Edit Reason Code: 5FSEP
Bill Type = 13X, 85X
CPT/HCPCS/Modifiers:90832- 90834

Overview

The Medical Review Department of National Government Services will be performing service specific post-payment reviews for claims submitted to Medicare Part A. When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.

Documentation Requirements

• • Physician orders and progress notes with a clear history of why the beneficiary is in treatment and how they have progressed with treatment.
  • History and physical/history of why the beneficiary is in treatment.
  • Record must include a signed, current plan of care/treatment plan stating the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals.
  • Type and total time spent in each psychotherapy session must be documented.
  • Services rendered must be directly related to the treatment plan (active treatment) with rationale for frequency/duration of services and progress towards goals.
  • Clinic note for date(s) billed which summarizes the diagnosis, symptoms, functional status, focused mental status examination, treatment plan, prognosis and progress to date with the signature and credentials of personnel licensed by the state to render the service.
  • Medication management by personnel licensed to prescribe: to include review of the medications such as dosage, side effects, response. Prescriptions and dosage adjustment/changes.
  • Documented pharmacologic management to include prescription and dosage adjustment/changes.
  • Any documentation to justify medical necessity of services billed.
  • If applicable - documentation of physician supervision if services provided off site or off facility grounds.
  • Any documentation to justify medical necessity of services billed.
  • If an ABN was issued, please include a copy of the signed and dated ABN of noncoverage given to the beneficiary.

Reference Documentation:

• • Local Coverage Determination (LCD): Psychiatry and Psychology Services (L33632)
  • Local Coverage Article: Billing and Coding: Psychiatry and Psychology Services (A56937)

Posted 12/14/2020