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August 11, 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 of claims for Cataract Removal (HCPCS Codes 66984, 66983, 66982) in Kentucky and Ohio from March through June 2016. Based on the results summarized below, the complex edit review will be continued in Kentucky and Ohio.

Kentucky Service-Specific Complex Edit Results

  Charges Claims
Reviewed $1,789,839.63 392
Denied $944,451.32 251
Charge Denial Rate 52.8%  

Ohio Service-Specific Complex Edit Results

  Charges Claims
Reviewed $2,971,751.70 676
Denied $1,596,520.56 320
Charge Denial Rate 53.7%  

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.
  • Additional tips:
    • During this quarter of review, 461 claims were denied for no documentation of medical necessity.
    • Missing documentation included: biometry results, visual acuity exams, description of impairment of ADLs, and documentation to support cataracts as the primary cause of the beneficiary's decreased visual acuity.
    • When responding to an ADR for this edit, please include office notes from the opthalmologist that support the medical necessity of cataract removal (see L33954 Cataract Extraction on the CMS website for clarification).

For more information, refer to:

5D169 – Services not documented

Reason for denial:

  • This claim was partially or fully denied because the provider billed for services/items not documented in the submitted medical record.

How to prevent denials:

  • Submit all documentation related to the services billed when responding to the Additional Documentation Request (ADR).
  • Ensure that results submitted are for the dates of service billed, the correct beneficiary, and the specific service billed.

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 in Direct Data Entry (DDE). Claims in status/location SB6001 have 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.
  • Ensure your mail room staff is aware of any mail you receive from CGS.
  • Ensure medical records are submitted within 45 days of the date in the upper left corner of the ADR letter.
  • 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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