review

The J15 Part A Medical Review department performed a service-specific probe review on outpatient claims for spinal injections (CPT code 62311) in Kentucky and Ohio. Based on the results summarized below, the probe edit review will be advanced to targeted medical review in both regions.

Kentucky Service-Specific Probe Edit Results: Spinal Injections (CPT code 62311)

  Charges Claims
Reviewed $225,664.96 129
Denied $170,336.69 97
Charge Denial Rate 75.5%  

Ohio Service-Specific Probe Edit Results: Spinal Injections (CPT code 62311)

  Charges Claims
Reviewed $233,361.23 131
Denied $149,476.56 80
Charge Denial Rate 64.1%  

The top denial reasons associated with this review are:

5D164/5H164 — No documentation of medical necessity

Reason for denial:

  • Claims 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).
  • 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.
  • Submit documentation of the medical necessity for all elective surgical procedures, including but not limited to: results of diagnostic tests; and imaging studies.

For more information, refer to:

56900 — Requested Records Not Submitted

Reason for denial:

  • The requested medical records were not received in response to an ADR in the required time frame; therefore, we were unable to determine medical necessity.

How to prevent denials:

  • Monitor your claim status on Direct Data Entry (DDE). If the claim is in status/location SB6001, the claim has been selected for review and records must be submitted. Please note: CGS may request records through our Medical Review or Claims departments, and other contractors such as the Zone Program Integrity Contractor (ZPIC) may also request records. Ensure the records are submitted to the appropriate entity.
  • Alert your mail room staff to be aware of any mail you receive from CGS.
  • Be aware of the need to submit medical records within 30 days of the date on the ADR in the upper left corner.
  • Gather all information and submit at one time.
  • Submit medical records as soon as the ADR is received.
  • Attach a copy of the ADR to each individual claim.
  • If you are responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Ensure each set of medical records is bound securely so the submitted documentation is not detached or lost.
  • Do not mail packages COD; we cannot accept them.
  • Return the medical records to the address indicated in the ADR. Be sure to include the appropriate mail code.

5D169/5H169 — Services Not Documented

Reason for denial:

  • Claims fully or partially denied because the provider billed for services/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 410.32 and 424.5External 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.

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