Review of Critical Access Hospital Claims With CPT 82962
This information applies to providers who submit claims to the Cahaba office in Des Moines, Iowa.
Medical Review has recently completed the third quarter widespread targeted prepay review of Critical Access Hospitals (CAH) claims with Current Procedural Terminology (CPT) 82962 (Glucose, blood by glucose monitoring device(s), cleared by the FDA specifically for home use) processed between April 1, 2007, and June 30, 2007.
The results of the current review are as follows:
| Providers included in review | 21 |
| Claims Reviewed | 51 |
| Claims Denied | 37 (partial or full denial) |
| Charges Reviewed | $ 24,574.81 |
| Charges Denied | $ 19,800.52 |
| Error Rate*: | 80.57% |
*Error rate is based on the charges denied divided by the charges reviewed.
The review decisions were based on the Centers for Medicare & Medicaid Services (CMS) criteria for laboratory services set forth in part in Section 1862(a)(1)(A) of the Social Security Act which requires services to be reasonable and necessary for diagnosis and treatment in order to be covered by Medicare. The 42 CFR sect;410.32 further specifies that for a laboratory service to be reasonable and necessary, it must not only be ordered by the physician but the ordering physician must also use the result in the management of the beneficiary's specific medical problem. Implicitly, the laboratory result must be reported to the physician promptly in order for the physician to use the result and instruct continuation or modification of patient care; this includes the physician's order for another laboratory test.
Lack of documentation to support the medical justification for the services rendered (Denial Reason 5NM03): The majority of denials occurred as a result of the medical record documentation lacked the medical justification for the laboratory services as outlined in the above-cited CMS regulations. A standing order for intermittent blood glucose testing, (e.g. before meals and at bedtime) and/or sliding scale insulin injections are examples of non-covered laboratory services when they do not meet the ordering physician's utilization requirements described above. Both instances lack support of a clear use of a laboratory result prior to a similar subsequent laboratory order or use as a result's driven intervention by the ordering physician and therefore do not qualify for separate payment under the Medicare laboratory benefit.
Lack of timely submission of requested documentation (Denial Reason 56900): Additionally, claims were denied due to a lack of record submission in a timely manner. According to The Medicare Program Integrity Manual, Pub. 100-8, Ch. 3, sect; 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the fiscal intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond. If the ADR requested information is not received within 45 days after the date of the request, the claim must be denied.
Five claims were denied because the ADR information was not received. An ADR is a request for additional information for a claim(s) that has been selected for prepayment review. You are notified of ADRs through the Fiscal Intermediary Standard System (FISS) if you bill electronically. When a claim is selected for medical review, it moves to status/location SB6001. It is very important that you establish a procedure in your office to monitor the ADR status/location on a regular basis. As a result of this probe review, Medical Review will continue the 100 percent targeted pre-pay review of CAHs (type of bill 85X) billing CPT 82962, identified by edit reason code 5121K. Also, providers identified through data analysis as driving this aberrancy may warrant provider specific medical review.
It is your responsibility to check for ADRs. If we do not receive the requested information by the timeline noted on the ADR, the entire claim will be denied with reason code 56900.
In addition to the aforementioned references, CAH providers billing for laboratory services should review 42 CFR sect;411.15, Medicare Benefit Policy Manual Pub. 100-2, Ch. 15, sect; 80.1, to ensure adherence to all coverage criteria.
Page last updated: Aug. 6, 2007
