Postpayment Service-Specific Probe Results for Outpatient Hyperbaric Oxygen for January through March 2021

Palmetto GBA performed service-specific postpayment probe review on Outpatient: HCPCS Code G0277 — Hyperbaric Oxygen. This edit was set in Alabama, Georgia and Tennessee. The results for the service-specific edit in Tennessee will be presented in a future article. The results for the first quarter probe review, for claims processed January through March, 2021, are presented here.

Cumulative Results 
A total of 104 claims were reviewed, with 49 of the claims either completely or partially denied, resulting in an overall claim denial rate of 47.12 percent. The total dollars reviewed was $117,148.28, of which $51,962.80 was denied, resulting in a charge denial rate of 44.36 percent. Overall, there were no auto-denied claims in the region. 

Alabama Results
A total of 81 claims were reviewed, with 42 of the claims either completely or partially denied. This resulted in a claim denial rate of 51.85 percent. The total dollars reviewed was $72,105.58, of which $42,608.28 was denied, resulting in a charge denial rate of 59.09 percent. The top denial reasons identified, based on dollars denied:  

Georgia Results
A total of 23 claims were reviewed, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 30.43 percent. The total dollars reviewed was $45,042.70, of which $9,354.52 was denied, resulting in a charge denial rate of 20.77 percent. 

Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was denied because the documentation submitted does not support the medical necessity of the service reviewed. The records did not contain any covered condition, indication, symptomology or diagnostic results that would support the service was reasonable and necessary for the treatment of the beneficiary.

How to Avoid This Denial

• Submit all documentation related to the services billed which support the medical necessity of the services. Documentation should support:
  • A covered indication or condition for the service billed
  • A physician/NPP is managing the care of the covered indication or condition
  • Any medical history that supports a need for the service
  • Any diagnostic results or symptomology that supports a need for the service
• A legible physician or nonphysician provider (NPP) signature is required on all documentation necessary to support medical necessity
• Use the most appropriate ICD-10-CM codes to identify the beneficiary’s medical diagnosis

More Information

• Code of Federal Regulations, 42 CFR — Section 411.15
• Social Security Act (SSA) — Section 1862(a)(1)(A)
• Palmetto GBA Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles which are available on our website
• CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF. 652.5 KB)
• CMS Medicare Learning Network (MLN) Matters article MM6698 Signature Guidelines for Medical Review Purposes
• Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices

5D920/5H920 — The Recommended Protocol was not Ordered and/or Followed

Reason for Denial
Medicare cannot pay for this service because one or more requirements for coverage were not met.

How to Avoid a Denial
Documentation that may be helpful to avoid future denials for this reason may include, but are not limited to, the following:

• Clear physician’s order with indication of need, dose, frequency and route 
• Date and time of associated chemotherapy, as applicable
• Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include:
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable 
• Clear and complete documentation of administration signed by the person providing the service
• Ensure the service was provided per the coverage guidelines for the service
• Documentation of administration

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

• Medicare Benefit Policy Manual, Publication 100-02: Chapter 15, Section 50
• Medicare Claims Processing Manual, Publication 100-04: Chapter 17
• Outpatient Therapy: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 220 & 230

The Next Steps
The service-specific targeted medical review edits for Outpatient: HCPCS Code G0277 — Hyperbaric Oxygen in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to Redetermination: 1st Level Appeal Form (PDF, 236 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.