Pre-Payment Review Results for Intensity Modulated Radiotherapy for April Through June 2024

Published 09/24/2024

Pre-Payment Review Results for Intensity Modulated Radiotherapy (IMRT) for Targeted Probe and Educate (TPE) for April Through June 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for Current Procedural Terminology (CPT®) code 77301 for IMRT. The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results

Table 1: Cumulative Results.
Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
8 7 1 0
Table 2: Cumulative Results.
Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate

196

12

6%

$893,231.27

$22,643.17

3%

Probe One Findings

Table 3: Probe One Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
N.C. 1 1 0 0
S.C. 0 0 0 0
Va. 3 2 1 0
W.Va. 0 0 0 0
Table 4: Probe One Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
N.C. 17 0 0% $66,990.03 $0 0%
S.C. 0 0 0% $0 $0 0%
Va. 85 7 8% $257,107.83 $9,975.65 4%
W.Va. 0 0 0% $0 $0 0%

Probe Two Findings

Table 5: Probe Two Findings.
State Number of Providers with Edit Effectiveness Providers Compliant Completed/Removed After Probe Providers Non-Compliant Progressing to Subsequent Probe Providers Non-Compliant/Removed for Other Reason
N.C. 1 1 0 0
S.C. 1 1 0 0
Va. 1 1 0 0
W.Va. 1 1 0 0
Table 6: Probe Two Findings.
State Number of Claims with Edit Effectiveness Number of Claims Denied Overall Claim Denial Rate Total Dollars Reviewed Total Dollars Denied Overall Charge Denial Rate
N.C. 24 0 0% $215,811.29 $0 0%
S.C. 12 1 8% $64,376.21 $7,691.84 12%
Va. 40 4 10% $196,132.57 $4,975.68 3%
W.Va. 18 0 0% $92,813.34 $0 0%

Risk Category
The categories for CPT® code 77301 for IMRT are defined as:

Table 7: Risk Category.
Risk Category Error Rate
Minor 0–20%
Major 21–100%

Fig. 1. Risk Cagegory IMRT.

The categories for CPT code 77301 for Intensity Modulated Radiotherapy (IMRT) are defined as: major 13 percent and minor 88 percent.
 
Top Denial Reasons

Table 8: Top Denial Reasons.

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences
38% 5D164, 5H164 No Documentation of Medical Necessity 3
25% 56900 Requested Records Not Submitted Timely 2
25% 5D920, 5H920 The Recommended Protocol Was Not Ordered and/or Followed 2
13% 5D169, 5H169 Insufficient Documentation 1

Denial Reasons and 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

References

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the ADR is received 
  • Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
  • Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the Medical Review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the ADR request to each individual claim
  • If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
  • Do not mail packages C.O.D.; we cannot accept them

References

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:

For Drugs and Biologicals

  • Clear physician’s order with indication of need, dose, frequency, administration time 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, but not limited to:
    • Clear indication of the diagnosis and need for the related service(s)
    • Clinical signs and symptoms
    • Prior treatment and response as applicable
    • Stage of treatment as applicable
    • Documentation of administration and signed by the person providing the service
  • Ensure the service was provided per the coverage guidelines for the service

 For Outpatient Therapy

  • Clear physician’s order with indication of specific skilled service, frequency and duration
  • Relevant medical history documented prior to the DOS and signed by the physician or appropriate nonphysician provider to include, but not limited to:
    • Clear indication of the diagnosis and need for the related therapy services
    • Documentation related to the therapy services to include beneficiary's functional level, treatment plan, short- and long-term goals, beneficiary's response to therapy services, treatment and progress notes
    • Prior treatment and response as applicable
  • Ensure the service was provided per the coverage guidelines for the service

For IMRT

  • Clear physician/radiation oncologist orders for radiation treatment course, including specific anatomical target volumes, treatment technique, current dosage, type of radiation measuring and monitoring devices to be used and treatment fields
  • Relevant medical history documented prior to the DOS and signed by the physician/radiation oncologist or appropriate nonphysician provider to include:
    • Clear indication of the diagnosis being treated and medical necessity of the services
    • Supporting reports such as dosimetry, physicist, simulation, oncology and radiology 
    • Documentation of design and construction of Multi-Leaf Collimator
    • Detailed itemized bill and supporting documentation of all billed services
    • Documentation of treatment plan, including goals, treatment notes, specific dose constraints for the target and administration
  • Ensure the service was provided per the coverage guidelines for the service

References

5D169/5H169 — Insufficient Documentation

Reason for Denial
This claim was partially or fully denied because the documentation submitted is insufficient for the services billed. 

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

For more information, refer to:

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations, or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form (PDF).

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date. 


Was this article helpful?