Postpayment Service-Specific Probe Results for Surgical Services: Extracapsular Cataract Removal for July through September 2021


Postpayment Service-Specific Probe Results for Surgical Services — Extracapsular Cataract Removal with Insertion — in Alabama, Georgia and Tennessee for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on CPT 66984, Extracapsular Cataract Removal with Insertion. This edit was set in Alabama, Georgia and Tennessee. The results for the probe review for claims processed July through September 2021 are presented here.

Cumulative Results 
A total of 918 claims were reviewed in Alabama, Georgia and Tennessee combined. Of the claims reviewed, 228 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 24.84 percent. The total dollars reviewed was $547,090.27, of which $138,096.27 was denied, resulting in a charge denial rate of 25.24 percent. Overall, there were a total of 448 auto-denied claims in the region. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

82.89%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

189

9.21%

NOSIG

Documentation Lacks the Necessary Provider’s Signature

21

4.82%

BILER

Claim Billed in Error per Provider

11

3.07%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination (as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and This Service Has Been Denied)

7

Alabama Results
A total of 283 claims were reviewed in Alabama, with 39 of the claims either completely or partially denied. This resulted in a claim denial rate of 13.78 percent. The total dollars reviewed was $155,518.11, of which $20,779.89 was denied, resulting in a charge denial rate of 13.36 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

53.85%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

21

35.90%

NOSIG

Documentation Lacks the Necessary Provider’s Signature

14

5.13%

BILER

Claim Billed in Error per Provider

2

5.13%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination (as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and This Service Has Been Denied)

2

Georgia Results
A total of 532 claims were reviewed in Georgia, with 145 of the claims either completely or partially denied. This resulted in a claim denial rate of 27.26 percent. The total dollars reviewed was $331,055.90, of which $91,752.27 was denied, resulting in a charge denial rate of 27.72 percent. The top denial reasons were identified, and the numbers of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

91.72%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

133

3.45%

NOSIG

Documentation Lacks the Necessary Provider’s Signature

5

3.45%

BILER

Claim Billed in Error per Provider

5

1.38%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination (as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and This Service Has Been Denied)

2

Tennessee Results
A total of 103 claims were reviewed in Tennessee, with 44 of the claims either completely or partially denied. This resulted in a claim denial rate of 42.72 percent. The total dollars reviewed was $60,516.26, of which $25,564.11 was denied, resulting in a charge denial rate of 42.24 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

79.55%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

35

9.09%

BILER

Claim Billed in Error per Provider

4

6.82%

NODOC

Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination (as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and This Service Has Been Denied)

3

4.55%

NOSIG

Documentation Lacks the Necessary Provider’s Signature

2

Denial Reasons and Prevention Recommendations

NOTML — Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

  • Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological, or laboratory results.
  • Verify that documentation to support the level of service billed is included. Please refer to our website for documentation requirements.
     

NOSIG — Documentation Lacks the Necessary Provider’s Signature

BILER — Claim Billed in Error per Provider

  • Prior to billing claims, review the information to determine that the correct information is listed in the appropriate fields
  • For all claims previously billed and denied by medical review, do not resubmit the claims. If you disagree with the decision from Medical Review, you must submit the appropriate documentation with a completed redetermination request form to the Appeals Department. This information can be sent by fax to JM Part B Appeals (803) 699–2427, JJ Part B Appeals (803) 870–0139, or RRB Appeals (803) 462–2218.
  • If documentation indicates that both an NPP and a physician performed the service, and the claim is billed under the physician’s NPI, the billing physician must sign the record. Additionally, the documentation must include a statement that the billing provider had face-to-face contact with the patient and performed a substantive portion of the E/M visit. (A substantive portion of the E/M visit includes at least one of the three key components: history, exam, or medical decision-making.)
  • If documentation occurs in a teaching environment, review the documentation to ensure that the billing provider has provided a teaching attestation and a signature
     

NODOC — Documentation Requested for this Date of Service Was Not Received or Was Incomplete; Therefore We Are Unable to Make a Reasonable and Necessary Determination (as Defined Under Section 1862(A) (1) (A) of the Act for the Service Billed and This Service Has Been Denied)

  • Submit all documentation related to the services billed within 45 days of the date on the ADR letter
  • Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
  • Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
  • For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
     

The Next Steps
The service-specific postpayment medical review edits for Surgical Services — CPT 66984 — Extracapsular Cataract Removal with Insertion in Alabama, Georgia, and Tennessee have been discontinued based on the resumption of the Targeted Probe and Educate (TPE).

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 JJ Redetermination: 1st Level Appeal form (PDF, 232 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.





Last Updated: 11/08/2021