Redeterminations: Top Five Requested Codes and Tips
Noridian conducted data analysis on the top procedure codes from redetermination requests submitted since October 2013. Below are the top five CPT/HCPCS codes, resources and tips to assist your office when submitting such requests.
CPT 88305 - Pathology Examination of Tissue Using a Microscope
CPT 88305 - Pathology Examination of Tissue Using a Microscope
- These appeals were denied because the requesting party failed to provide the following:
- Indicate requirement of a valid order/intent to order.
- Documentation must be signed and dated by the performing provider.
- Pathology Reports - Include surgery/procedure notes when biopsies taken.
- These appeals were denied because the requesting party failed to provide the following:
- Evaluation and Management (E/M) outpatient/office notes must be dated and signed by the performing provider. Medical necessity is required for this level of service. Services must meet requirements of this code, including two of the three components:
- Detailed history
- Detailed exam
- Medical decision making of moderate complexity located in CPT book
- For further clarification:
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30
- CMS IOM Publication100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.7
- CMS 1995 Documentation Guidelines for Evaluation and Management Services
- CMS 1997 Documentation Guidelines for Evaluation and Management Services
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 30
- Evaluation and Management (E/M) outpatient/office notes must be dated and signed by the performing provider. Medical necessity is required for this level of service. Services must meet requirements of this code, including two of the three components:
- These appeals were denied because the requesting party failed to provide the following:
- 99232 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in same the day for unrelated issues. Medical necessity is required for this level of service. Documentation must support additional services.
- Documentation submitted with the redetermination request must be signed and dated by the performing provider and must meet two of the three key components
- Expanded problem focused history
- Expanded problem focused exam or
- Medical decision making of moderate complexity
- For further clarification:
- These appeals were denied because the requesting party failed to provide the following:
- Provides the same instructions as those for 99232 with the following exception:
- 99233 should meet two of the three components:
- Detailed interval history
- Detailed exam
- Medical decision making of high complexity
- Medical necessity is required for this level of service.
- For further clarification:
- 99233 should only be billed once per day by providers of the same group/specialty. Exception: Multiple visits in the same day for unrelated issues. Documentation must support additional services.
- For further clarification:
- These appeals were denied because the requesting party failed to provide the following:
- Include the following documentation in the request:
- Trip report which must be signed and dated by a crew member.
- Discharge notes
- Progress notes that support the necessity of the ambulance trip
- Certification for medical necessity of the ambulance transport
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 10
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15
- Include the following documentation in the request:
Last Updated Jan 30, 2014
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