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Spinal Injections (CPT Code 62311): Complex Medical Review – Ohio - Continue

The J15 Part A Medical Review department performed a service-specific targeted medical review of outpatient claims for Spinal Injections (CPT code 62311) in Ohio from July through September 2016. Based on the results summarized below, the targeted medical review will be continued in Ohio.

Ohio Service-Specific TMR Edit Results:

  Charges Claims
Reviewed $2,470,190.84 1,169
Denied $1,537,730.53 689
Charge Denial Rate 62.3%  

The top denial reasons associated with this review are:

5D164/5H164 – No documentation of medical necessity

Reason for denial:

  • 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 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, 573 claims were denied for no documentation of medical necessity.
    • Missing documentation included: description of conservative treatments, description of impairment or neurological deficits affecting ADLs, details of previous ESIs and effects, and imaging reports to support medical necessity for treatment.
    • When responding to an ADR for this edit, please include office notes from any physician that are relevant to this procedure per the CGS LCD policy, L34807, "Lumbar Epidural Steroid Injections (ESI)".

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). 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 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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