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May 22, 2017

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 January through March 2017. 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 $2,935,165.91 593
Denied $943,551.85 186
Charge Denial Rate 32.1%  

Ohio Service-Specific Complex Edit Results:

  Charges Claims
Reviewed $4,558,231.44 1,055
Denied $1,871,645.43 349
Charge Denial Rate 41.1%  

The top denial reasons associated with this review are:

5D164/5H164 – No documentation of medical necessity

5D169 – Services not documented

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 routes any mail you receive from CGS to the appropriate person/department for handling.
    • Submit medical records as soon as the ADR is received, but not later than 45 days of the date in the upper left corner of the ADR letter.
    • Gather all information and submit at one time.
    • 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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