Jurisdiction 1 Part B
Completion of Service Specific Complex Review
E/M Services (CPT Code 99214)
April - June 2012, Southern California
Palmetto GBA J1 Part B Medical Review has completed the prepayment service specific complex review for CPT Code 99214, Evaluation and Management Services for Provider Specialties 06, 08 and 11 for April 2012 through June 2012 in Southern California.
Provider Specialty 06: Cardiology
Provider Specialty 08: Family Practice
Provider Specialty 11: Internal Medicine
Provider Specialty 06
There were 1,728 claims reviewed in Southern California for provider specialty 06, out of which 786 claims were denied resulting in a claim denial rate of 45.5 percent. The total dollars denied resulted in a charge denial rate of 34.6 percent. See below for review results and recommendations on how to avoid future denials.
The top denial reasons identified from the review are:
76 percent – Missing or incomplete documentation for this date of service
15 percent – Level of service billed not supported; Downcoded claim
3 percent – Illegible documentation
Denial Reasons and Prevention Recommendations
Documentation requested for this date of service was not received or was incomplete
To avoid future claim denials:
Submit all documentation supporting the services billed within 30 days of the date on the ADR letter
Verify if all documentation is complete and all dates of service requested are included before billing
Include any additional information pertinent to the date of service requested to support the services billed: original chart notes, diagnostic, radiological or laboratory results
Fax all documentation for the claim with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims were denied with a N102 code listed on the remittance advice (RA)
Fax all documentation for the claim or date of service with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims or dates of service were denied with a N29 code listed on the RA
Payer deems the information submitted does not support this level of service: downcoded
To avoid future claim denials:
Provide documentation supporting the level of service billed and submit all documentation for review. This can include documentation from prior dates of service, as well as original chart notes, diagnostic, radiological or laboratory results from prior dates of service.
Verify if all documentation supporting the level of service billed is included. Please refer to the E/M Scoresheet Tool through the 'LCDs and NCDs' page on the J1 Part B Web site.
Information submitted deemed illegible
To avoid future claim denials:
Print or clearly write progress notes and all medical documentation if dictation is not used
Submit typed or dictated exact copy of any written documentation which may be considered illegible
Ensure that all typed/dictated copies are signed by the rendering provider
Ensure that provider signature is legible by clearly printing or typing provider’s full name near the provider signature
Submit information by mail rather than fax for documentation of poor imaging quality from a hospital or other care facilities
The Next Steps
The service specific prepayment review for CPT Code 99214 for provider specialty 06 in Southern California will be continued based on the moderate risk charge denial and claim denial rates indicated above. In the future, we will be implementing provider specific pre-payment or post-payment reviews for the top providers that had the highest individual charge denial or claim denial rates from the service specific edit effectiveness results.
Provider Specialty 08
There were 1,644 claims reviewed in Southern California for provider specialty 08, out of which 804 claims were denied resulting in a claim denial rate of 48.9 percent. The total dollars denied resulted in a charge denial rate of 35.9 percent. See below for review results and recommendations on how to avoid future denials.
The top denial reasons identified from the review are:
57 percent – Missing or incomplete documentation for this date of service
18 percent – Level of service billed not supported; Downcoded claim
9 percent – Illegible documentation
5 percent – Missing provider signature
Denial Reasons and Prevention Recommendations
Documentation requested for this date of service was not received or was incomplete
To avoid future claim denials:
Submit all documentation supporting the services billed within 30 days of the date on the ADR letter
Verify if all documentation is complete and all dates of service requested are included before billing
Include any additional information pertinent to the date of service requested to support the services billed: original chart notes, diagnostic, radiological or laboratory results
Fax all documentation for the claim with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims were denied with a N102 code listed on the remittance advice (RA)
Fax all documentation for the claim or date of service with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims or dates of service were denied with a N29 code listed on the RA
Payer deems the information submitted does not support this level of service: downcoded
To avoid future claim denials:
Provide documentation supporting the level of service billed and submit all documentation for review. This can include documentation from prior dates of service, as well as original chart notes, diagnostic, radiological or laboratory results from prior dates of service.
Verify if all documentation supporting the level of service billed is included. Please refer to the E/M Scoresheet Tool through the 'LCDs and NCDs' page on the J1 Part B Web site.
Information submitted deemed illegible
To avoid future claim denials:
Print or clearly write progress notes and all medical documentation if dictation is not used
Submit typed or dictated exact copy of any written documentation which may be considered illegible
Ensure that all typed/dictated copies are signed by the rendering provider
Ensure that provider signature is legible by clearly printing or typing provider’s full name near the provider signature
Submit information by mail rather than fax for documentation of poor imaging quality from a hospital or other care facilities
Documentation lacks the necessary provider's signature
To avoid future claim denials:
Verify if all documentation is legibly signed by the rendering physician or non-physician practitioner
Verify if electronic signature meets the CMS signature requirements listed in the article 'Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices' on the J1 Part B Web site
Submit a valid Signature Attestation with any documentation that lacks the rendering provider's signature. For examples, review the article 'Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices' on the J1 Part B Web site.
The Next Steps
The service specific prepayment review for CPT Code 99214 for provider specialty 08 in Southern California will be continued based on the moderate risk charge denial and claim denial rates indicated above. In the future, we will be implementing provider specific pre-payment or post-payment reviews for the top providers that had the highest individual charge denial or claim denial rates from the service specific edit effectiveness results.
Provider Specialty 11
There were 1,703 claims reviewed in Southern California for provider specialty 11, out of which 868 claims were denied resulting in a claim denial rate of 51 percent. The total dollars denied resulted in a charge denial rate of 38.8 percent. See below for review results and recommendations on how to avoid future denials.
The top denial reasons identified from the review are:
57 percent – Missing or incomplete documentation for this date of service
17 percent – Illegible documentation
16 percent – Level of service billed not supported; Downcoded claim
Denial Reasons and Prevention Recommendations
Documentation requested for this date of service was not received or was incomplete
To avoid future claim denials:
Submit all documentation supporting the services billed within 30 days of the date on the ADR letter
Verify if all documentation is complete and all dates of service requested are included before billing
Include any additional information pertinent to the date of service requested to support the services billed: original chart notes, diagnostic, radiological or laboratory results
Fax all documentation for the claim with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims were denied with a N102 code listed on the remittance advice (RA)
Fax all documentation for the claim or date of service with a completed Redetermination/Reopening Request Form to (803) 462-3929 if your claims or dates of service were denied with a N29 code listed on the RA
Information submitted deemed illegible
To avoid future claim denials:
Print or clearly write progress notes and all medical documentation if dictation is not used
Submit typed or dictated exact copy of any written documentation which may be considered illegible
Ensure that all typed/dictated copies are signed by the rendering provider
Ensure that provider signature is legible by clearly printing or typing provider’s full name near the provider signature
Submit information by mail rather than fax for documentation of poor imaging quality from a hospital or other care facilities
Payer deems the information submitted does not support this level of service: downcoded
To avoid future claim denials:
Provide documentation supporting the level of service billed and submit all documentation for review. This can include documentation from prior dates of service, as well as original chart notes, diagnostic, radiological or laboratory results from prior dates of service.
Verify if all documentation supporting the level of service billed is included. Please refer to the E/M Scoresheet Tool through the 'LCDs and NCDs' page on the J1 Part B Web site.
The Next Steps
The service specific prepayment review for CPT Code 99214 for provider specialty 11 in Southern California will be continued based on the moderate risk charge denial and claim denial rates indicated above. In the future, we will be implementing provider specific pre-payment or post-payment reviews for the top providers that had the highest individual charge denial or claim denial rates from the service specific edit effectiveness results.
If you have any questions about general coverage criteria, medical review documentation requests, status of claims in the system, receipt of documentation by Medical Review, claim denials or educational opportunities, please call the J1 Part B Provider Contact Center at (866) 931-3901.
last updated on 08/31/2012