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CLARIFICATION - Widespread Probe Review Results Notification Article - J10 MAC A - Notice to providers of review results from Widespread Probe Review of CPT 85025 for Bill Type 13X
Please note clarification to the previous review results article and further explanation of denials. The previous article stated that review of the documentation submitted indicated that a majority of the denials were due to Complete Blood Counts (CBC) ordered by the physician and CBC with differential performed. There was no protocol submitted to support the provision of the CBC with differential.
The primary issue with this review is that CPT 85025 (CBC with Differential) is provided and billed and the physician order indicates CPT 85027 (CBC) was requested. The reviewer would expect to see that the provider is performing and billing what the physician has ordered.
Other issues related to this review indicate that there was not a signed order by the physician for the lab requested, the documentation submitted did not support that the service was provided or there was no documentation submitted for the review.
When there is no physician's order, documentation contained in the medical record must support the intent or the presence of the specific indication for provision of CBC with differential.
The following resources may be used to ensure complete and accurate knowledge of the various Medicare benefits and billing requirements associated with this review:
- www.cms.hhs.gov - CMS web site
- www.cms.hhs.gov/MLNMattersArticles - the Medicare Learning Network web site
- www.cahabagba.com - Cahaba GBA web site
Medicare National Coverage Determination (Publication 100-3 Chapter 1, Section 190.15
Please note clarification to the previous review results article and further explanation of denials. The previous article stated that review of the documentation submitted indicated that a majority of the denials were due to Complete Blood Counts (CBC) ordered by the physician and CBC with differential performed. There was no protocol submitted to support the provision of the CBC with differential.
The primary issue with this review is that CPT 85025 (CBC with Differential) is provided and billed and the physician order indicates CPT 85027 (CBC) was requested. The reviewer would expect to see that the provider is performing and billing what the physician has ordered.
Other issues related to this review indicate that there was not a signed order by the physician for the lab requested, the documentation submitted did not support that the service was provided or there was no documentation submitted for the review.
When there is no physician's order, documentation contained in the medical record must support the intent or the presence of the specific indication for provision of CBC with differential.
The following resources may be used to ensure complete and accurate knowledge of the various Medicare benefits and billing requirements associated with this review:
- www.cms.hhs.gov - CMS web site
- www.cms.hhs.gov/MLNMattersArticles - the Medicare Learning Network web site
- www.cahabagba.com - Cahaba GBA web site
- Medicare National Coverage Determination (Publication 100-3 Chapter 1, Section 190.15
Page last updated: January 20, 2010
