FEB 15, 2023
Failure to Document Medical Necessity Continues
Palmetto GBA has released new prepayment provider-specific probe results from North Carolina, South Carolina, Virginia and West Virginia that showed most claims were denied because of documents that were incomplete or lacked medical necessity.
In a follow-up to implementing the Targeted Probe and Educate (TPE) process for Current Procedural Terminology (CPT®) code 66984: Extracapsular Cataract Removal, that began Sept. 1, 2021; this probe reviewed claim dates between July 2022 and September 2022.
Denials for lack of medical necessity in chart notes as well as insufficient documentation for services billed remain at the top of probe findings.
Claim Denial Rate By State
| North Carolina |
3% |
| South Carolina |
10% |
| Virginia |
16% |
| West Virginia |
18% |
|
Percent of Total Denials
|
Denial Code
|
Denial Description
|
|
40%
|
NOTML
|
Per Applicable LCD, Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed
|
|
36%
|
NODOC
|
Documentation Requested for This Date of Service Was Not Received or Was Incomplete; Therefore, We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed and This Service Has Been Denied
|
|
16%
|
NOSIG
|
Documentation Lacks the Necessary Provider's Signature
|
|
4%
|
WRONG
|
Documentation Received Contains an Incorrect, Incomplete or Illegible Patient Identification or Date of Service
|
|
4%
|
BILER
|
Claim Billed in Error per Provider
|
Help us help you meet the documentation requirements for cataract surgery. The Academy is dedicated to making sure physicians meet cataract surgery documentation guidelines and has launched a new Cataract Surgery Documentation hub at aao.org/cataract-surgery.