Widespread Probe Review Results – IA – FI – Review for HCPCS 29580 Strapping: Unna Boot All Bill Types

Alabama Medical Review Part A has recently completed the prepay probe review HCPC 29580 Strapping:  Unna Boot for all bill types.  The topic for this review was 5142W.  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:     17
Claims Reviewed:     90
Claims Approved:      0
Claims Fully or Partially Denied:     25
Charges Reviewed:   $19,178.24
Charges Approved:      $4,139.54
Charges Denied:        $15,038.70
Error Rate:     78%

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

The medical review decisions were based on the Local Coverage Determination (LCD) for Debridement Services:  L1505.

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

  1. 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 information is not is 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:

  • As of 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.
  1. Per the CPT Manual this code is used for services related to fractures or dislocations.  When an Unna boot is applied for wound care, this CPT code should not be utilized.

As a result of this prepay probe review a recommendation for targeted review will be given to Wisconsin Physicians Service (WPS) Medicare.  WPS will begin administering Iowa claims effective May 1, 2008.  Additional information regarding the May 1, 2008 implementation can be found on the WPS web site Globe to indicate www link. by accessing the Part A/Part B MAC link, accepting the license agreement, and clicking on the “Select This” link for J5 Implementation Information from the Part A/Part B MAC Home Page.   

Page last updated: April 24, 2008

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