Twenty-four provider specific probes were completed with an average error rate of 13.67%. A total of 900 claims were sampled for review; 300 were denied/reduced. The reasons for denials/reductions consisted of:

• Documentation failed to support the medical need for the transport (air or ground);
• Ambulatory patients could have traveled another way;
• Billing a higher level transport than medically necessary;
• Insufficient or missing ALS assessment or intervention;
• Missing or incomplete Physician Certification Statement (PCS);
• Guidelines for Specialty Care Transport (SCT) were not met;
• Failure to support the medical need required for coverage of a transfer from one facility to another (services needed were available at the facility of origin);
• Mileage billed beyond the nearest facility (no documentation to support why the nearest facility was bypassed);
• Flight crew credentials were not documented;
• Illegible documentation;
• Untimely signatures.

Thirty-two provider specific probes were completed with an average error rate of 99.6%. A total of 1,080 claims were sampled for review. No records were received for 9 claims; they were denied. Medical record review occurred on 1,071 claims, and 1,067 were denied/reduced. The reasons for denials/reductions consisted of:

• Documentation failed to support the LCD L33982 guidelines for Chiropractic Treatment
  • No documentation of the initial date;
  • No treatment plan, measurable goals, objective measures, or outcomes were documented;
  • Treatment, type, means of adjustment and level of care provided was not documented;
  • Treatment plans were not updated for an exacerbation
• Services were found to be medical unnecessary for Medicare payment purposes (including cloning and maintenance therapy);
• Illegible documentation;
• Missing signatures;
• Billing provider was not the provider of record;
• No medical records were received for review.

Sixteen provider specific probes were completed with an average error rate of 67.51%. A total of 479 claims were sampled for review. No medical records were received for 120 claims; they were denied. Medical record review occurred on 359 claims, and 263 were denied/reduced. The reasons for denials/reductions consisted of:

• Documentation failed to meet critical care guidelines;
• No documentation to support imminent decline;
• Failure to document time;
• Medically unnecessary services;
• Cloning;
• Guidelines concerning the use of a scribe and split/shared services were not met;
• Signature requirements were not met (missing and late signatures);
• Inappropriate use of CPT modifier 25;
• Untimely documentation;
• Billing provider was not the provider of record;
• HCPCS modifier CG was not appended appropriately;
• Service note was not among the documentation submitted;
• No documentation received.

Two service specific probes were completed with an average error rate of 55.77%. A total of 151 claims were sampled for review. No medical records were received for 36 claims; they were denied. Medical record review occurred on 115 claims, and 83 were denied/reduced. The reasons for denials/reductions consisted of:

• No diagnosis of Wet AMD;
• No documentation of wastage;
• Missing and untimely signatures;
• Wrong date of service submitted;
• Eylea given in less than 28 days;
• Wrong code billed;
• Documentation did not support both eyes injected when billed bilaterally;
• Duplicate claim;
• No updated exam;
• No records received.

Three provider specific probes were completed with an average error rate of 41.48%. 110 claims were sampled for review. No records were received for 11 claims; they were denied. Medical record review occurred on 99 claims. Of those, 75 were denied/reduced due to:

• Failure to meet the minimum key component levels required of the code billed (for example, medical necessity for the exam level was not supported, and the decision making was determined to be of moderate risk);
• Billing provider was not the provider of record;
• Late documentation;
• No documentation received.

Eight provider specific probes were completed with an average error rate of 76.11%. A total of 299 claims were sampled for review. No records were received for 47 claims; they were denied. Medical record review occurred on 252 claims, and 234 were denied/reduced. The reasons for denials/reductions consisted of:

• Documentation failed to meet the key component levels required of the code billed;
• Insufficient documentation to support a home visit in lieu of an office or outpatient visit;
• The frequency in which services were billed and the level of service billed were medical unnecessary;
• Wrong date of service;
• The performer of the service was undecipherable;
• Inappropriate use of CPT modifier 25;
• No documentation received.

Twenty-three provider specific probes were completed with an average error rate of 57.13%. A total of 904 claims were sampled for review. No records were received for 148 claims; they were denied. Medical record review occurred on 756 claims, and 642 were denied/reduced. The reasons for denial/reduction consisted of:

• Documentation failed to meet the minimum key component levels required of the code billed;
• Billing a higher level of service than medically necessary;
• Documentation failure to support medical necessity for the visit;
• Cloning;
• Insufficient/incomplete documentation;
• The service note was not among the documentation submitted;
• Failure to meet split/share and signature guidelines;
• Missing signatures;
• Failure to provide attestations upon request;
• Wrong date of service;
• No documentation to support add-on CPT code 90833;
• Guidelines regarding record addenda were not followed;
• Non-response/failure to provide medical records for the review.

One provider specific probe was completed with an error rate of 10%. A total of 20 claims were sampled for review. Medical record review occurred on 18 claims, and all were paid as billed. No medical records were received for 2 claims; they were denied. Other findings that did not result in denial were:

• Illegible documentation
• Inappropriate use of CPT modifier 25 (the modifier was not necessary).

Twenty-one provider specific probes were completed with an average error rate of 72.51%. A total of 760 claims were sampled for review. No records were received for 82 claims; they were denied. Medical record review occurred on 678 claims, and 568 were denied/reduced. The reasons for denial/reduction consisted of:

• Documentation failed to meet the key component levels required of the code billed;
• Documentation failed to support medical necessity for the visit, frequency of visits, or level of service;
• Failure to meet federally mandated criteria;
• The documentation did not support face-to-face encounter occurred;
• Failure to meet guidelines concerning the use of a scribe;
• Improper use of "incident to" (there is no "incident to" provision in the inpatient setting);
• Incorrect date of service;
• Billing provider was not the provider of record;
• The provider reported no medical records could be found for the services billed;
• Illegible documentation;
• Blanks within the documentation;
• Failure to meet signature guidelines (late and illegible signatures) ;
• Inappropriate use of CPT modifier 25 (billing an E&M service when only foot care was done);
• No documentation received.

Thirty-eight provider specific probes were completed with an average error rate of 49.18%. A total of 1,139 claims were sampled for review. No records were received for 169 claims; they were denied. Medical record review occurred on 970 claims, and 896 were denied/reduced. The reasons for denials/reductions included:

• Failure to meet the key components required of the code billed;
• Medically unnecessary services (level of service and frequency for stable, chronic conditions);
• Conflicting dates and documentation within the notes;
• Late and missing signatures;
• Failure to meet guidelines concerning the use of a scribe, "incident to", and record addenda;
• New patient visits billed as established patient visits;
• Illegible documentation;
• Billing for services not rendered;
• Missing documentation (no service note was included with the documentation provided);
• Improper documentation for counseling;
• Inappropriate use of CPT modifier 25;
• Inappropriate billing for Protimes;
• Missing and questionable signatures;
• Failure to provide medical records.