Medicare Prepayment Review Results for CPT Codes 98940 & 98941 for June-Aug'14
Category: Insurance News
Oct
20
Providers in Connecticut (98941), Queens, NY (98940), Downstate NY (98941) and Upstate NY (98941)
National Government Services’ Medical Review Department is currently conducting a prepayment review on JK Part B chiropractic services in the states of CT and NY. This article includes the results of these reviews for June, July and August 2014.Background
During these reviews, documentation is reviewed to adjudicate claims for payment based on the LCD and Medicare coverage guidelines.Findings
The following results are based upon the completion of the reviews for JK Part B chiropractic providers in CT and NY.- Connecticut
- June 2014 - of 23 services billed; 22 (95.7%) were reduced or denied
- July 2014 - of 161 services billed; 133 (82.6%) were reduced or denied
- August 2014 – of 221services billed; 188 (85.1%) were reduced or denied
- Queens, NY
- June 2014 – of 242 services billed; 240 (99.2%) were reduced or denied/li>
- July 2014 – of 1,401 services billed; 1,246 (88.9%) were reduced or denied/li>
- August 2014 – of 2,383 services billed; 2,181 (91.5%) were reduced or denied
- Downstate NY
- June 2014 – of 74 services billed; 72 (97.3%) were reduced or denied
- July 2014 – of 371 services billed; 339 (91.4%) were reduced or denied
- August 2014 – of 576 services billed; 461 (80%) were reduced or denied
- Upstate NY
- June 2014 – of 136 services billed; 124 (91.2%) were reduced or denied
- July 2014 – of 357 services billed; 313 (87.7%) were reduced or denied
- August 2014 – of 641 services billed; 588 (91.7%) were reduced or denied
Claims were reduced and/or denied for the following reasons:
- Lack of patient’s specific subjective complaint – A relevant medical history in a patient’s record must indicate a beneficiary subjective complaint(s) and the area(s) of complaint(s) should correlate to the area(s) of subluxation(s) cited and/or treated.
- Lack of functional status – Documentation does not describe a patient’s current level of functioning and activities of daily living, nor treatment goals related to functional levels.
- Lack of objective documentation of specific level(s) of subluxation in the exam – The precise level(s) of subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. The level(s) of spinal subluxation must bear a direct causal relationship to the patient's symptom(s), and the symptom(s) must be directly related to the level(s) of the subluxation that has been diagnosed. Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information. If using P.A.R.T exam, the documentation requirement must be fully met per policy. Policy requires documentation of two of the four criteria, one of which must be asymmetry/misalignment or range of motion abnormality.
- Lack of area(s) of chiropractic manipulative treatment (CMT)that corresponds to subjective complaint(s) – The specific spinal area(s) that was treated on the day of the visit must be clearly documented and the area(s) treated must correspond to patient’s subjective compliant(s). Documentation needs to be clearly legible without the use of abbreviations, checks or circles that provide minimal and unclear information.
- Treatment plan and goals not documented/not addressed – Documentation of a treatment plan must include the recommended level of care (duration and frequency of visits); specific treatment goals and objective measures to evaluate the treatment effectiveness. The patient’s progress or lack thereof related to the established treatment plan and goals should be addressed on subsequent visits. If treatment continues on without evidence of improvement or the clinical status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is a non-covered benefit.
- Documentation supporting maintenance – Maintenance therapy is a noncovered benefit. Examples of maintenance therapy would include long term treatment per history without the documentation supporting exacerbation, subjective complaint of “minimal pain” on multiple visits without showing improvements or no positive response; documentation remains the same or template for multiple visits. Also, documentation of “chronic” condition with no documentation to support an exacerbation and/or improvement.
Other issues that resulted in claim denials include:
- Nonresponse to development letters – When an ADR letter is received, submitting information and appropriate documentation suggested in the ADR letter is required to consider payment of the claim in question. If the requested medical record is not submitted in a timely manner, the services will be systematically denied.
- Illegible Documentation – Medical record must be legible. If the reviewer cannot decipher the documentation, it may result in the denial of a claim.
- Missing or illegible provider signature - Documentation must be legible and include a provider’s signature. The method used can either be electronic or handwritten, stamp signatures are not acceptable. A signature key or signature log can be included with the documentation to identify the author associated to the illegible signature.
- Incorrect rendering physician – The rendering physician on the documentation did not correspond with the rendering physician submitted on the claim form.
- Incomplete or missing beneficiary information – A patient’s medical record must include a legible beneficiary name for identification. Also, the medical record should be clearly dated and correspond to the date of service billed. If this information is missing or incomplete, it may result in denial of a claim.
Recommendations
We recommend that you perform random sample claim audits within your practice to ensure that these errors do not exist. You may also use the errors identified in the prepay audit as a checklist before submitting future claims. Please also take time to review the chiropractic services LCD (L27350) and SIA (A47385) posted on our website under Medical Policy & Review > Medical Policy Center.The National Government Services Provider Outreach and Education Department can assist with Medicare coverage, medical policy, medical necessity, and documentation questions through the JK Provider Contact Center at 866-837-0241.
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