Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: Column Chromatography and Mass Spectrometry for July through September 2021
Postpayment Service-Specific Probe Results for Diagnostic Services — Drugs of Abuse Laboratory Tests: Column Chromatography/Mass Spectrometry — in North Carolina, South Carolina, Virginia and West Virginia for July through September 2021
Palmetto GBA performed service-specific postpayment probe review on Diagnostic Services: Drugs of Abuse Laboratory Tests: CPT Code 82542 — Column Chromatography/Mass Spectrometry. 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 eight claims were reviewed with two of the claims either completely or partially denied, resulting in an overall claim denial rate of 25.0 percent. The total dollars reviewed was $192.72, of which $48.18 was denied, resulting in a charge denial rate of 25.0 percent. Overall, there were a total of 22 auto-denied claims in the region.
North Carolina Results
A total of eight claims were reviewed, with two of the claims either completely or partially denied. This resulted in a claim denial rate of 25.0 percent. The total dollars reviewed was $192.72, of which $48.18 was denied, resulting in a charge denial rate of 25.0 percent. The top denial reason was identified, based on dollars denied:
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
No results were processed for the July through September 2021 period for South Carolina.
Virginia Results
No results were processed for the July through September 2021 period for Virginia.
West Virginia Results
No results were processed for the July through September 2021 period for 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.
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
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.
The Next Steps
The service-specific postpayment medical review edits for Diagnostic Services: Drugs of Abuse Laboratory Tests: CPT Code 82542 — Column Chromatography/Mass Spectrometry 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 Appeals web page. Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.