National Government Services Part B Medical Review Newsletter September 2020

National Government Services MR Department would like to welcome you to our newest service; a regular newsletter. It is our hope that you will find this newsletter helpful in providing you the resources you need to help you stay up-to-date on the MR activities performed here at NGS.

Our plan is to include:

• • Educational Resources
  • Updates and News
  • Contact Information
  • Reminders
  • Helpful Tips

What’s New?

Please note: TPE reviews continue to be on hold due to the PHE related to COVID-19. However, the NGS MR Department will be performing service specific post payment reviews for a random selection of claims billed to Medicare Part A and B.

Providers are encouraged to visit the Medical Review Focus Areas on our website. This dedicated area will identify which services are being selected, what documentation will be requested, and provide more details on these service specific post-payment reviews.

Note: If the link above does not take you directly to the MR focus area topic, it is often due to it being your initial visit to the NGS website. You may see a red box that requests a username and password. If this occurs, click on the link below the login boxes that says Continue as a Guest. It will then have you put in your Part B provider information. Once you do this and continue, you will be prompted to verify you read a short attestation statement. After completing this information once, you should not have to do it a second time as long as you choose Remember my choice when putting in your provider information. Once you do this, click on the Medical Policy & Review tab near the top.

JK Part B

Service Specific Post Payment Review Announcements

JK MR will be conducting a service specific review of CPT codes A0425 and A0428 (Ambulance Transport).

In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of the services mentioned. The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for CPT A0425 and A0428 for post payment review in JK for Part B providers in the states of New York, Connecticut, Massachusetts, Rhode Island, Vermont, Maine and New Hampshire.

• • A0425 - Ground mileage, per statue mile
  • A0428 - Ambulance service, basic life support, non-emergent transport (BLS)

NGS is also randomly selecting claims billed for CPT codes 11719, 11720 and 11721 for post payment review in JK for Part B providers in the states of New York, Connecticut, Massachusetts, Rhode Island, Vermont, Maine and New Hampshire.

• • 11719 - Trimming of nondystrophic nails, any number
  • 11720 - Debridement of nail(s) by any method(s) 1 to 5
  • 11721 - Debridement of nails by any method(s) 6 or more

In addition to those services listed above, NGS will also randomly select claims billed for CPT codes 11055, 11056 and 11057 for post payment review in JK for Part B providers in the states of New York, Connecticut, Massachusetts, Rhode Island, Vermont, Maine and New Hampshire.

• • 11055 - Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
  • 11056 - Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions
  • 11057 - Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions

J6 Part B

Service Specific Post Payment Review Announcements

J6 MR will be conducting a service specific review of CPT code 90837 (Psychotherapy, 60 minutes with patient).

In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of the services mentioned. The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for CPT 90837 for post payment review in J6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• • 90837 - Psychotherapy, 60 minutes with patient

NGS will also randomly select claims billed for CPT A0425-A0428 for post payment review in J6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• • A0425 - Ground mileage, per statue mile
  • A0426 - Ambulance service, advanced life support, non-emergency transport (ALS)
  • A0428 - Ambulance service, basic life support, non-emergent transport (BLS)

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

Visit our website for more details and educational resources relating to these review topics. 

Provider Tips

• • NGS recommends responding to ADRs within 35‒40 days of letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
  • Be sure to forward the requested documentation to the preferred method of submission.
  • If you are mail in your ADR, please send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
  • Include all records necessary to support the services for the dates requested.
  • Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
  • Records must be complete and legible. Be sure to include both sides of double-sided documents.
  • The NGS self-service portal, NGSConnex, allows both Part A (including home health, hospice and FQHCs) and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. Further details are available on our website. If you are a current user of NGSConnex, click on the link for the NGSConnex User Guide for step-by-step instructions on how to submit ADR. If you are not a current user, sign up and get started!
  • All services must include necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”.
  • Visit the Medical Review Focus Areas on the NGS website for educational resources relating to these services being reviewed.

Contact Us

If you have received an ADR letter relating to these reviews and have questions, you may contact the MR department at the following email address

Posted 8/26/2020