Jurisdiction K Part B Targeted Probe and Educate: Medical Review Topics

• The documentation does not include some or all of the required elements including the necessary class findings, the presence of a qualifying systemic illness causing a peripheral neuropathy, and/or does not include precise and specific findings including specific location of lesion(s).
• The documentation does not support the class findings modifier billed.

• The documentation does not support that nondystrophic nails were present and/or treated.

A07 – The documentation does not support the medical necessity per policy guidelines.

• The documentation does not support one or more of the medical necessity and/or documentation requirements as noted in the LCD.

DA80 – The documentation does not support a significant, separately identifiable evaluation and management services on the same day as treatment of the nails.

Local Coverage Determination (LCD): L33636- Routine Foot Care and Debridement of Nails

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6B

Title XVIII of the SSA, Section 1833(e)

• The reviewer recoded the service to the appropriate level supported within the documentation.

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.6.2.2, 3.6.2.4, 3.6.2.5

CMS IOM Publication 100-03,Medicare National Correct Coding Initiative Policy Manual, Chapter 3, Section G and L9

Title XVIII of the SSA, Section 1862(a)(1)(A)

• The submitted documentation does not include specific signs or symptoms describing the clinical characteristic of the lesion(s) to support the medical necessity of the service, the site of lesion removed, and/or the number of lesions removed.

• The submitted documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.

Billing and Coding Article: Removal of Benign Skin Lesions (A54602)

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20 and Section 180

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

• The documentation does not support if the joint disease is evidenced by conventional radiography, or MRI.
• The documentation does not support unsuccessful nonsurgical medical management.

• Information received was for the incorrect beneficiary, date of service, or did not include the procedure report.

• Cataract causing symptomatic impairment of visual function.
• Impaired of visual function is not correctable with a tolerable change in glass or contact lenses.
• Visual impairment resulting in specific activity limitation and/or participation restrictions.
• Other eye disease(s) including, but not limited to, macular degeneration or diabetic retinopathy have been ruled out as the primary cause of decreased visual function.

• Information received was for the incorrect beneficiary, date of service, or did not include the procedure report.

• The documentation does not support the presence of cerumen impaction to support the medical necessity of the service.
• The documentation does not support the requirement of symptomatic impacted cerumen to support the medical necessity of the service.
• The documentation does not support that instrumentation was used, requiring physician skills, to remove the cerumen to support the medical necessity of the service.

• The submitted documentation does not include an indication to support the medical necessity of the chest X-ray.

• ABN was invalid due to a missing a signature date and/or the options box was not completed by the beneficiary.

• The documentation does not include an indication.
• The breast ultrasound is being completed as supplemental screening with mammography for patients with dense breasts or a personal/family history of breast cancer.
• The breast ultrasound must be diagnostic. Medicare does not pay for screening breast ultrasounds.

• The documentation does not include an indication to support the medical necessity of the service.

• The documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.

• The treatment plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals.
• The psychiatric diagnostic procedure requires the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient's ability and capacity to respond to treatment, and an initial plan of treatment.
• Information may be obtained from not only the patient, but also other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history. If unable to obtain the history, attempts at obtaining must be documented.

• The documentation does not include an individualized plan that includes the type, amount, frequency, duration, diagnosis, and anticipated goals.
• The treatment note does not include total time of psychotherapy, modalities, focused mental status exam, and/or progress to date.

B05 - Provider or provider representative indicated that this service was billed in error.

Local Coverage Determination (LCD) L33632-Psychiatry and Psychology Services

Title XVIII of the SSA, Section 1833(e)

• The documentation does not include an individualized treatment plan that includes the type, amount, frequency, duration, diagnosis and anticipated goals.
• The documentation does not include an encounter note that includes functional status, focused mental status exam, and progress to date.
• The documentation does not support the correct billing of the telehealth visit.
• The documentation included late provider signatures and the signature guidelines were not followed.

• The submitted documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.
• Incident-to requirements were not met when services were provided by a nonphysician practitioner.

Local Coverage Determination (LCD) L33632-Psychiatry and Psychology Services

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 30 and 60.1-60.2

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

MLN® Fact Sheet: Complying with Medicare Signature Requirements

Billing for telehealth: Billing and coding Medicare Fee-for-Service telehealth claims

• The documentation does not include an indication supported by signs and symptoms including an arterial brachial index (ABI).

• The submitted documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.

Local Coverage Determination (LCD): Non-Invasive Vascular Studies (L33627)

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)
 

• The documentation does not include all the required elements of a physical therapy evaluation including: a treatment plan with short term and measurable goals, the required prior level of function assessment impacting quality of life, current level of function, and beneficiary's social supports to support the medical necessity of the service.
• The documentation does not include all the required elements of a physical therapy initial evaluation including: a complete functional assessment

• The submitted documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.

Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631)

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 30, 220

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

42 Code of Federal Regulations (CFR) Sections 409.17, 409.44, 410.60, 410.61(a) and (c)
 

Acupuncture

• The documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.

• Exceeded 12 treatments in 90 days with lack of improvement
• Exceeds 20 treatments in a year
• Documentation does not support definition of cLBP

A65 – Information requested from the provider was insufficient/incomplete.

• Information received was for the incorrect beneficiary, date of services, or did not include the procedure report.
• The documentation did not include a treatment note.

B51 – The information provided does not support the need for this service or item.

• The submitted documentation did not support the medical necessity of the service.

CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.29

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 30

Title XVIII of the SSA, Section 1833(e)

• The submitted documentation does not include one or more of the required elements to meet or support the criteria of an annual wellness visit. 

• The documentation does not support improvement of functional capacity for subsequent injections.
• Frequent cloned documentation.
• The documentation does not include subjective patient report of knee pain at the time of injection.
• Incorrect code billed when ultrasound guidance was used.
• The documentation was missing one or more of the following: a diagnosis and/or history of symptomatic osteoarthritis of the knee, radiologic evidence to support osteoarthritis diagnosis, and documentation to support failure of at least three months of conservative treatment

• The modifier JZ was not appended to the drug code to attest that there are no amounts of drugs or biologicals from single-dose containers or single-use packages that were unused or discarded.

• The documentation lacked the requirements to support the medical necessity of the additional services beyond the therapy threshold.
• The documentation lacked justification to support the need for additional therapy and how the additional therapy would directly and significantly impact the rate of recovery of the condition being treated such that it is appropriate to exceed the threshold.
• The documentation lacked evidence to support the ongoing skills of a qualified therapist were required to complete the treatment.
• The documentation did not support that the level of complexity or condition of the patient required the services that could only be performed safely and effectively by a qualified therapist.

• The submitted documentation does not support that the rendering provider of the service is the rendering provider reported on the claim.
• Medical necessity could not be determined due to the documentation received was not from the billing provider.