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November 2, 2015

Cataract Removal (CPT Codes 66984, 66983, 66982): Complex Medical Review – Kentucky — Continue

The J15 Part A Medical Review department performed a service-specific complex review on claims for Cataract Removal (CPT Codes 66984, 66983, 66982) in Kentucky. Based on the results summarized below, the complex edit review will be continuedin Kentucky.

Kentucky Service-Specific Complex Edit Results: Cataract Removal (CPT Codes 66984, 66983 and 66982)

  Charges Claims
Reviewed $491,589.81 107
Denied $311,229.16 68
Charge Denial Rate 63.3%  

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 avoid denials:

  • Submit documentation to support all required components of the service when responding to the Additional Documentation Request (ADR).
  • A legible, handwritten signature is required on all documentation necessary to support orders and medical necessity.
  • Use the most appropriate ICD-9-CM/ICD-10-CM codes to identify the beneficiary's medical diagnosis.

For more information, refer to:

  • CMS Medicare Program Integrity Manual (Pub. 100-08), Chapter 3, Section
  • CMS MLN Matters Article MM6698, Signature Guidelines for Medical Review Purposes
  • Definition of "medically necessary": Social Security Act (SSA), Section 1862 (a)(1)(A)
  • Code of Federal Regulations: 42 CFR 410.32

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 avoid 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 410.32 and 424.5

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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