Postpayment Service-Specific Probe Results for Surgical Services: Surgical Debridement for July through September 2021


Postpayment Service-Specific Probe Results for Surgical Services — Surgical Debridement — in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on CPT codes 11042–11047, Surgical Debridement. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review for claims processed July through September, 2021, are presented here.

Cumulative Results
A total of 36 claims were reviewed, with three of the claims either completely or partially denied, resulting in an overall claim denial rate of 8.33 percent. The total dollars reviewed was $3,586.98, of which $232.10 was denied, resulting in a charge denial rate of 6.47 percent. Overall, there were a total of 82 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

66.67%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

2

33.33%

DNSRP

Documentation Not Signed by the Rendering Provider

1

North Carolina Results
A total of 18 claims were reviewed, with two of the claims either completely or partially denied. This resulted in a claim denial rate of 11.11 percent. The total dollars reviewed was $1,529.02, of which $120.47 was denied, resulting in a charge denial rate of 7.88 percent. The top denial reason was identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100.0%

NOTMN

Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

2

South Carolina Results
A total of 18 claims were reviewed, with one of the claims either completely or partially denied. This resulted in a claim denial rate of 5.56 percent. The total dollars reviewed was $2,057.96, of which $111.63 was denied, resulting in a charge denial rate of 5.42 percent. The top denial reason was identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100.0%

DNSRP

Documentation Not Signed by the Rendering Provider

1

Virginia Results
No results were processed for the July through September 2021 processing period in Virginia.

West Virginia Results
No results were processed for the July through September 2021 processing period in West Virginia.

Denial Reasons and Prevention Recommendations

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 applicable LCDs, NCDs, and Coverage Articles for documentation requirements.
     

DNSRP — Documentation Not Signed by the Rendering Provider

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 codes 11042–11047 — Surgical Debridement in North Carolina, South Carolina, Virginia and West Virginia 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 the JM Part B Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.





Last Updated: 11/10/2021