J1 Part B Service Specific Complex Edit Review for CPT Codes 71010 and 71020, Radiology Services: August ñ October 2010 Results

J1 Part B Medical Review has completed the service specific complex edit review on CPT codes 71010 and 71020, radiology services in Northern and Southern California. The reporting period for this quarter was August 2010 through October 2010. There were 1,369 claims from Southern California reviewed and processed during this time frame. The resulting charge denial rate for Southern California was 54 percent. In Northern California, 7,739 claims were reviewed and processed with a charge denial rate of 19 percent. Major Denial Reasons in Northern California

• 79 percent of the total amount denied was due to no documentation received for review
• 6 percent of the total amount denied was due to no chest X-ray report included in the documentation
• 5 percent of the total amount denied was charges that were deemed payable to another provider billing the same procedure, date of service and beneficiary
• 10 percent of the total amount denied was for a combination of incorrect or incomplete date of service or patient identification on documentation received; missing, invalid or illegible provider signature and charges that were deemed to be not medically necessary based on LCD L28298.

Denial Reason Summary and Analysis In summary, lack of response to requests for documentation for the review remains the number one reason for claim denials in both regions. In both regions, missing radiology report is one of the top three reasons for denials. Without the radiology report, nurses reviewing documentation cannot validate the professional component which is necessary for the claim to be deemed payable. Results of the Reviews Due to the consistently lower charge denial rate in Northern California, we have discontinued selection of claims for the service specific review in this region.