Widespread Probe Review Results for Alabama Providers for CPT Code 96152
Part A Medical Review has recently completed the prepayment probe review of CPT code 96152, Health and Behavioral Intervention, each 15 minutes, face to face: individual, 13X bill type. The claims were randomly selected across the provider community billing this service that met the parameters of the edit. The review results are as follows:
Providers Reviewed: 2
Claims Reviewed: 49
Claims Approved: 0
Claims Denied: 49
Charges Reviewed: $44,644.00
Charges Approved: $0
Charges Denied: $44,644.00
Error Rate: 100%
* Error rate is based on the charges denied divided by the charges reviewed
The medical review decisions were based on Title XVIII of the Social Security Act Section 1862(a)(1)(a), 42 USC 1395y. This section allows coverage and payment for only those services that are considered to be reasonable and necessary.
The majority of denials were due to one of the following reasons:
- Inadequate medical justification submitted (Denial Reason 56155): This denial reason was the result of the documentation submitted did not support medical necessity for the services provided as submitted on the claim. The documentation lacked a physician’s order, evaluation and plan of care to support medical necessity for the services provided. Unable to determine length of time in treatment and progress with the services provided.
- The medical record did not validate that the services provided by the billing of a HCPCS code and/or the billing of units for the HCPCS code was provided (Denial Reason 53604). Review of the documentation did not support that the services were provided as per the CPT manual. The services provided did not appear reasonable and necessary. Services provided were neurofeedback/EEG. These services appear to be experimental and therefore are not reasonable and necessary.
As a result of this prepay probe review, Part A Medical Review will continue with a prepay targeted review of CPT 96152. The edit for this review will be 5150K. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.
Page last updated: Feb. 27, 2008
