Palmetto GBA begins Complex Review of 99205 and 99204 Services for Ophthalmology California, Hawaii and Nevada

Palmetto GBA, the Medicare Administrative Carrier (MAC) for a number of states, announced it would begin a complex pre-payment review of CPT codes 99205 and 99204 “… based on a data analysis that indicated significant incidence of errors found in prior review …”

This notice was posted on January 10, 2013, to the Palmetto GBA website for Area J1, Part B covering California, Hawaii and Nevada. The link to the 99204 announcement for CA services can be found here. The link for the HI and NV 99204 review can be found here. Pre-payment review means that records will be requested and evaluated for suitability prior to payment.

The Palmetto announcement notes it is for a large number of specialties, and ophthalmology (specialty 18) is included in this 99204 review. Some particulars related to these announcements are:

  • Optometry (specialty 41) is not included in any of these 99204 reviews on the west coast.
  • All 99205 claims for Nevada, Hawaii and the Islands are subject to review, regardless of specialty.
  • Ophthalmology and optometry are not part of the 99205 review in CA but other specialties are.
  • The complex pre-payment review will be gathered from “… a percentage of claims … [that will be] randomly selected daily …”
  • The pre-payment review will last for at least 3 months.
  • When the review ends, Palmetto GBA will determine the effectiveness by closely scrutinizing the error rate for the 99204 and 99205 claims evaluated.
  • Those claims selected for review will receive notification via a request known as an “Additional Documentation Request”, or ADR. It will come from Palmetto GBA.
    • A response is required within 30 days of the date listed on the ADR.
    • No response means an automatic denial of the claim at 45 days
    • All of the information requested as well as anything else that supports the code must be submitted with the ADR.
    • Palmetto GBA has documents on their website about responding to ADR’s. You can link to Palmetto’s ADR response page here. A special Palmetto GBA form is required when submitting documentation; the ADR cover sheet link is here.

If you receive such a notice, Corcoran Consulting Group can help you. We pride ourselves on providing timely, accurate, and up-to-date information to our clients. Contact us via phone during business hours or 24 hours via our website.


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