- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
Edit Reason Code: 5AAGP
Bill Type: 32x or 33x
Dates of Service: 1/1/2020 thru 2/29/2020
Overview
The Medical Review Department of National Government Services will be performing service specific post-payment reviews for claims submitted to Medicare Part A. The focus of these audits is to determine whether providers have the correct understanding of both CMS billing and coverage requirements.When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.
Documentation Requirements
- Actual clinical note (discharge summary, progress note, plan of care, etc.) for the face-to-face encounter.
- Initial (start of care) certification by one certifying physician and the initial plan of care regardless of dates of service billed.
- Recertification, also by one physician and plan of care to cover this period billed if subsequent date of service.
- Home health agency generated documentation, including, but not limited to the initial nursing, therapy and OASIS assessments.
- If a patient’s sole skilled service need is for skilled oversight of unskilled services, submit the physician’s brief narrative documentation describing the clinical justification of the need for service. This statement can be part of the certification or recertification or as a signed addendum.
- All signed physician’s orders
- Home health discipline notes for all services billed and flowsheets supporting coverage of visits
- Initial therapy (PT/OT, SLP) evaluation regardless of dates of service billed
- Therapy documentation, including assessment/re-assessments; and/or re-evaluations
- If there is an ABN on file, please include a copy of the signed and dated ABN of noncoverage to the beneficiary.
Related Content
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Home Health Services
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10, Home Health Agency Billing
Revised 9/3/2020
Posted 8/31/2020
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex
Visit our Contact Us page for other methods of submission
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.