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September 27, 2021

J15 Part A Post Pay Resumptive Review Status Update 01/01/2021 – 03/31/2021

Beginning August 17, 2020, CMS directed the MACs to resume fee-for-service medical review activities beginning with post payment reviews of items/services provided before March 1, 2020. Items and services were selected based upon high error rates and/or potential overutilization identified through data analysis.

CGS Medical Review is dedicated to the integrity of the Medicare program. CGS welcomes provider inquiries and continues to offer education sessions to ensure providers understand CMS regulations with the goal of successful reviews resulting in claim payment.

Results for service specific post payment reviews are listed below.

Drugs/Biologicals – HCPCS J2505, J9312, J9299

Service Specific Results

Kentucky

Ohio

Sampled Claims

75

148

Reviews Completed

47

91

Claims Allowed

29

68

Claims Denied

18

23

No Provider Response

28

57

Overall Error Rates

61.3%

54.1%

Screen Shot

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.External PDF

  • The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
    • Common Documentation Found Missing: orders, detailed history and physical, office visit notes, treatment plan supporting covered diagnosis, chemotherapy administration information, correct HCPC coding for medication delivery, and Body Surface Area (BSA) if applicable.

Hyperbaric Oxygen Therapy (HBOT) – HCPCS G0277

Service Specific Results

Kentucky

Ohio

Sampled Claims

15

101

Reviews Completed

8

58

Claims Allowed

2

29

Claims Denied

6

29

No Provider Response

7

43

Overall Error Rates

86.6%

71.3%

Screen Shot

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.External PDF

  • The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
    • Common Documentation Found Missing: detailed history and physical, covered condition verified by pathology or imaging results, HBOT order (inclusive of time the physician desires the beneficiary to be under 100% oxygen and # of prescribed sessions), each HBOT session billed (treatment notes with dive times (ascent, decent, air breaks, treatment depth, etc., reason/rationale for all units billed.

Therapeutic Exercise – 97110

Service Specific Results

Kentucky

Ohio

Sampled Claims

40

0

Reviews Completed

20

0

Claims Allowed

0

0

Claims Denied

20

0

No Provider Response

20

0

Overall Error Rates

100.0%

0.0%

Screen Shot

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.External PDF

  • The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
  • Common Documentation Found Missing: detailed history and physical, total number of minutes for timed services, signature attestation for plan of care/certification/re-certification, prior functional level, therapy notes, reason for therapy

Pulmonary Rehabilitation – G0424

Service Specific Results

Kentucky

Ohio

Sampled Claims

24

13

Reviews Completed

4

13

Claims Allowed

3

3

Claims Denied

1

10

No Provider Response

20

0

Overall Error Rates

87.5%

76.2%

Screen Shot

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.External PDF

  • The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
    • Common Documentation Found Missing: detailed history and physical, pulmonary function test results, signatures on assessments, frequency of exercise, psychosocial assessment, individual treatment plan, physician-prescribed exercise with duration and frequency of sessions noted, evidence of moderate to severe COPD, outcomes assessment, session documents do not match billed claim, no records returned for review

Cardiac Rehabilitation – 93798

Service Specific Results

Kentucky

Ohio

Sampled Claims

0

17

Reviews Completed

0

17

Claims Allowed

0

6

Claims Denied

0

11

No Provider Response

0

0

Overall Error Rates

0.0%

64.7%

Screen Shot

Top Finding: The documentation submitted does not support medical necessity for the services billed. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.External PDF

  • The submitted documentation lacked required elements to support the reason for the services and why they were medically reasonable and necessary.
    • Common Documentation Found Missing: detailed history and physical, physician order for Phase II Cardiac Rehab, signatures on assessments, psychosocial assessment, individual treatment plan, physician-prescribed exercise with duration and frequency of sessions noted, timed sessions, ITP not dated to support physician review/signature every 30 days, outcomes assessment, signed treatment plan

Resources:

CGS Part A MR Activities and Documentation Requirements Checklists

Provider inquiries and education requests may be emailed to J15AMREDUCATION@cgsadmin.com.

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review activity log and by using tools such as Comparative Billing Reports (CBRs) offered through our web portal at myCGS.

To learn more about the post payment resumptive process, please refer to the following links:

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