Postpayment Service-Specific Probe Results for HBO Therapy for April through June 2021

Postpayment Service-Specific Probe Results for HCPCS Code G0277 — Hyperbaric Oxygen Therapy — in North Carolina, South Carolina, Virginia and West Virginia for April through June 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code G0277— Hyperbaric Oxygen (HBO) Therapy. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed April through June, 2021, are presented here.

Cumulative Results
A total of 458 claims were reviewed in North Carolina, South Carolina, Virginia and West Virginia combined, with 137 of the claims either completely or partially denied. This resulted in an overall claim denial rate of 29.91 percent. The total dollars reviewed was $1,160,113.75, of which $314,850.93 was denied, resulting in a charge denial rate of 27.14 percent. Overall, there were a total of 104 auto-denied claims in the region. 

North Carolina Results
A total of 215 claims were reviewed, with 27 of the claims either completely or partially denied. This resulted in a claim denial rate of 12.56 percent. The total dollars reviewed was $572,364.12, of which $81,818.16 was denied, resulting in a charge denial rate of 14.29 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

South Carolina Results
A total of 71 claims were reviewed, with 44 of the claims either completely or partially denied. This resulted in a claim denial rate of 61.97 percent. The total dollars reviewed was $208,429.65, of which $92,985.20 was denied, resulting in a charge denial rate of 44.61 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Virginia Results
A total of 140 claims were reviewed, with 65 of the claims either completely or partially denied. This resulted in a claim denial rate of 46.43 percent. The total dollars reviewed was $326,702.35, of which $136,406.53 was denied, resulting in a charge denial rate of 41.75 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

West Virginia Results
A total of 32 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 3.13 percent. The total dollars reviewed was $52,617.63, of which $3,641.04 was denied, resulting in a charge denial rate of 6.92 percent. The top denial reason was identified:

Denial Reasons and Prevention Recommendations

5D164/5H164 — No Documentation of Medical Necessity

Reason for Denial
This claim was fully or partially denied because the documentation submitted for review does not support the medical necessity of some of the services billed.

How to Avoid This Denial

• Submit all documentation related to the services billed which support the medical necessity of the services
• A legible signature is required on all documentation necessary to support orders and 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)
• CMS Medicare Learning Network (MLN) Matters article MM6698: Signature Guidelines for Medical Review Purposes
• 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 surgery has been denied. For example, the surgical procedure was denied as documentation did not support medical necessity, therefore all other charges cannot be allowed and will be denied as dependent to the medical denial of the qualifying service.

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 documentation of medical necessity for the 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)
   

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)
   

5D151/5H151 — Units Billed More Than Ordered

Reason for Denial 
The physician’s orders submitted did not cover all the units billed.

How to Avoid This Denial
To avoid unnecessary denials for this reason, the provider should ensure that the physician’s orders cover all the services to be billed prior to billing Medicare. When responding to an Additional Documentation Request (ADR), ensure that all orders for services billed are included with the medical records.

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 17, Section 90.2 (PDF, 493.16 KB)
   

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

More Information

• Code of Federal Regulations, 42 CFR – Sections 410.32 and 424.5
• Articles on responding to an outpatient therapy Additional Documentation Request (ADR) on the Palmetto GBA website
   

5D199/5H199 – Billing Error

Reason for Denial
The services billed were not covered. According to documentation in the medical record, the hospital has billed items and/or services in error. The hospital may not charge the beneficiary for items and/or services that were billed in error.

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/diagnostic test was rendered, and the dates of service billed
   

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code G0277 — HBO Therapy — in North Carolina, South Carolina, Virginia and West Virginia 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 the Redetermination: 1st Level Appeal form (PDF, 237 KB) Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.