Medical Review

Railroad Medicare does not reimburse the cost associated with the compiling, copying or mailing of medical records from any setting. Per CMS Internet-Only Manual (IOM) Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.6 (PDF), "Reimbursing Providers and HIHs for Additional Documentation," Medicare Administrative Contractors are not required to pay for medical documentation for either prepayment or postpayment review.

Last Reviewed: 9/21/2023

Medicare contractors request medical records from the provider that billed for a service. As a reminder, hospitalist and hospitalist groups are required to adhere to all documentation requirements as are all providers.

When requested, a hospitalist or hospitalist group is required to obtain and furnish documentation to support services billed to Medicare even if that means the hospitalist or hospitalist group must obtain records to support billed services from the hospital or other entity where the records are maintained.

Last Reviewed: 9/21/2023

You can request a copy of the ADR letter from our Provider Contact Center. Please call 888–355–9165 and choose option 5 for Customer Service.

Last Reviewed: 9/21/2023

If the only service provided was an injection or venipuncture, Palmetto GBA will not reimburse CPT code 99211 unless another unrelated service is provided and the requirements for CPT code 99211 have been met.

Example
The patient presents to office for routine blood work; however, he/she started on a new medication for hypertension and the provider requested he/she follow-up with the ancillary for a blood pressure check and response to medication.

Last Reviewed: 9/21/2023

Illegible records will be considered to be missing or incomplete documentation. If we cannot read the notes, the service will be denied. If you feel your notes may not be readable by the Medicare Review staff, you are advised to translate these notes prior to submitting them to the contractor for review. Medicare will accept transcribed notes in addition to copies of the original.

Last Reviewed: 9/21/2023

No, do not submit a new claim. If your claim was denied with remittance advice remark code RARC M127 because the information requested by Medical Review was not returned within 45 days of the ADR letter date, return your ADR response(s) as soon as possible within 120 days from the date of the receipt of the denial. Submit your documentation with a Medical Review ADR Response — Late Submission form (PDF). If we receive your response more than 120 days from the receipt of the M127 denial, Medical Review will not review the documentation. The documentation will be handled as a redetermination by Appeals. The receipt of the notice of the denial is presumed to be received five days from the date of the remittance advice.

Last Reviewed: 9/21/2023

No. The supervising physician’s signature is not required when a physician assistant (PA) performs services in the emergency department and the PA submits the services with his or her National Provider Identifier (NPI).

Last Reviewed: 9/21/2023

Medicare encourages providers to take the initiative and review medical records prior to submission. However, highlighting information on the copy of the medical records you submit to Medical Review may render the information unreadable. A better practice to draw attention to a specific part of the medical record is to circle or mark the information with an asterisk on the copy you return to be reviewed.

Please note original records should not be highlighted or annotated for the purpose of drawing attention to a specific part of the record. Any amendments, corrections or addenda to original medical record entries must follow the guidelines found in CMS Internet-Only Manual (IOM) Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5 (PDF).

Last Reviewed: 9/21/2023

Yes. You can fax your Additional Documentation Request (ADR) response to (803) 264–8832. Your ADR letter will also include the fax number and/or the mailing address you must reply to. Include a copy of your ADR letter with your supporting documentation for each request. If you are responding to multiple ADRs, please use our Additional Documentation Request Separator Sheet (PDF) between the documentation for each request. 

For more information about responding to ADRs, including other options for submitting your response, see our article Medical Review: Additional Documentation Requests (ADRs).

Last Reviewed: 9/21/2023

The ADR letters for prepayment reviews are sent to the billing (remittance) address on the provider’s Railroad Medicare enrollment record. If you are having trouble receiving your ADRs, or any other correspondence from Railroad Medicare, please contact us to verify we have your current address on file. Please call 888–355–9165 and choose option 5 for Customer Service.

As an alternative to receiving ADRs by mail, providers who are registered to use our eServices portal can receive paperless ADRs via eDelivery. With eDelivery, ADRs will be sent as a secure eServices inbox message, with an option to also receive email notification when new ADRs are available in eServices. For more information about eServices, including how to choose eDelivery for Medical Review ADRs, please see our eServices User Manual (PDF).

Last Reviewed: 9/21/2023

In these situations, the services are not billable to Medicare. Palmetto GBA will not consider attestation statements from someone other than the author of the medical record entry in question. This is even in cases where two individuals are in the same group. One may not sign for the other in medical record entries or attestation statements.

Last Reviewed: 9/21/2023

Medical review is a term for the process Medicare contractors use to examine data and request supporting documentation for claims submitted to Medicare. The goal of the medical review program is to reduce payment errors by identifying and addressing documentation and billing errors made by providers concerning coverage and coding. 

Palmetto GBA performs medical review on some services before they are paid. This focused medical review process is called Progressive Corrective Action (PCA).

Palmetto GBA may perform a postpayment review of claims, meaning that medical documentation is requested for claims that have already been processed and paid. Post payment review can be done in cases where a high error rate and/or potential overutilization has been identified through data analysis. Upon review of the documentation, Palmetto GBA will make a determination that either affirms the original payment, or denies the payment (in part or in full). If any part of the claim is denied, an overpayment is assessed, and funds are recouped from the provider.

Reference: Per CMS Internet-Only Manual (IOM) Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3 (PDF).

Last Reviewed: 9/21/2023

If you disagree with decisions regarding the identified services, you can request a redetermination within 120 days of the determination (date on the original remittance advice). Additional information about requesting a redetermination can be found on the Appeals section of the Palmetto GBA website.

Last Reviewed: 9/21/2023

When submitting information to support billing for a global service (technical and professional components), the following documentation must be included:

• Documentation to support the service was rendered (example: the diagnostic test report)
• Some type of "signed" order or documentation that clearly reflects the ordering provider’s intent

The following documentation must be included when submitting information to support billing for the technical component (TC):

• Some type of signed order or documentation that clearly reflects the ordering provider’s intent

The following documentation must be included when submitting information to support billing for the professional component (PC):

• A signed diagnostic test report

Reminder: All documents that require a signature must meet the Centers for Medicare and Medicaid (CMS) requirements outlined in the Program Integrity Manual, Chapter 3, Section 3.3.2.4.

Resources

• CMS Internet-Only Manual (IOM) Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6 (PDF)
• CMS IOM Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF,)
• MLN Fact Sheet — Complying with Documentation Requirements for Laboratory Services
• Chest X-Ray Checklist  
• Bone Density Study Checklist 
• Portable X-Ray Checklist

Last Reviewed: 9/21/2023

The prepayment review process when you receive ADR letters is separate from the postpayment review process. If you have been selected for a postpayment review it is because a high error rate on a billed procedure code and/or potential overutilization has been identified through data analysis.

Last Reviewed: 9/21/2023

Yes. You can call our Provider Contact Center at 888–355–9165, Option 5 to request a copy of the letter. 

Last Reviewed: 9/21/2023

No. We request records from the provider that billed the claims to Railroad Medicare. When requested, it is the provider's obligation to obtain and furnish documentation to support services billed to Medicare even if that means the provider must obtain records to support billed services from a hospital or other entity where the records are maintained.

Last Reviewed: 9/21/2023

Our Medical Review unit has the discretion to grant extensions to providers who need more time to comply with a postpayment review documentation request. You may call our Provider Contact Center at 888–355–9165, Option 5 to request an extension.

Last Reviewed: 9/21/2023

You can return your documentation via fax to (803) 264–8832. You can return your documentation via postal mail to the addresses below:

Last Reviewed: 9/21/2023