Palmetto GBA
Close Window [x]
  • Entire Site
  • J1 WPS Transition
  • J1 Part A
  • J1 Part B
  • LA & MS Part A EDI
  • NSC
  • Ohio Part B
  • Part A Intermediary
  • Railroad
  • RHHI
  • SC Part B
  • WV Part B
permaLink
Change Font Appearance Change Font to Serif Change Font to Sans-Serif Decrease Font size Expand Font size
Bookmark E-mail PDF Print Digg It! Tweet FB Like

Ohio Part B Carrier
Medical Review Findings 2nd 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 second quarter of 2010. Please note this is not an all-inclusive list and is in no specific order.  This list reflects 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 electronic medical record or contains an illegible signature. 
  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.  Also, please keep in mind several laboratory tests have National Coverage Determinations that contain specific guidelines that must be met.
  4. Hospital and Nursing Facility Discharge Services:  Documentation of amount time spent performing the discharge is often excluded from the medical record and/or does not contain detailed information regarding the discharge.  Example:  Provider states, “May discharge to home today.”  Reminder:  The discharge service must be billed on the day it was performed.
  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.  The initial visit and subsequent visit often was missing key elements/requirements outlined in the Internet-Only Manual Medicare Claims Processing Manual 100-04, Chapter 12, section 220.  Reminder:  Subluxation may be established by either an examination or hands-on examination (P.A.R.T.)
  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.
  9. 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
  10. Legibility:  We accept transcribed notes in addition to copies of originals.
  11. No response to request for medical records:  Often times this is because a provider failed to update his/her address/phone number; therefore we are unable to locate the provider.  Please keep in mind it is the provider’s responsibility to notify Palmetto GBA within 90 days of any changes that occur.  Please follow all instructions provided on any letter requesting documentation. 

 

last updated on 05/11/2010
ver 1.0.5.5