Nebraska

Medical Review has completed an article for the Widespread Service-Specific Probe for Hemoglobin A1C, CPT code 83036. Records were reviewed to determine whether the procedure code billed met all documentation requirements for the services billed. Services for CPT code 83036 were denied if the documentation did not support the service billed as defined in the NCD 190.21 - Glycated Hemoglobin/Glycated Protein.

The major issues identified that led to the denial of 70.00% of these services are as follows:

The National Correct Coding Initiative (NCCI) edits are effective for claims received on or after April 1, 2011, for service dates beginning 10/1/2010. Compliance with the edits may be determined prospectively (pre-payment editing that results in a claim denial) or retrospectively (post-payment editing that results in a refund request). Nebraska Medicaid applied retrospective claims editing during the month of October 2012 for claims received between April 1, 2011 and November 1, 2011. When a claim receives an NCCI edit retrospectively, a refund of the payment is requested.

The below laboratory findings are reported based on the type of documentation, coding, or billing error assessed by the CERT Contractor. WPS Medicare received error findings in the following categories during the second quarter of 2012.

Insufficient Documentation - 60% of total errors

ï Missing valid physician order or progress note supporting intent for diagnostic services (labs, x-rays)

Incorrect Coding - 32% of total errors

ï CBC with differential (85025) recoded to CBC without differential (85027) - physician did not indicate differential on order

Effective January 1, 2013 the Department of Health and Human Services, Division of Medicaid will make a change to the regulations, requiring the receipt of claims within 6 months (180 days) of the date of service.