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June 9, 2016

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

The J15 Part A Medical Review department performed a service-specific complex review on claims for Cataract Removal (HCPCS Codes 66984, 66983, 66982) in Kentucky and Ohio from December 2015 through February 2016. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

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

  Charges Claims
Reviewed $1,928,351.76 424
Denied $1,185,257.03 251
Charge Denial Rate 61.5%  

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

  Charges Claims
Reviewed $3,020,181.89 741
Denied $2,067,510.65 479
Charge Denial Rate 68.5%  

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).
    • 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 medical records were not received in response to an Additional Documentation Request (ADR) in the required timeframe; 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 45 days of the date on the Additional Documentation Request (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.

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 that 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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