Computed Tomography (CT scan) with Contrast, Abdomen and Pelvis Targeted Probe and Educate Review Results - JE Part A
Computed Tomography (CT scan) with Contrast, Abdomen and Pelvis Targeted Probe and Educate Review Results
The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of for Current Procedural Terminology (CPT®) code 74177 - Computed tomography, abdomen and pelvis; with contrast material(s). The findings of the claims reviewed from April 1, 2024 through June 30, 2024 are as follows:
Top Denial Reasons
- 57 claims were reviewed with 10% error rate
Top Trending Errors
- Coverage of Computed Tomography
- Documentation Supporting Services Rendered
- Expectation of Correct Billing
Educational Resources
- National Coverage Determination (NCD): Computed Tomography
- Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80.6
- IOM, Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 4, Section 20.6.6
- IOM, Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 13, Sections 20-30
Education
Coverage of Computed Tomography
National Coverage Determination (NCD) 220.1 provides coverage criteria for computed tomography (CT). Per the NCD, documentation must clearly support the CT scan was medically necessary for the individual beneficiary taking into consideration their symptoms and potential diagnosis.
Documentation Supporting Services Rendered
Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
No Medicare payment can be paid for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed.
Expectation of Correct Billing
Services provided by your facility are expected to be billed in compliance with CMS claims processing guidelines. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect. Noted continued billing errors may be referred to the Provider Outreach and Education (POE) representatives for education on proper billing in accordance with CMS requirements. If a provider is consistently billing incorrectly, this may be highlighted for review and possible referral to the Unified Program Integrity Contractor (UPIC) for potential compliance or abuse issue.
