Postpayment Service-Specific Probe Results for Ambulance Service, Advanced Life Support, Emergency Transport for July through September 2021

Postpayment Service-Specific Probe Results for Ambulance Service, Advanced Life Support, Emergency Transport in Alabama, Georgia and Tennessee for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code A0427 — Ambulance Services, Advanced Life Support, Emergency Transport. This edit was set in Alabama, Georgia and Tennessee. The results for the postpay review for claims processed July through September, 2021, are presented here. 

Cumulative Results 
A total of 337 claims were reviewed in Alabama, Georgia, and Tennessee combined. Of the claims reviewed, 87 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 25.82 percent. The total dollars reviewed was $145,812.36, of which $31,228.90 was denied, resulting in a charge denial rate of 21.42 percent. Overall, there were three auto-denied claims in the region. The top five denial reasons were identified, and the number of occurrences based on dollars denied are:

Alabama Results
A total of 54 claims were reviewed in Alabama, with 13 claims either completely or partially denied, resulting in a claim denial rate of 24.07 percent. The total dollars reviewed was $24,053.46, of which $4,454.57 was denied, resulting in a charge denial rate of 18.52 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Georgia Results
A total of 260 claims were reviewed in Georgia, with 65 of the claims either completely or partially denied. This resulted in a claim denial rate of 25.0 percent. The total dollars reviewed was $112,129.21, of which $23,005.58 was denied, resulting in a charge denial rate of 20.52 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Tennessee Results
A total of 23 claims were reviewed in Tennessee, with nine of the claims either completely or partially denied. This resulted in a claim denial rate of 39.13 percent. The total dollars reviewed was $9,629.69, of which $3,768.75 was denied, resulting in a charge denial rate of 39.14 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Denial Reasons and Prevention Recommendations

BNSIG — Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature

• Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
• For illegible signatures, clearly print or type the full name of the owner of the signature
   

NOTMN — 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 links to applicable LCDs and NCDs for documentation requirements.
   

NOCRD — Provider Signature Does Not Include the Necessary Provider Credentials

• Verify that electronic signature meets the CMS signature requirements as listed in the article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
• Print or type the rendering provider’s full name below or near the provider’s signature
• For documentation that contains letterhead including the rendering provider’s full name, ensure that the name is clearly marked or circled to indicate the owner of the signature
• Submit a valid Signature Attestation with any documentation that contains an invalid or illegible rendering provider signature. Do not resubmit altered documentation with late corrected provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices.
   

NORUN — Documentation Received Lacks the Necessary Run Report

• Review documentation prior to submission to ensure that a complete legible run report is included
   

ASAVA — Alternative Services Were Available and Should Have Been Utilized

• Prior to billing, ensure that the appropriate HCPCS code is used
• Ensure that the appropriate modifier (GZ or GA) is used for billing claims for non-emergent or non-medically necessary runs when the patient has been informed in advance that the service is expected to be denied by Medicare as not reasonable and necessary
• Include all necessary supporting medical documentation if required for submissions
   

NOSIG — Documentation Lacks the Necessary Provider's Signature

• Verify that all documentation is legibly signed by the rendering physician or nonphysician practitioner
• Verify that electronic signature meets the CMS signature requirements as listed in the article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices
• Submit a valid Signature Attestation with any documentation that lacks the rendering provider's signature. Do not resubmit altered documentation with late added provider signature. This will not be accepted by medical review. For an example of a signature attestation, refer to the article Medicare Medical Records: Signature Requirements Acceptable and Unacceptable Practices.
   

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 Step
The service-specific postpayment medical review edits for HCPCS Code A0427 — Ambulance Services, Advanced Life Support, Emergency Transport in Alabama, Georgia, and Tennessee has 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 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.