Palmetto GBA
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West Virginia Part B Carrier
Medical Review Findings 1st Quarter

The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors concerning coverage and coding. The Palmetto GBA (OH/WV) Medical Review Department has identified the following problem areas for the first quarter of 2010. Please note this is not an all-inclusive list but does reflect the majority of documentation issues discovered during the review process.
  1. Split/Shared visits: Must be a member of the same group. Emergency room setting especially a problem area when Non Physician Practitioners (NPP) are not credentialed by the practice therefore we are unable to verify if they are in the group.
  2. Signatures:  Documentation missing signature authentication by the author of the medical record
  3. Labs/Diagnostic Testing:  Missing some type of 'signed' (electronic or otherwise) order or documentation that clearly reflects the ordering provider’s intent for the test being performed
  4. Hospital and Nursing Facility Discharge Services:  Documentation of time is often excluded from the medical record
  5. Chiropractic Services:  Missing treatment plan with specific objective, measurable treatment goals. Follow thru with these specific objective treatment goals on subsequent visits is often omitted.
  6. Therapy Services:  Missing initial evaluation, treatment plan, and time for time-based therapy CPT codes
  7. Individual Psychotherapy Services:  Missing time, goals, unable to determine if service was insight oriented, behavior modifying and/or supportive psychotherapy. Reminder: we do not need to see the specific details that were discussed.
  8. Evaluation and Management Services:  Services do not meet the minimum documentation requirements.  Specific concerns: Use of noncontributory; documenting ‘labs reviewed’ without further information; referred to documentation that was not included with medical review request, ancillary staff or scribe documentation requirements were not met; and counseling/coordination of care missing time and/or documentation to support service.
  9. Legibility:  We accept transcribed notes in addition to copies of originals
  10. Teaching Physician Services:  Documentation received does not support the teaching physician’s documentation requirements

 

last updated on 04/01/2010
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