Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code 74177; Computed tomography, abdomen and pelvis; with contrast material(s). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services randomly selected 600 claims billed for CPT 74177 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

74177 – Computed tomography, abdomen and pelvis; with contrast material(s)

Results

Decision	Number of Claims
Allow	342
Deny	23
Recode	1
Non-Response Denial	233
Rescinded	1

324 claims from Illinois with 132 allowed and 192 denied for a claims error rate of 59.26%
129 claim from Minnesota with 109 allowed and 20 denied for a claims error rate of 15.50%
147 claims from Wisconsin with 101 allowed and 46 denied for a claims error rate of 31.29%

Key Reasons Services Were Denied

Documentation did not support medically necessity due to one or more of the following: the use of the scan was not found to be medically appropriate considering the patient’s symptoms and preliminary diagnosis; documentation did not support test was ordered by the beneficiary’s treating physician; documentation of the plan or intent to order computed tomography (CT scan) was insufficient to support medical necessity
Documentation was insufficient or incomplete
Failure to respond to the request for documentation

Recommendations

Send the requested records within the requested time frame to avoid a denial for no documentation
Familiarize yourself with available Computed tomography, abdomen and pelvis; with
contrast material(s) guidelines and other CMS publications listed below
Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
If you feel your application of this code is correct, ensure your documentation supports your usage.