Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests for April through June 2021

Published 08/13/2021

Postpayment Service-Specific Probe Results for Diagnostic Services: Drugs of Abuse Laboratory Tests: HCPCS Code G0483 — Drug Test Definitive 22 or More Drug Classes (drug test def 22+ classes) 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 G0483 — Drug test def 22+ classes. 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 68 claims were reviewed with 35 of the claims either completely or partially denied, resulting in an overall claim denial rate of 51.47 percent. The total dollars reviewed was $16,790.56, of which $8,642.20 was denied, resulting in a charge denial rate of 51.47 percent. Overall, there were no auto-denied claims in the region. 

North Carolina Results
A total of 40 claims were reviewed, with 18 of the claims either completely or partially denied. This resulted in a claim denial rate of 45.00 percent. The total dollars reviewed was $9,876.80, of which $4,444.56 was denied, resulting in a charge denial rate of 45.00 percent. The top denial reason were identified, and the number of occurrences based on dollars denied are:

Percent of Total Denials

Denial Code

Denial Description

Number of Occurrences

100.00%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

18

South Carolina Results
A total of 28 claims were reviewed, with 17 of the claims either completely or partially denied. This resulted in a claim denial rate of 60.71 percent. The total dollars reviewed was $6,913.76 of which $4,197.64 was denied, resulting in a charge denial rate of 60.71 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

100.00%

NOTML

Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

17

Virginia Results
No results have been processed for the April through June 2021 period for Virginia. 

West Virginia Results
No results have been processed for the April through June 2021 quarter for West Virginia.

Denial Reasons and Prevention Recommendations

NOTML — Per Applicable LCD, 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 the website at www.PalmettoGBA.com/medicare for documentation requirements.
     

296 — 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 Additional Development Request to request reopening. Do not resubmit the claim.

How to Avoid This Denial

  • Be aware of the Additional Development Request date and the need to submit medical records within 45 days of the ADR date
  • Submit the medical records as soon as the Additional Development Request 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 Additional Development Request. 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 Additional Development Request.
  • Gather all of the information needed for the claim and submit it all at one time
  • Attach a copy of the Additional Development Request to each individual claim 
  • If responding to multiple Additional Development Requests, 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

For further information on the above Medicare coverage issue, references include, but are not limited to, these resources:

The Next Steps
The service-specific targeted medical review edits for Diagnostic Services: Drugs of Abuse Laboratory Tests: HCPCS Code G0483 — Drug test def 22+ classes 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 JM Redetermination: 1st Level Appeal form (PDF 223 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.


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