Medical Review

National Government Services Part A MR Department analyzes national and local data to identify possible improper payment for Medicare services. In an effort to reduce the Part A CERT error rate, the MR Department will be conducting a service specific post payment review of:

  • ?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FCompliance%2Band%2BAudits%2FMedical%2BReview%2FMedical%2BReview%2BFocus%2BAreas%2BSupporting%2FA-JK_Prothrombin%2BTime-Partial%2BThromboplastin%2BTime%2B%2528Edit%2BReason%2BCode%2B5B554%2529
  • SkinTOEdit Reason Code: 5AAHP
  • Bill Type: 32X, 33X
  • Service Description: Home Health Services

The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for the services mentioned in JK for HHH providers in the states of New York, Connecticut, Massachusetts, Maine, New Hampshire, Vermont and Rhode Island.

If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

It is important to submit all documentation which supports the medical necessity of the mentioned services. The medical record must be legible and the name of the beneficiary, the date of service and authenticated by an acceptable handwritten or electronic signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review. 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, etc.) for the face-to-face encounter.
  • Initial SOC certification by one certifying physician and the initial POC regardless of dates of service billed.
  • Signed physician's orders for all services billed.                          
  • Physician's progress notes, including medical necessity/justification for all services billed and treatment plan/POC for DOS billed.                        
  • Diagnosis to justify service.    
  • HHA generated documentation, including, but not limited to the initial nursing, therapy and OASIS assessments.
  • HH discipline notes for all services billed and flowsheets supporting coverage of visits.
  • Initial therapy (PT/OT/SLP) evaluation(s) regardless of dates of services billed, when applicable; and any therapy assessments/re-assessments/re-evaluations.
  • If a beneficiary’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 a signed addendum. 
  • Documentation to support homebound criteria and all related services.                                                             
  • If an ABN was issued, please include a copy of the signed and dated ABN of noncoverage to the beneficiary.

Related Content

Posted 2/17/2021

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex

Visit our Contact Us page for other methods of submission

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.

Helpful Resources

Targeted Probe and Educate Manual

The preferred method to submit Medical Records is NGSConnex:

Visit our Contact Us page for other methods of submission.