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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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November 2, 2015

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

The J15 Part A Medical Review department performed a service-specific targeted medical review on outpatient claims related to Spinal Injections (CPT Code 62311) in Kentucky and Ohio. Based on the results summarized below, the targeted medical review will be continuedin both regions.

Kentucky Service-Specific TMR Edit Results: Spinal Injections (CPT Code 62311)

	Charges	Claims
Reviewed	$726,333.24	372
Denied	$307,834.87	177
Charge Denial Rate	42.4%

Ohio Service-Specific TMR Edit Results: Spinal Injections (CPT Code 62311)

	Charges	Claims
Reviewed	$1,136,056.98	585
Denied	$567,545.40	280
Charge Denial Rate	50.0%

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 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 3.3.2.4
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

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 avoid 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 45 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.
You also have the option to respond to ADRs electronically via the myCGS web portal.

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 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.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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

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