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Jurisdiction 1 Part B
All Regions Service Specific Prepayment Review Update: E/M Services (CPT Code 99214)

Based on the preliminary minor risk charge denial rates, Palmetto GBA J1 Part B Medical Review will discontinue claim selection for evaluation and management (E/M) CPT code 99214 for provider specialties 06, 08 and 11 in all J1 states. However, the review of documentation for claims previously selected continues at this time. Upon completion of all reviews, final edit effectiveness will be performed. Results will be posted to the J1 Part Web site.

Based on preliminary findings, Medical Review has identified the following top denials reasons:

  • Missing or incomplete documentation for the requested date of service
  • Invalid/illegible provider signature
  • Incorrect/incomplete/illegible patient identification or date of service
  • Illegible documentation

Please find below recommendations to avoid the top denial reasons.

  1. Missing or incomplete documentation for the requested date of service:
    To avoid future claim denials:
    • Submit all documentation supporting the services billed within 30 days of the date on the ADR letter
    • Verify that 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 (e.g., original chart notes, diagnostic, radiological or laboratory results)
    • Fax all documentation for the claim with a completed 'Redetermination: 1st Level Appeal Form' or 'Reopening: Simple Claim Correction Form' in the Forms Section of the J1 Part B Web site, 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 (PDF, 120 KB) to (803) 462-3929 if your claims or dates of service were denied with a N29 code listed on the RA
  2. Invalid/illegible provider signature:
    To avoid future claim denials:
    • Verify that 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.
    • Print or type the rendering provider’s full name below or near the provider’s signature
    • Ensure that the name is clearly marked or circled to indicate the owner of the signature for documentation that contains letterhead including the rendering provider’s full name
    • Submit a valid Signature Log to the Medical Review department. For examples, review the article ‘Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices’ link above.
    • Submit a valid Signature Attestation with any documentation that contains an illegible rendering provider signature. For examples, review the article ‘Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices’ link above.
  3. Incorrect/incomplete/illegible patient identification or date of service:
    To avoid future claim denials:
    • Review if all documentation contains correct patient and date of service information prior to submission
    • Ensure that patient identifiers are legible and complete
    • Ensure that the complete date of service is clearly and legibly noted on all documentation
    • Review the information to determine that the correct patient identifier and the correct date of service are listed in the appropriate fields prior to submission
  4. Illegible documentation:
    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

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 at no cost to you, please call the J1 Part B Provider Contact Center at (866) 931-3901.

 

last updated on 11/21/2011
ver 1.0.37