Jurisdiction K Part B Targeted Probe and Educate: Medical Review Topics
Topic | CPT Code(s) | Common Denials | Resources |
---|---|---|---|
Paring or Cutting of Benign Hyperkeratotic Lesion | 11055, 11056, 11057 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD): L33636- Routine Foot Care and Debridement of Nails CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290 Title XVIII of the Social Security Act (SSA), Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Trimming of Nondystrophic Nails and/or Nail Debridement with or without an E/M code | 11719, 11720, 11721, 99211-99215 | B65 – Services not furnished directly to the patient and/or not documented.
|
Local Coverage Determination (LCD): L33636- Routine Foot Care and Debridement of Nails CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6B |
Destruction of Benign Lesions; up to 14 Lesions | 17110 | TBD | Billing and Coding Article: Removal of Benign Skin Lesions (A54602) |
Total Knee Arthroplasty | 27447 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD) L36039-Total Joint Arthroplasty CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(A) and (B) Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Extracapsular Cataract Removal | 66984 | A07 – The documentation does not support the medical necessity per policy guidelines. The documentation lacks one or more of the following requirements:
|
Local Coverage Determination (LCD) L33558-Cataract Extraction CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 260.2 CMS IOM Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Sections 10.1 and 80 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(A) and (B) Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Removal of Impacted Cerumen | 69210 | A98 – The documentation does not support the medical necessity of the service billed.
|
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.6B Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Diagnostic Chest X-Ray | 71046 | A98 – The documentation does not support the medical necessity of the service billed.
|
CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.1.F Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) and (a)(7) |
Breast Ultrasound | 76641 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD) L33585-Breast Imaging: Breast Echography (Sonography)/Breast MRI/Ductography Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Vitamin D Assay | 82306 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD) L37535-Vitamin D Assay Testing CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 Title XVIII of the SSA, Section 1833(e) |
Natriuretic Peptide | 83880 | A07 – The documentation does not support the medical necessity per policy guidelines.
B65 – Services not furnished directly to the patient and/or not documented.
|
Local Coverage Determination (LCD): L33573 - B-type Natriuretic Peptide (BNP) Testing CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Psychiatric Diagnostic Evaluation | 90791 | A07 - The documentation does not support the medical necessity per policy guidelines. The documentation lacks one or more of the following requirements:
|
Local Coverage Determination (LCD) L33632-Psychiatry and Psychology Services Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) |
Psychotherapy | 90834, 90837 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD) L33632-Psychiatry and Psychology Services CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1 CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 30 and 60.1-60.2 Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) MLN® Fact Sheet: Complying with Medicare Signature Requirements Billing for telehealth: Billing and coding Medicare Fee-for-Service telehealth claims |
Acupuncture | 97810-97814 | B53 – Medically unnecessary item(s) or service(s); billed with the GA modifier. There was no ABN submitted with the documentation. The documentation lacks the required information that the pain is not related to a systemic cause or surgery in order to support the medical necessity of the service. B65 – Services not furnished directly to the patient and/or not documented.
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National Coverage Determination (NCD): Acupuncture for Chronic Lower Back Pain (cLBP) (30.3.3) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.1.1.F-Advanced Beneficiary Notice (ABN) Title XVIII of the SSA, Section 1833(e) |
Annual Wellness Visit when billed with an E/M Code | G0438, G0439 99211-99215 |
TBD
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CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 280.5 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1 and Section 30.6.6B CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 30.6.1.1 and Section 140 42 Code of Federal Regulations (CFR) Section 410.15 Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) and 1862 (a)(7) |
Hyaluronan or Derivative, for Intra-Articular Injection | J7318-J7332, 20610, 20611 | A07 – The documentation does not support the medical necessity per policy guidelines.
|
Local Coverage Determination (LCD) L33394: Drugs and Biologicals, Coverage of, for Label and Off-Label Uses CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 17, Sections 10 and 40 Title XVIII of the SSA, Section 1833(e) |
Outpatient Physical Therapy, Occupational Therapy, and/or Speech Language Pathology | All therapy codes when billed with KX modifier | A07 – The documentation does not support the medical necessity per policy guidelines.
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Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L33631) CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 30, 220 CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.3.2-10.3.3 CMS IOM Publication 100- 08, Medicare Program Integrity Manual, Chapter 3, Sections 3.4.1.3, 3.6.2.1, 3.6.2.2 Title XVIII of the SSA, Section 1833(e) Title XVIII of the SSA, Section 1862(a)(1)(A) 42 Code of Federal Regulations (CFR) Sections 409.17, 409.44, 410.60, 410.61(a) and (c) |
*Not an all-inclusive list of resources
If a non-response to an ADR occurs, the claim may deny with denial code 692. A 692 denial will negatively impact a provider's error rate and may result in additional rounds of TPE review. By implementing TPE best practices and responding to ADRs, this is an easily preventable denial.
Additional References
- NGSConnex User Guide - Respond to ADR
- Best Practices for a Successful Targeted Probe and Educate Review
- TPE Manual
Revised 2/14/2024