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May 6, 2016

Spinal Injections (HCPCS Code 62311): Complex Medical Review – Ohio, Continue

The J15 Part A Medical Review department performed a service-specific targeted medical review of outpatient claims related to Spinal Injections (HCPCS 62311) in Ohio from December 2015 through February 2016.

Based on the results summarized below, the targeted medical review will be continued in Ohio.

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

  Charges Claims
Reviewed $2,887,728.95 1,471
Denied $1,755,156.94 893
Charge Denial Rate 60.8%  

The top denial reasons associated with this review are:

5D164/5H164 – No documentation of medical necessity

Reason for denial:

  • Claims were fully or partially denied because the documentation submitted for review did 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 signature is required on all documentation necessary to support orders and medical necessity.
  • Use the most appropriate ICD-10-CM codes to identify the beneficiary's medical diagnosis.

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 avoid denials:

  • Monitor your claim status in 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 route any mail you receive from CGS to the appropriate department for handling.
  • Submit medical records as soon as the ADR is received, but no later than 45 days of the date on the ADR letter (located in the upper left corner).
  • Gather all information needed for the claim and submit it all at one time.
  • Attach a copy of the ADR letter to each individual claim.
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR letter 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 C.O.D.; we cannot accept them.
  • Return the medical records to the address indicated in the ADR letter.

5C199 – Billing Error

Reason for denial:

  • The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

How to prevent denials:

  • Check all claims for accuracy prior to submitting to Medicare.
  • Ensure that the documentation submitted in response to the ADR corresponds with the date the service/diagnostic test was rendered and the dates of service billed.

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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