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

J1 Part B Medical Review has completed the service specific probe review for CPT codes 71010 and 71020, radiology services in Northern and Southern California in the second quarter (May through July 2010). There were 985 claims from Southern California reviewed and processed with a charge denial rate of 49 percent. In Northern California, 4,773 claims were reviewed and processed with a charge denial rate of 18 percent. Major Denial Reasons of Northern California • 72 percent of the total dollar amount denied was due to no documentation received for review • 9 percent of the total dollar amount denied was due to invalid, illegible or missing provider signature on the documentation received • 9 percent of the total dollar 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 dollar amount denied was for a combination of illegible documentation, incorrect or incomplete date of service or patient identification on documentation received, no chest X-ray report included with the documentation 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. Without the presence of valid, legible documentation, verification cannot be performed to ensure services were medically reasonable and necessary and billed appropriately. Therefore, any claim randomly selected for review will be automatically denied if no documentation is received to validate payment of services billed. In Northern California, signature issues were noted as the second leading cause of denials during this edit. When documentation is found to contain an illegible or invalid provider signature, or the signature is missing entirely, the Medical Review department sends a letter requesting an attestation for verification and validation of these provider signatures. It is required that providers respond to these requests in a timely manner for these claims to be eligible for payment. Results of the Reviews Due to the lower charge denial rate noted in Northern California, we will discontinue selection of claims for the service specific review in this region at this time.