Jurisdiction 6 Part B Targeted Probe and Educate: Medical Review Topics

• The documentation does not include some or all of the required medical necessity and/or documentation requirements such as (but not limited to):
  • An operative note or procedure note for the debridement service. This note should describe the anatomical location treated, the instruments used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post procedure care and follow-up instructions.
  • Identification of the wound location, size, depth and stage either by description and/or a drawing or photograph.

• Information received was for the incorrect beneficiary, date of service, or did not include the procedure report.

• The documentation does not include some or all the required elements including the necessary class findings, the presence of a qualifying systemic illness causing a peripheral neuropathy, and/or does not include precise and specific findings including specific location of lesion(s).
• The documentation does not support the class findings modifier billed.

• The documentation does not include a description of the lesion(s) indicating signs/symptoms which would support medical intervention.
• The documentation does not support clinical uncertainty as to the likely diagnosis (skin tag), particularly where malignancy is a realistic consideration based on lesion appearance.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• Review completed according to NGS Medical Directors
• CPT 15734 should be included/bundled with another CPT, which was billed on the claim, and not separately billed.
• The documentation does not support a flap was present and/or that a true flap was created.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• The documentation does not include precise and specific findings including specific nails that were debrided
• The documentation does not specify which nails were debrided.
• The documentation does not support a systemic disease, such as metabolic, neurologic, or peripheral vascular disease, of sufficient severity that performance of such services by a nonprofessional person would put the patient at risk.
• The documentation does not support the class findings that were billed.

• The documentation does not support that there were signs or symptoms present indicating the removal of the benign skin lesion(s).
• The documentation submitted did not support that there were signs or symptoms present indicating the noncosmetic removal of the benign skin lesion(s). The submitted documentation supports that the removal of warts was cosmetic.

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20 and Section 180

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

• The documentation does not support if the joint disease is evidenced by conventional radiography, or MRI.
• The documentation does not support unsuccessful nonsurgical medical management, when appropriate, and attempted for a minimum of 3 months. (When nonsurgical medical management is not appropriate, the medical record must clearly document the basis for that conclusion).

• Information received was for the incorrect beneficiary, date of service, or did not include the procedure report.

• The documentation does not include test results to confirm the presence and location of incompetent perforating veins; the level of incompetence of the vein(s) involved and/or documentation to support absence of thrombosis or vein tortuosity.

• Cataract causing symptomatic impairment of visual function.
• Impaired of visual function is not correctable with a tolerable change in glass or contact lenses.
• Visual impairment resulting in specific activity limitation and/or participation restrictions.
• Other eye disease(s) including, but not limited to, macular degeneration or diabetic retinopathy have been ruled out as the primary cause of decreased visual function.

• Information received was for the incorrect beneficiary, date of service, or did not include the procedure report.

• The documentation does not include an indication.
• The breast ultrasound is being completed as supplemental screening with mammography for patients with dense breasts or a personal/family history of breast cancer.
• The breast ultrasound must be diagnostic. Medicare does not pay for screening breast ultrasounds.

• The treatment plan must state the type, amount, frequency, and duration of the duration of the services to be furnished and indicate the diagnoses and anticipated goals.
• The psychiatric diagnostic procedure requires the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient's ability and capacity to respond to treatment, and an initial plan of treatment.
• Family history was not documented.
• Information may be obtained from not only the patient, but also other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history. If unable to obtain the history, attempts at obtaining must be documented.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• The treatment plan must state the type, amount, frequency, and duration of the duration of the services to be furnished and indicate the diagnoses and anticipated goals.
• The psychiatric diagnostic procedure requires the elicitation of a complete medical (including past, family, social) and psychiatric history, a mental status examination, establishment of an initial diagnosis, an evaluation of the patient's ability and capacity to respond to treatment, and an initial plan of treatment.
• Family history was not documented.
• Information may be obtained from not only the patient, but also other physicians, healthcare providers, and/or family if the patient is unable to provide a complete history. If unable to obtain the history, attempts at obtaining must be documented.

• Information received was for the incorrect beneficiary, date of service, or did not include a visit note and/or treatment plan.

• The documentation does not include an initial and/or updated individualized treatment plan that includes the type, amount, frequency, duration, diagnosis and anticipated goals.
• The documentation does not include an encounter note that includes functional status, focused mental status exam, and progress to date.
• The documentation does not support the correct billing of the telehealth visit.
• The documentation does not include an updated treatment plan to support the continued need for prolonged services.
• The documentation does not include specific time spent in Psychotherapy.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.
• Incident-to requirements were not met when services were provided by a nonphysician practitioner.

• The documentation does not include an initial and/or updated individualized treatment plan that includes the type, amount, frequency, duration, diagnosis and anticipated goals.
• The documentation does not include an encounter note that includes functional status, focused mental status exam, and progress to date.
• The documentation does not include an updated treatment plan to support the continued need for prolonged services.
• The documentation does not include specific time spent in Psychotherapy.
• The documentation does not support the correct billing of the telehealth visit.
• The submitted provider notes were not authenticated.

Duplex scan of extremity veins – bilateral

A07 – The documentation does not support the medical necessity per policy guidelines.

• The documentation lacked a relevant medical history, physical exam, and/or a progress note or other assessment of the patient from a treating provider that clearly supports the clinical need for the study on the billed date of service.
• The documentation was missing an order/intent to order for the study.
• The documentation did not support the provider performing and/or interpreting the study possessed the appropriate credentialing and accreditation requirements.

362 – The documentation does not support the medical necessity for the level of care billed. The documentation supported the medical necessity for a unilateral study; therefore, the claim was recoded to a lower level of care.

Local Coverage Determination (LCD) L33627 – Non-Invasive Vascular Studies

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80

Title XVIII of the Social Security Act (SSA), Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

A07 – The documentation does not support the medical necessity per policy guidelines.

• The documentation lacked a relevant medical history, physical exam, and/or a progress note or other assessment of the patient from a treating provider that clearly supports the clinical need for the study on the billed date of service.
• The documentation was missing an order/intent to order for the study.
• The documentation did not support the provider performing and/or interpreting the study possessed the appropriate credentialing and accreditation requirements.

Local Coverage Determination (LCD) L33627 – Non-Invasive Vascular Studies

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80

Title XVIII of the Social Security Act (SSA), Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

• The documentation does not include a complete assessment including a complete mental status exam, goals and/or expected duration of specific interventions.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• The documentation failed to support one or more of the following: An operative note or procedure note for the debridement service which includes the anatomical location treated, the instrument(s) used, anesthesia used if required, the type of tissue removed from the wound, the depth and area of the wound and the immediate post procedure care and follow-up instructions.

118 – The documentation does not support the medical necessity for the level of care billed. The reviewer recoded the service to a higher or lower level of care, depending on what the documentation supported.

B65 - Services not furnished directly to the patient and/or not documented.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

A98 – The documentation does not support the medical necessity of the service billed.

• Documentation does not support a split/shared service was performed
• Billed modifiers should be supported in the documentation

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 and 60

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6 and 100.11

2023 CPT E/M Descriptors and Guidelines

Evaluation & Management Visits

Title XVIII of the SSA, Section 1833(e)

Title XVIII of the SSA, Section 1862(a)(1)(A)

A98 – The documentation does not support the medical necessity of the service billed.

• The documentation submitted lacks evidence to support emergent, Advanced Life Support Service.
• The documented miles do not equal billed miles.
• The documentation does not support that the more distant facility was the appropriate facility to provide the necessary care.

A65 – Information requested from the provider was insufficient/incomplete.

• Missing, Illegible and/or incomplete signature(s).
• The documentation submitted does not include the beneficiary and/or beneficiary representative’s signature and is insufficient to support the authorization of assignment of benefits.

CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10

CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 15

CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4

42 Code of Federal Regulations (CFR) Section 424.36

Title XVIII of the Social Security Act (SSA), Section 1833(e)

Title XVIII of the SSA, Section 1861(s)(7)

Title XVIII of the SSA, Section 1862(a)(1)(A)

• The documentation is missing dosage given per site.
• The documentation is missing a covered indication for the Botox to be given more than every 12 weeks.
• The documentation does not include a history of the chronic headaches, nor does it identify or link a specific significant disability caused by the headaches, all of which is needed to support the initiation of the treatment.
• The documentation does not support a significant decrease in the number and frequency of headaches and an improvement in function upon receiving the injections.
• The documentation does not include the current number of headache days the patient is experiencing. Documentation should include current information on headaches.
• Evidence of conservative treatment tried and proven unsuccessful should be documented.
• Frequent cloned documentation.

• The documentation does not support the medical necessity for the administration of IVIG.
• The documentation did not include some or all the required elements based on the diagnosis.

• The documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• The documentation does not support improvement of functional capacity for subsequent injections.
• The documentation does not include subjective patient report of knee pain at the time of injection.
• The documentation was missing one or more of the following: a diagnosis and/or history of symptomatic osteoarthritis of the knee, radiologic evidence to support osteoarthritis diagnosis, and documentation to support failure of at least three months of conservative treatment

• Medicare requires a valid, legible handwritten or electronic signature for all documentation.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.

• The documentation does not support the approval/certification of the POC for the therapy services and/or POC submitted was signed by a medical assistant and not signed by a physician/ nonphysician practitioner.
• The documentation does not indicate the amount and type of assistance required by the therapist for the beneficiary to complete the treatments, and/or did not support that the level of complexity or condition of the patient required the services that could only be performed safely and effectively by a qualified therapist.
• The documentation lacked the requirements to support the medical necessity of the additional services beyond the therapy threshold and/or lacked justification to support the need for additional therapy and how the additional therapy would directly and significantly impact the rate of recovery of the condition being treated such that it is appropriate to exceed the threshold and/or lacked evidence to support the ongoing skills of a qualified therapist were required to complete the treatment.

• The submitted documentation does not support that the rendering provider of the service is the billing provider reported on the claim.