March 3, 2021
J15 Post Pay Resumptive Review Status Update 08/17/2020 – 12/31/2020
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 are 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.
Ambulance – A0428 |
||
---|---|---|
Service Specific Results |
Kentucky |
Ohio |
Reviews Completed |
167 |
378 |
Claims Allowed |
122 |
265 |
Claims Denied |
45 |
113 |
No Provider Response |
11 |
13 |
Top Finding: The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.
- The Physician Certification Statement and patient transport documentation did not support why other means of transportation were contraindicated.
Drugs/Biologicals – J0129, J0178, J2507 |
||
---|---|---|
Service Specific Results |
Kentucky |
Ohio |
Reviews Completed |
3 |
9 |
Claims Allowed |
1 |
4 |
Claims Denied |
2 |
5 |
No Provider Response |
0 |
0 |
Top Finding: The documentation submitted does not support medical necessity. Refer to SSA 1862, IOM, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.1, 3.6.2.2.
- The submitted documentation lacked elements such as orders, purchase orders, patient signed consent, and progress notes supporting the medical necessity of the drug/biological administration.
Resources:
- Ambulance Services Fact Sheet
- HCPCS J0129 Fact Sheet
- HCPCS J0178 Fact Sheet
- HCPCS J2507 Fact Sheet
- Signature Tips
Provider inquiries and education requests may be email to J15BMREDUCATION@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.
To learn more about the post payment resumptive process, please refer to the following links: