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

• • CPT code 74177 (Computed Tomography, Abdomen and Pelvis; with Contrast Materials).

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 J6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

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 the signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review.

Documentation Requirements

•  
• Physician/non-physician practitioner’s office and progress notes
• History and physical examination notes
• Physician's orders
• Computed Tomography Report with results and interpretations
• Medication Administration Record
• Any additional documentation verifying medical necessity
• ALL other pertinent documents
• A copy of any mandatory ABN of noncoverage to the beneficiary
• Legible signature/sample signature log/signature key/signature page, etc. to affirm the provider signature

Related Content

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• SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer Social Security Act Section 1862
• SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits Social Security Act Section 1833
• 42 CFR Section 410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. Tests not ordered by the physician (or other qualified non-physician provider) who is treating the beneficiary are not reasonable and necessary (see Sec. 411.15(k)(1) of this chapter). Electronic Code of Federal Regulations (eCFR)
• National Correct Coding Initiative Chapter IX – Radiology Services
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 4, Section 20.6.13 through 20.6.15
• CMS IOM Publication 100-03, National Coverage Determinations (NCD) Manual, Computed Tomography Chapter 1, Part 4 Section 220 through 310.1

Posted 3/26/2021