Postpayment Service-Specific Probe Results for Outpatient Hyperbaric Oxygen for April through June 2021

Postpayment Service-Specific Probe Results for Outpatient: HCPCS Code G0277 — Hyperbaric Oxygen — in Alabama, Georgia and Tennessee for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on Outpatient HCPCS G0277 — Hyperbaric Oxygen Therapy. This edit was set in Alabama, Georgia and Tennessee. The results for the probe review, for claims processed April through June, 2021, are presented here.

Cumulative Results 
A total of 711 claims were reviewed, with 372 of the claims either completely or partially denied, resulting in an overall claim denial rate of 52.32 percent. The total dollars reviewed were $1,644,604.79, of which $684,712.19 were denied, resulting in a charge denial rate of 41.63 percent. Overall, there were 45 auto-denied claims in the region. The top denial reasons were identified, and thre number of occurrences based on dollars denied were:  

Alabama Results
A total of 193 claims were reviewed, with 122 of the claims either completely or partially denied. This resulted in a claim denial rate of 63.21 percent. The total dollars reviewed were $463,642.93, of which $225,613.80 were denied, resulting in a charge denial rate of 48.66 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Georgia Results
A total of 294 claims were reviewed, with 135 of the claims either completely or partially denied. This resulted in a claim denial rate of 45.92 percent. The total dollars reviewed were $723,953.08, of which $273,102.30 were denied, resulting in a charge denial rate of 37.72 percent.The top denial reasons were identified, and the number of occurrences based on dollars denied were:

Tennessee Results
A total of 224 claims were reviewed, with 115 of the claims either completely or partially denied. This resulted in a claim denial rate of 51.34 percent. The total dollars reviewed were $457,008.78, of which $185,996.09 were denied, resulting in a charge denial rate of 40.70 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied were:

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 or 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)
• Local Coverage Determination (LCD) and National Coverage Determination (NCD) articles on Palmetto GBA's website
• CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF, 652.50 KB)
• Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
   

5DMDP/5HMDP — Dependent Services Denied (Qualifying Service Denied Medically)

Reason for Denial
The dependent services will not be covered if the qualifying service has been denied. For example, the service was denied as documentation did not support medical necessity, therefore all other charges associated with the service under review cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

How to Avoid This Denial
Ensure the documentation provided supports the services were reasonable and medically necessary for the treatment of the beneficiary.

• Ensure all records are properly and legibly signed
• Ensure documentation supports the service(s) was rendered

More Information

• 42 (CFR) Code of Federal Regulations, Section 410.32
• CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 6 (PDF, 215.49 KB)
   

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 This 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 history and physical and/or progress notes
  • Clear indication of the diagnosis
  • Clinical signs and symptoms
  • Prior treatment and response as applicable
  • Stage of treatment as applicable 
• Documentation of administration 

More Information

• CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50 (PDF, 1.55 MB)
• CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 17 (PDF, 493.16 KB)
   

5D199/5H199 — Billing Error

Reason for Denial
The services billed were not covered because the documentation provided did not support the claim as billed by the provider.

How to Avoid This Denial
To avoid future denials for this reason:

• Check all bills for accuracy prior to submitting to Medicare
• Ensure that the documentation submitted, in response to the ADR, corresponds with the date that the service was rendered, and the dates of service billed

More Information

• CMS Internet-Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 (PDF, 652.50 KB)
• CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual
   

5D169/5H169 — Services Not Documented

Reason for Denial
This claim was partially or fully denied because the provider billed for services/items not documented in the medical record submitted.

How to Avoid This Denial

• Submit all documentation related to the services billed
• Ensure that results submitted are for the date of service billed, the correct beneficiary and the specific service billed
• Ensure that the documentation is complete with proper authentication and the signature is legible

More Information

• Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
   

5HTDP/5DTDP – Dependent Services Denied (Qualifying Service Denied Technically)

Reason for Denial
The dependent services will not be covered if the qualifying surgery has been denied. For example, the surgical procedure was not documented, therefore all other charges cannot be allowed.

How to Avoid This Denial
Documentation that may be helpful to avoid future denials for this reason may include, but is not limited to, the following: all documentation to support orders, documentation of services rendered and the medical necessity of qualifying services for the date(s) billed. 

More Information

• 42 (CFR) Code of Federal Regulations, Section 410.32
• CMS Internet-Only Manual (IOM), Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 120 (PDF, 589.83 KB)
   

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial
The medical record provided for the outpatient service did not support the number of units billed on the claim. Per the documentation more units were billed than provided.

How to Avoid This Denial
Under the Outpatient Prospective Payment System (OPPS), when HCPC code reporting is required the number of times the service or procedure was performed, or the amount of the service used must also be accurately reported in the service units.

• For time based general outpatient services, make sure the start and end time, or total length of the service is documented clearly in the record
• For other general outpatient services, make sure the amount of the service is documented clearly in the record
• When reporting drugs or biologicals make sure the amount of the drug given is clearly documented and properly converted into units when submitted for payment
• For outpatient therapy services, make sure the timed treatment minutes for the timed services provided are documented clearly in the record

More Information

• 42 (CFR) Codes of Federal Regulations, Sections 410.27 and 424.5
• CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.4 — General Outpatient Billing (PDF, 1.68 MB)
• CMS Internet-Only Manual (IOM), Pub 100-04: Medicare Claims Processing Manual, Chapter 17, Section 90.2 — Drugs and Biologicals (PDF, 493.16 KB)
• CMS Internet-Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 5, Section 20.2 — Outpatient Rehabilitation (PDF, 693.68 KB)
   

The Next Steps
The service-specific postpayment medical review edits for Outpatient HCPCS Code G0277– HBO Therapy in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and/or 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 the 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.