New Jersey Service Wide Lipid Panel and Venipuncture Probe Results
New Jersey Claim Review on HCPC 80061 and 36415
In an effort to safeguard the Medicare Trust Fund by lowering the Comprehensive Error Rate Testing (CERT) paid claims error rate, Highmark Medicare Services’ Medical Review Department performs reviews and provides education based on data analysis performed to identify problem areas. The CERT program is the driver of this data analysis. The Centers for Medicare and Medicaid Services (CMS) and Highmark Medicare Services uses the information from the CERT error rate findings to determine the underlying reasons for claim errors and develops appropriate action plans to improve compliance in payment, claims processing, and provider billing practices.
Recent CERT data analysis indicated that there were claim errors in New Jersey for procedure code 80061 Lipid Panel and 36415 Venipuncture. As a result of this data analysis, Highmark Medicare Services’ Medical Review Department conducted a widespread post payment review in New Jersey on procedure code 80061 and 36415.
Our findings indicated that approximately 46% of the claims sampled were lacking supporting documentation.
The majority of the reductions/denials were based on the following:
• Physician order/referral information was missing from supporting documentation
• Submitted documentation did not support the billed diagnosis
• Requested documentation was not received in a timely manner
Please refer to the following publication for information on billing procedure codes 80061 and 36415:
• Medicare National Coverage Determination (NCD) 190.23 – Lipid Testing
As a result of these findings, and to assist in the reduction of the overall claims payment error rate, a prepayment review will be implemented on procedure code 80061 and 36415, for New Jersey providers.
Medical records will be requested to verify that services billed were rendered, medically necessary, adequately documented, and billed appropriately to the Medicare program. Please, do not send in documentation until requested by the Additional Documentation Request (ADR) process. If the requested medical record documentation is not made available upon request to support services billed, the service may be denied.