Widespread Probe Review Results - AL – FI – Review of CPT 90806

Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45-50 minutes face -to-face with the patient, bill type 13X

Alabama Medical Review Part A has recently completed the prepay probe review of outpatient hospital billing of Healthcare Common Procedure Coding System (HCPCS) 90806, Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 45-50 minutes face-to-face with the patient. 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:                         7
Claims Reviewed:                           96
Claims Approved:                             3
Claims Denied:                               93
Charges Reviewed:          $16,810.25
Charges Approved:                $319.65
Charges Denied:               $16,490.60
Error Rate:                                   98%

*Error rate is based on the charges denied divided by the charges reviewed

The medical review decisions were based on the medical necessity for the services provided.

The majority of denials were due to one of the following reasons:

Lack of timely submission of requested documentation (Denial Reason 56900): Claims were denied due to a lack of record submission in a timely manner. According to the Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 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.

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

Beginning January 1, 2007, Cahaba no longer sends letters to inform providers of ADRs. Instead, providers will need to access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR. Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001. Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
Print screen the ADR letter and attach the copy to the front of the requested medical documentation
Send requested information to the address on the ADR letter
Do NOT send certified mail or overnight mail
Include ALL requested documentation outlined in the ADR
Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request

Lack of medical necessity to support providing the service for 90806. Denial Reason 56155 was due to the documentation submitted not supporting medical necessity for the services provided. The documentation lacks a physician order for the initiation of treatment, as well as, an initial evaluation to establish medical necessity for initiation of services. The documentation does not support physician involvement in treatment. The daily notes do not support medical necessity for continued treatment provided. The reviewer was unable to determine length of time in treatment & patient's progress/response to treatment.
Medical record did not validate that the services provided by the billing of a HCPCS code and/or the billing of units for a HCPCS code was provided (Denial Reason 53604). Review of the documentation did not support that the treatment was provided as submitted on the claim for the dates of service in review.

As a result of this prepay probe review, Alabama Part A Medical Review will continue a targeted pre-pay review of all outpatient hospitals (Bill Type 13X) billing 90806, identified by edit reason code 5154K. Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.

Page last updated: March 31, 2008