January 22, 2013
Area(s) of Interest: Payor Contracting Practice Management
Palmetto GBA, California's Medicare contractor, has expanded its procedure specific audits, called probes, to include procedure codes 99204 and 99205 when rendered by providers with specific specialties:
- 99204 performed by general practice (CMS specialty designation 01), otolaryngology (04), family practice (08), ophthalmology (18), physical medicine and rehabilitation (25), podiatrist (48) and rheumatology (66)
- 99205 performed by cardiology (06), family practice (08), internal medicine (11), neurology (13), podiatry (48) and hematology/oncology (83)
Palmetto conducts complex reviews based on data analysis. An analysis of these procedure codes when performed by physicians in these specialties indicated a significant incidence of errors and a higher utilization by California providers when compared to national claim payment ratios for the same services by the same specialties.
Palmetto will be randomly selecting for audit a percentage of claims billed for these services on a daily basis for a minimum period of three months.
If you receive an "additional documentation request" (ADR) from Palmetto, please return the requested documentation to the J1 Part B Medical Review department address within 30 days of the request date. Failure to provide the requested information will result in a denial.
Documentation that may support the services billed include:
- Legible copy of the patient's medical record for listed date(s) of service
- Legible physician signature
- Consultation reports
- Physician progress notes
- Diagnostic test results/reports, including imaging reports if applicable
- Any other documentation to support the CPT Code that was billed
For more assistance on signature and documentation requirements, refer to the E/M Help Center on Palmetto’s website www.palmettogba.com/J1B. When the audit is complete, Palmetto will analyze the results and determine if any subsequent actions are necessary. The results will be posted to Palmetto's J1 Part B website.
Palmetto Completes Audit on Procedure Code 95024
Palmetto has completed its Southern California audit on CPT Code 95024: Intracutaneous Tests with Allergenic Extracts. The primary issue identified was missing or incomplete medical record documentation. Although Palmetto will not continue the pre-payment review at this time, the California Medical Association encourages you to review Palmetto's Local Coverage Determination number L28234 on allergy testing for tips on what auditors may look for in medical records.