Provider signature requirements - Medical record

Signature Requirements

In the content of health records, each entry must be authenticated by the author. Authentication is the process of providing proof of the authorship signifying knowledge, approval, acceptance or obligation of the documentation in the health record, whether maintained in a paper or electronic format accomplished with a handwritten or electronic signature. Individuals providing care for the patient are responsible for documenting the care. The documentation must reflect who performed the service.

a. The handwritten signature must be legible and contain at least the first initial and full last name along with credentials and date. A typed or printed name must be accompanied by a handwritten signature or initials with credentials and date.

b. An electronic signature is a unique personal identifier such as a unique code, biometric, or password entered by the author of the electronic medical record (EMR) or electronic health record (EHR) via electronic means, and is automatically and permanently attached to the document when created including the author’s first and last name, with credentials, with automatic dating and time stamping of the entry. After the entry is electronically signed, the text-editing feature should not be available for amending documentation. Example of an electronically signed signature: “Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX A.M.”

c. A digital signature is a digitized version of a handwritten signature on a pen pad and automatically converted to a digital signature that is affixed to the electronic document. The digital signature must be legible and contain the first and last name, credentials, and date.

d. Rubber stamp signatures are not permissible. This provision does not affect stamped signatures on claims, which remain permissible.


Documentation of Medical Services


Medical records are expected to contain all the elements required in order to file and substantiate a claim for the services as well as the appropriate level of care, i.e., evaluation and management service (see Policy Memo No. 2). Each diagnosis submitted on the claim must be supported by the documentation in the patient’s medical record.

The contracting provider agrees to submit claims only when appropriate documentation supporting said claims is present in the medical record(s) which shall be made available for audit and review at no charge.

Letters/checklists are not acceptable as documentation of medical necessity and do not replace what should be in the complete medical record. Abbreviations must be those that are generally accepted by your peers and clearly translated to be understandable to the reviewer.

2. BCBSKS has adopted the following standards for documentation of medical services.

Each patient’s health record shall meet these requirements:

a. Be legible in both readability and content.

b. Contain only those terms and abbreviations that are or should be comprehensible to similar providers/peers.

c. Contain patient-identifying information on each page to ensure pages are not lost or misfiled.

d. Indicate the dates any professional service was provided and date of each entry.

e. Contain pertinent information concerning the patient’s condition and justify the course of treatment. The record must document the medical necessity and appropriateness of each service.
f. Documentation of examination and treatment(s) performed or recommended (why it was done and for how long) and physical area(s) treated, vital signs obtained and tests (lab, x-ray, etc.) performed, and the results of each.

g. List start and stop times or total time for each CPT code/service performed on all timed codes per CPT nomenclature.

h. Document the initial diagnosis and the patient’s initial reason for seeking the provider’s care.

i. Document the patient’s current status and progress during the course of treatment provided.

j. Indicate the medications prescribed, dispensed, or administered, and the quantity and strength of each.

k. Include all patient records received from other health care providers if those records formed the basis for treatment decision by the provider.

l. Each entry shall be authenticated by the person making the entry (see Signature Requirements) unless the entire patient record is maintained in the provider’s own handwriting.
m. Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form; the final form shall accurately reflect the care and services rendered to the patient.

Critical Care Services and Physician Time

Critical care is a time- based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided. More than one physician can provide critical care at another time and be paid if the service meets critical care, is medically necessary and is not duplicative care. Concurrent care by more than one physician (generally representing different physician specialties) is payable if these requirements are met (refer to the Medicare Benefit Policy Manual, Pub. 100-02, Chapter 15, §30 for concurrent care policy discussion).

The CPT critical care codes 99291 and 99292 are used to report the total duration of time spent by a physician providing critical care services to a critically ill or critically injured patient, even if the time spent by the physician on that date is not continuous. Non-continuous time for medically necessary critical care services may be aggregated. Reporting CPT code 99291 is a prerequisite to reporting CPT code 99292. Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5).



1. Off the Unit/Floor

Time spent in activities (excluding those identified previously in Section C) that occur outside of the unit or off the floor (i.e., telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care because the physician is not immediately available to the patient. This time is regarded as pre- and post service work bundled in evaluation and management services.



2. Split/Shared Service

A split/shared E/M service performed by a physician and a qualified NPP of the same group practice (or employed by the same employer) cannot be reported as a critical care service. Critical care services are reflective of the care and management of a critically ill or critically injured patient by an individual physician or qualified non-physician practitioner for the specified reportable period of time.

Unlike other E/M services where a split/shared service is allowed the critical care service reported shall reflect the evaluation, treatment and management of a patient by an individual physician or qualified non-physician practitioner and shall not be representative of a combined service between a physician and a qualified NPP.

When CPT code time requirements for both 99291 and 99292 and critical care criteria are met for a medically necessary visit by a qualified NPP the service shall be billed using the appropriate individual NPI number. Medically necessary visit(s) that do not meet these requirements shall be reported as subsequent hospital care services.


3. Unbundled Procedures

Time involved performing procedures that are not bundled into critical care (i.e., billed and paid separately) may not be included and counted toward critical care time. The physician's progress note(s) in the medical record should document that time involved in the performance of separately billable procedures was not counted toward critical care time.




4. Family Counseling/Discussions

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and

b) The discussion is necessary for determining treatment decisions.


For family discussions, the physician should document:

a.The patient is unable or incompetent to participate in giving history and/or making treatment decisions

b. The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family",

c.Medically necessary treatment decisions for which the discussion was needed, and

d. A summary in the medical record that supports the medical necessity of the discussion

All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.

Documentation requirements for subsequent visits - Chiropractic billing

The following documentation requirements apply whether the subluxation is demonstrated by X-ray or by physical examination:

1. History

a. Review of chief complaint;

b. Changes since last visit; and

c. Systems review if relevant.

2. Physical examination

a. Examination of area of spine involved in diagnosis;

b. Assessment of change in patient condition since last visit;

c. Evaluation of treatment effectiveness.


3. Documentation of treatment given on day of visit.


 Necessity for treatment of acute and chronic subluxation

The patient must have a significant health problem in the form of a neuromusculoskeletal condition necessitating treatment, and the manipulative services rendered must
have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

The patient must have a subluxation of the spine as demonstrated by X-ray or physical examination, as described below.

Most spinal joint problems fall into the following categories:

*** Acute subluxation – a patient’s condition is considered acute when the patient is being treated for a new injury, identified by X-ray or physical examination as specified above. The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression, of the patient’s condition.

*** Chronic subluxation – a patient’s condition is considered chronic when it is not expected tosignificantly improve or be resolved with further treatment as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered.

You must place the HCPCS (healthcare common procedure coding system) modifier AT on a claim when providing active/corrective treatment to treat acute or
chronic subluxation. However, the presence of the HCPCS modifier AT may not  in all instances indicate that the service is reasonable and necessary.

Documentation requirements for the initial visit - X RAY and Date of Initial treatment

The following documentation requirements apply for initial visits whether the subluxation is demonstrated by x-ray or by physical examination:


1. History: The history recorded in the patient record should include the following:

*** Chief complaint including the symptoms causing patient to seek treatment;

*** Family history if relevant; and

*** Past medical history (general health, prior illness, injuries, or hospitalizations; medications; surgical history).


2. Present illness: Description of the present illness including:

*** Mechanism of trauma;

*** Quality and character of symptoms/problem;

*** Onset, duration, intensity, frequency, location, and radiation of symptoms;

*** Aggravating or relieving factors;

*** Prior interventions, treatments, medications,secondary complaints; and

*** Symptoms causing patient to seek treatment.



Note: Symptoms must be related to the level of the subluxation that is cited. A statement on a claim that there is “pain” is insufficient. The location of the pain must be described and whether the particular vertebra listed is capable of producing pain in that area.

3. Physical exam: Evaluation of musculoskeletal/ nervous system through physical examination. To demonstrate a subluxation based on physical examination, two of the following four criteria (one of which must be asymmetry/misalignment or range of motion abnormality) are required and should be documented:

*** P - pain/tenderness: The perception of pain and tenderness is evaluated in terms of location, quality, and intensity. Most primary neuromusculoskeletal disorders manifest primarily by a painful response. Pain and tenderness findings may be identified through one or more of the following: observation, percussion, palpation,
provocation, etc. Furthermore, pain intensity may be assessed using one or more of the following; visual analog scales, algometers, pain questionnaires, and so forth.

*** A - asymmetry/misalignment: Asymmetry/ misalignment may be identified on a sectional or segmental level through one or more of the following: observation (such as,  osture and heat analysis), static palpation for misalignment of vertebral segments, diagnostic imaging.

*** R - range of motion abnormality: Changes in active, passive, and accessory joint movements may result in an increase or a decrease of sectional or segmental mobility. Range of motion abnormalities may be identified through one or more of the following: motion palpation, observation, stress diagnostic imaging, range of motion, measurement(s).

*** T -tissue tone, texture, and temperature abnormality: Changes in the characteristics of contiguous and associated soft tissue including skin, fascia, muscle, and ligament may be identified through one or more of the following  procedures: observation, palpation, use of  instrumentation, test of length and strength.

Note: The P.A.R.T. (pain/tenderness; asymmetry/  misalignment; range of motion abnormality; and tissue tone, texture, and temperature abnormality) evaluation
process is recommended as the examination alternative to the previously mandated demonstration of subluxation by X-ray/MRI/CT for services beginning January 1, 2000. The acronym P.A.R.T. identifies diagnostic criteria for spinal dysfunction (subluxation).

4. Diagnosis: The primary diagnosis must be subluxation, including the level of subluxation,  either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. The precise level of the subluxation must be specified by the chiropractor to substantiate a claim for manipulation of the spine. This designation is made in relation to the part of the spine in which the subluxation is identified as shown in the following table:


Area of spine     Names of vertebrae    Number of  vertebrae      Short form  or other  name   Subluxation ICD-10 code

Neck Occiput     Cervical  Atlas Axis      7         Occ,  CO  C1-C7   C1  2         M99.00  M99.01

Back         Dorsal or  Thoracic  Costovertebral    12          D1-  D12  T1-T12  R1-  R12  R1-  R12     M99.02
           
Low back      Lumbar          5             L1-L5                M99.03

Pelvis              Ilii, R and L (I, Si)        I, Si                    M99.05

Sacral            Sacrum,  coccyx            S, SC             M99.04


In addition to the vertebrae and pelvic bones listed, the Ilii (R and L) are included with the sacrum as an area where a condition may occur which would be appropriate for chiropractic manipulative treatment. There are two ways in which the level of the subluxation may be specified in patient’s record.

*** The exact bones may be listed, for example: C 5, 6;

*** The area may suffice if it implies only certain bones such as: occipito-atlantal (occiput and Cl (atlas)), lumbo-sacral (L5 and Sacrum) sacro-iliac sacrum and
ilium).


Following are some common examples of acceptable descriptive terms for the nature of the abnormalities:


*** Off-centered;

*** Misalignment;

*** Malpositioning;

*** Spacing - abnormal, altered, decreased, increased;

*** Incomplete dislocation;

*** Rotation;

*** Listhesis - antero, postero, retro, lateral, spondylo; and

*** Motion - limited, lost, restricted, flexion, extension, hypermobility, hypomotility, aberrant.

Other terms may be used. If they are understood clearly to  refer to bone or joint space or position (or motion) changes of vertebral elements, they are acceptable.
X-rays As of January 1, 2000, an X-ray is not required by  Medicare to demonstrate the subluxation. However, an x-ray may be used for this purpose if you so choose.
The x-ray must have been taken reasonably close to (within 12 months prior or three months following) the beginning of treatment. In certain cases of chronic
subluxation (for example, scoliosis), an older X-ray may be accepted if the beneficiary’s health record indicates the condition has existed longer than 12 months and there is a reasonable basis for concluding that the condition is permanent.

A previous CT scan and/or MRI are acceptable evidence if a subluxation of the spine is demonstrated.

5. Treatment plan: The treatment plan should always include the following:

*** Recommended level of care (duration and frequency of visits);

*** Specific treatment goals; and

*** Objective measures to evaluate treatment effectiveness.



Date of the initial treatment

The patient’s medical record.

*** Validate all of the information on the face of the claim, including the patient’s reported diagnosis(s), physician work (CPT® code), and modifiers.

*** Verify that all Medicare benefit and medical necessity requirements were met.

Medicare complex medical review CPT list

Complex Medical Review
Refer to the additional documentation request (ADR) letter for detailed documentation requirements You could download the entire excel here. http://medicare.fcso.com/wrapped/274351.zip
Line of Business	Jurisdiction	Provider Type	Description	Date Implemented	Date Last Revised
Part B	JN	All Specialties	Amniotic Membrane-Sutureless Placement on the Ocular Surface, 65778 utilization parameter	29-06-2015	N/A
Part B	JN	All Specialties	Anesthesia 00740, 00810 billed with Diagnosis V16.0, V18.51-V18.59, V69.1, V76.41, V76.50-V76.52 if no surgery billed	22-06-2009	30-10-2014
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 074x Clinic - Outpatient Rehabilitation Facility (ORF) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital	Biofeedback, 90911 billed on the same date of service as 97010-97530, G0283 with Diagnosis 599.82, 625.6, 787.60-787.63, 788.31, 788.32 or 788.38	04-06-2013	N/A
Part B	JN	All Specialties	Biofeedback, 97010-97530, G0283 Billed Same Day With 90911 & Diagnosis 599.82, 625.6, 787.60-787.63, 788.31, 788.32 or 788.38	04-06-2013	N/A
Part A	JN	013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital	Bisphosphonates Iv & Monoclonal Antibodies In The Treatment Of Osteoporosis And Their Other Indications J3489 and J0897 utilization parameter	16-10-2011	06-01-2014
Part B	JN	All Specialties	Bisphosphonates IV & Monoclonal Antibodies in the Treatment of Osteoporosis and Their Other Indications J3489 utilization parameter	01-07-2013	21-07-2014
Part B	JN	All Specialties	Bone Mineral Density Studies 77080 utilization parameter	14-06-2004	05-03-2012
Part B	Florida	All Specialties	Chelation Therapy, J0600	07-04-2011	N/A
Part B	JN	All Specialties	Circulating Tumor Cell Testing 86152, 86153 utilization parameter	20-03-2012	07-01-2013
Part B	Florida	All Specialties	Critical Care Services Utilization Parameter, 99291	18-02-2013	21-01-2014
Part B	Florida	All Specialties	Critical Care Services, 99291, Place of Service Other Than 21, 22 or 23	18-02-2013	21-01-2014
Part B	Florida	All Specialties	Destruction by Neurolytic Agent 64640, 64632 utilization parameter with diagnosis 355.6	20-04-2006	26-01-2010
Part B	JN	All Specialties	Dialysis (AV Fistula & Graft) Vascular Access Maintenance, 35475 and 35476 billed same date of service	09-10-2012	N/A
Part A	JN	011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital	Dialysis Vascular Access Maintenance, 35475 and 35476 billed same date of service	08-10-2012	26-03-2013
Part B	Florida	All Specialties	Drug Threshold	10-06-2013	11-04-2014
Part B	Florida	Specialties 11, 14, 20, 33	Drug Threshold	10-06-2013	03-07-2013
Part B	Florida	All Specialties	Duplex Scan of Lower Extremity, 93925, 93926 Utilization Parameter, Excluding Place of Service 21 & 23	22-05-2006	16-10-2013
Part B	Florida	Specialties 01, 12, 37, 41, 48	Evaluation and Management, 99215	18-01-2013	22-07-2013
Part B	Florida	All Specialties	Evaluation and Management 99201-99205, 99211-99215  billed with Modifier 24	18-05-2012	31-07-2014
Part B	Florida	Specialty 11	Evaluation and Management, 99223	21-10-2014	20-08-2015
Part B	Florida	Specialty 11	Evaluation and Management, 99233	24-10-2014	20-08-2015
Part B	JN	All Specialties	EEG Special Tests & Routine EEG Codes 95950, 95951, 95953, 95956 if routine EEG not billed in previous 90 days	07-10-2013	N/A
Part B	JN	All Specialties	EEG Special Tests Utilization Parameter, 95950, 95951, 95953, 95956, 95957	07-10-2013	N/A
Part B	JN	All Specialties	External Counterpulsation G0166 utilization parameter	27-01-2005	23-06-2006
Part B	JN	All Specialties	Herceptin Utilization Parameter, J9355	06-02-2013	N/A
Part A	JN	013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 023x Skilled Nursing - Outpatient 085x Critical Access Hospital	Herceptin, J9355 utilization parameter	06-02-2013	N/A
Part B	Puerto Rico	All Specialties	Home Domiciliary Visits, 99348-99350	22-01-2014	N/A
Part B	JN	All Specialties	Infliximab (Remicade), J1745 billed with or without GA Modifier & Diagnosis 446.7	23-04-2012	26-10-2012
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 085x Critical Access Hospital	Long-Term Wearable Electrocardiographic Monitoring (WEM) 0296T-0297T	09-10-2012	26-03-2013
Part B	JN	All Specialties	Long-Term Wearable Electrocardiographic Monitoring (WEM), 0295T, 0296T, 0297T, 0298T	09-10-2012	N/A
Part B	JN	All Specialties	Low Density (LDL) Apheresis, 36516	04-09-2012	21-01-2015
Part B	JN	All Specialties	Manipulation Under Anesthesia 23700, 24300, 27570 utilization parameter	25-01-2010	N/A
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital	Manipulation Under Anesthesia, 23700, 24300 or 27570 same date of service.	25-01-2010	26-03-2013
Part B	JN	All Specialties	Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing, 81374 Billed With Diagnosis 720.0	07-10-2013	N/A
Part B	JN	All Specialties	Molecular Pathology Procedures, 81287, 81400-81408	07-10-2013	19-02-2014
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 018x Hospital - Swing Beds 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health 072x Clinic - Hospital Based or Independent Renal Dialysis Center 073x Clinic - Freestanding 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 077x Clinic - Federally Qualified Health Center (FQHC) 083x Ambulatory Surgery Center 085x Critical Access Hospital	Molecular Pathology Procedures, 81400-81408	07-10-2013	01-01-2015
Part A	JN	013x Hospital Outpatient 085x Critical Access Hospital	Monitored Anesthesia Care (MAC) For Interventional Pain Management Services, 01991-01992 billed with GA and QS modifier	25-01-2010	26-03-2013
Part B	JN	All Specialties	Monitored Anesthesia Care 01991/01992 With Specific Procedures & With QS Modifier	25-01-2010	N/A
Part B	PR/USVI	Ambulance	Non-emergency Ambulance Transport, A0425, A0428 billed with dialysis facility transport modifier	15-12-2009	31-08-2015
Part B	Florida	All Specialties	Non-Invasive Evaluation of Extremity Veins, 93965, 93970, 93971 Utilization Parameter, Excluding Place of Service 21 & 23	22-05-2006	24-11-2009
Part B	Florida	All Specialties	Non-Invasive Extracranial Arterial Studies 93875, 93880, 93882 utilization parameter, excluding place of service 21 & 23	25-09-2006	04-10-2013
Part B	Florida	All Specialties	Noninvasive Physiologic Studies of Upper or Lower Extremity Arteries, 93922-93924 Utilization Parameter, Excluding Place of Service 21 & 23	24-11-2009	N/A
Part B	JN	All Specialties	Ocular Photodynamic Therapy with Verteporfin, 67221, 67225, J3396 Billed With or Without GA Modifier & Diagnosis 362.41	23-04-2012	12-08-2013
Part A	FL	013x Hospital Outpatient 085x Critical Access Hospital	Ocular Photodynamic Therapy, 67221-25, J3395-96 with diagnosis 362.41	10-01-2001	03-04-2013
Part A	PR/USVI	013x Hospital Outpatient 085x Critical Access Hospital	Ocular Photodynamic Therapy, 67221-25, J3395-96 with diagnosis 362.41	16-02-2009	03-04-2013
Part B	JN	All Specialties	Physician Recertification of Home Health Services G0179 utilization parameter	29-06-2007	N/A
Part B	JN	All Specialties	PROLIA AND XGEVA Utilization Parameter, J0897	14-10-2013	N/A
Part B	JN	All Specialties	Psychiatric Diagnostic Evaluation and Psychotherapy Services, 90839, 90840	04-06-2013	N/A
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health 075x Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) 076x Clinic - Community Mental Health Center 077x Clinic - Federally Qualified Health Center (FQHC) 085x Critical Access Hospital	Psychiatric Evaluation And Psychotherapy Services, 90839, 90840	04-06-2013	01-01-2015
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital	Radiation Therapy For Basal Cell And Squamous Cell 77401-77404, 77406, 77785, 77786, 77789 with specific diagnosis codes	13-02-2011	01-01-2015
Part B	JN	All Specialties	Radiation Therapy for T1 Basal & Squamous Cell Carcinoma's Billed With Specific Diagnosis, 77401-77406, 77785, 77786, 77789, G6003, G6004, G6005, G6006	13-02-2011	01-01-2015
Part B	JN	All Specialties	Reduction Mammaplasty, 19318	02-02-2009	N/A
Part B	Florida	All Specialties	Refilling & Maintenance of Portable Pump 96521 billed without J9000-J9999	21-04-2011	09-05-2011
Part A	Florida	013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health	Remicade, J1745 with diagnosis codes 556.0-556.3, 556.5, 556.6, 556.8, 556.9 and 714.2	26-07-2000	26-03-2013
Part A	PR/USVI	013x Hospital Outpatient 021x Skilled Nursing - Inpatient (Including Medicare Part A) 023x Skilled Nursing - Outpatient 071x Clinic - Rural Health	Remicade, J1745 with diagnosis codes 556.0-556.3, 556.5, 556.6, 556.8, 556.9 and 714.2	16-02-2009	26-03-2013
Part B	JN	All Specialties	Rituximab (Rituxan), J9310 Billed With Diagnosis 340	08-06-2012	N/A
Part B	Puerto Rico	All Specialties	Screening & Diagnostic Mammography 76641 & 76642 billed with 77056 or G0204; 77056 billed without 76641 & 76642	27-03-2012	13-05-2015
Part A	JN	012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 085x Critical Access Hospital	Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) 77371, G0173, G0251, G0339 or G0340 with dx 185	30-09-2009	01-01-2015
Part B	JN	All Specialties	Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT), 77371-77373, G0339-G0340	05-10-2009	N/A
Part B	JN	All Specialties	Surgical Management of Morbid Obesity, 43848	02-02-2009	N/A
Part B	Florida	Specialties 01, 08, 48	Therapy Services Billed With Modifier GO or GP	15-05-2013	N/A
Part B	Puerto Rico	Specialty 25	Therapy Services Billed With Modifier GP	24-07-2012	11-10-2012
Part A	JN	11X TOB – Inpatient Hospital services	Threshold Editing	04-10-2007	7/22/20014
Part A	JN	12X TOB – Hospital Based or Inpatient Part B services	Threshold Editing	04-10-2007	18-06-2014
Part A	JN	14X TOB – Other Hospital services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	13X TOB – Outpatient services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	18X TOB – Hospital Swing Beds	Threshold Editing	04-10-2007	16-07-2012
Part A	JN	22X TOB – SNF Hospital Based or Inpatient Part B services	Threshold Editing	04-10-2007	16-07-2012
Part A	JN	23X TOB – SNF Outpatient services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	71X TOB – Rural Health Clinic (Outpatient) services	Threshold Editing	04-10-2007	16-07-2012
Part A	JN	74X TOB – Outpatient Rehabilitation Facility (ORF) services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	75X TOB – Comprehensive Outpatient Rehabilitation Facility (CORF) services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	76X TOB – Clinic or Hospital Based Renal Dialysis Facility services	Threshold Editing	05-03-1998	16-07-2012
Part A	JN	85X TOB – Critical Access Hospital (CAH) services	Threshold Editing	04-10-2007	16-07-2012
Part A	JN	21X TOB – Inpatient SNF services	Threshold Editing	04-10-2007	16-07-2012
Part A	JN	72X TOB – Clinic ESRD services	Threshold Editing	04-10-2007	16-07-2012
Part B	Florida	All Specialties	Transthoracic Echocardiography (TTE) 93306, 93307 utilization parameter, excluding place of service 21 & 23	25-05-2004	31-01-2011
Part B	JN	All Specialties	Vertebroplasty, Vertebral Augmentation, 20225, 20250, 20251 same date of service 22510-22515,  22520-22525	31-03-2014	01-01-2015
Part B	JN	All Specialties	Viscosupplementation for Knee  J7325 utilization parameter	01-01-2010	N/A

Medicare Medical record review CPT codes list

Automated Medical Review  You could download from the below link. http://medicare.fcso.com/wrapped/274350.zip
Line of Business	Jurisdiction	Provider Type	Description	Date Implemented	Date Last Revised
Part B	JN	All Specialties	Allergy Testing 86003 utilization parameter	30-09-2010	N/A
Part B	JN	Excludes Specialties 18, 41 & 49	Amniotic Membrane-Sutureless Placement on the Ocular Surface, deny 65778 when rendering specialty is not 18, 41 or 49	29-06-2015	N/A
Part B	JN	All Specialties	Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities, Deny Q4112, Q4113, Q4114, Q4139, Q4145, Q4149, Q4155 as not medically reasonable and necessary	08-09-2015	N/A
Part B	JN	All Specialties	Arthrocentesis Deny 20610 if J7321, J7323-J7327 is denied	27-09-2007	01-01-2015
Part B	JN	All Specialties	Autonomic Function Test Deny 95943 non covered	24-03-2014	N/A
Part B	JN	All Specialties	Bisphosphonates J0897 quantity billed and  procedure to diagnosis	14-10-2013	13-05-2015
Part B	JN	All Specialties	Bisphosphonates J3489 quantity billed and  procedure to diagnosis	01-07-2013	01-01-2014
Part B	JN	All Specialties	Bisphosphonates J3489 utilization parameter	01-07-2013	01-01-2014
Part B	JN	All Specialties	Cardiovascular Nuclear Imaging Studies 78452/78454 utilization parameter	01-01-2010	N/A
Part B	JN	All Specialties	Collagenase (Xiaflex) Deny 54200/54235  when J0775 is denied same date of service	14-05-2014	N/A
Part B	JN	All Specialties	Collagenase (Xiaflex) 20527/26341 utilization parameter	06-04-2015	N/A
Part B	JN	All Specialties	CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing Deny 81227 and 81355 non covered	03-11-2014	N/A
Part B	JN	All Specialties	Destruction Of Paravertebral Facet Joint Nerve (S) Utilization Parameter	26-01-2010	01-01-2012
Part B	JN	All Specialties	Endoscopic Treatment Of Gastroesophageal Reflux Disease (Gerd) Deny 43257, C9724 non covered	12-06-2012	N/A
Part B	JN	All Specialties	Erythropoiesis Stimulating Agents  Deny J0882 or J0886 billed without HCT or HGB	28-02-2002	20-10-2010
Part B	JN	All Specialties	Erythropoiesis Stimulating Agents J0890  Deny non covered	02-05-2013	N/A
Part B	JN	All Specialties	Erythropoiesis Stimulating Agents J0888  Deny if not billed with Modifier EC	13-01-2015	N/A
Part B	JN	All Specialties	Flow Cytometry 88185 utilization parameter	30-09-2010	N/A
Part B	JN	All Specialties	Fundus Photography & SCODI, Deny 92250 billed on the same date of service with 92133, 92134	13-02-2011	N/A
Part B	JN	All Specialties	Fundus Photography & SCODI,Deny 92133 or 92134 billed on the same date of service with 92250 (Modifier 59)	13-02-2011	07-04-2011
Part B	JN	All Specialties	G-CSF (Neupogen, Granix), Deny J1442, J1446 billed with certain codes in range J9000-J9999	25-02-2005	01-01-2014
Part B	JN	All Specialties	Heparin Injection Deny J1642 billed with administration code same date of service	11-11-2011	13-12-2012
Part B	JN	All Specialties	Implantable Miniature Telescope (IMT), Deny 0308T & C1840 based on bene & date of service	11-02-2015	11-02-2015
Part B	JN	All Specialties	Long-Term Wearable Electrocardiographic Monitoring 93228, 93229 utilization parameter	26-10-2012	NA
Part B	JN	All Specialties	Long-Term Wearable Electrocardiographic Monitoring 93268, 93270, 93271, 93272 utilization parameter	26-10-2012	03-12-2013
Part B	JN	All Provider Types	Low Density Lipoprotein (LDL) Apheresis utilization parameter	03-11-2014	N/A
Part B	JN	All Specialties	Magnetic Resonance Angiography (MRA) 72159, 73225, C8931-C8936 Deny non-covered	04-08-2011	N/A
Part B	JN	All Specialties	Manipulation Under Anesthesia, Deny 22505 non-covered	25-01-2010	N/A
Part B	JN	All Specialties	Manipulation Under Anesthesia, Deny 27194 billed on the same date of service with 23700, 24300 or 27570	25-01-2010	N/A
Part B	JN	All Specialties	Molecular Pathology Procedures non- covered see LCD 33703	07-10-2013	01-01-2015
Part B	JN	All Specialties	Monitored Anesthesia Care 01991/01992 with Specific Procedures & QS Modifier	25-01-2010	N/A
Part B	JN	All Specialties	Nerve Conduction Studies & Electromyography 95860-95872, 95885-95887, 95907-95913 utilization parameter	30-07-2014	06-08-2014
Part B	JN	All Specialties	Non-Covered Codes By LCD	13-02-2011	09-09-2015
Part B	JN	All Specialties	Non-Covered Services, Deny 0387T-0391T if not billed in a clinical trial	29-06-2015	N/A
Part B	JN	Ambulance	Non-Emergency Ground Ambulance Services Deny mileage (A0425) if transport denied (A0426-A0429, A0433 OR A0434)	27-10-2009	N/A
Part B	JN	Ambulance	Non-Emergency Ground Ambulance Services, Deny mileage (A0425) if transport denied (A0426 or A0428)	30-06-2009	21-12-2011
Part B	JN	All Specialties	Non-Invasive Evaluation of Extremity Veins Deny 93965 billed on the same date of service with 93970 or 93971	23-01-2011	N/A
Part B	JN	All Specialties	Noninvasive Physiologic Studies Of Upper & Lower Extremity Arteries Deny 93922-93924 billed on the same date of service with 93925, 93926	31-01-2012	N/A
Part B	JN	All Specialties	Ocular Photodynamic Therapy (Opt) With Verteporfin Deny 67221 if J3396 not billed	16-07-2013	N/A
Part B	JN	All Specialties	Ophthalmological Services Deny 92002 or 92004 billed with 92226	02-02-2009	N/A
Part B	JN	All Specialties	Paravertebral Facet Joint Blocks Deny drug codes if joint injection denied	14-12-2009	04-02-2011
Part B	JN	All Specialties	Peripheral Nerve Blocks 64400-64455 utilization parameter	17-03-2014	10-04-2014
Part B	JN	All Specialties	Posterior Tibial Nerve Stimulation (Ptns) 64566 utilization parameter	31-01-2012	N/A
Part B	JN	All Specialties	Qualitative Drug Screening G0431, G0434, or G6058 Deny 82570 or 81003 if billed on the same date of service	25-01-2010	01-06-2015
Part B	JN	All Specialties	Qutenza (Capsaicin) J7335, J7336 Deny if billed without 64999	01-01-2011	01-01-2015
Part B	JN	All Specialties	Rhythm ECG Deny 93042 billed with inpatient or emergency evaluation and management services	23-08-2010	N/A
Part B	JN	All Specialties	Skin Substitutes Non-Covered see LCDs L29279/L29393	30-06-2009	01-01-2015
Part B	JN	All Specialties	Spinal Cord Stimulation for Chronic Pain, 63655  Utilization Parameter overtime	07-02-2015	07-02-2015
Part B	JN	All Specialties	Spinal Cord Stimulation for Chronic Pain 63655, Place of Service Other Than 21, 22, 24	07-02-2015	07-02-2015
Part B	JN	All Specialties	Surgical Management Of Morbid Obesity, Deny 43843, 43886, 43887, 43888 non-covered	13-02-2011	N/A
Part B	JN	All Specialties	Surgical Treatment of Nails 11730, 11732, 11750, 11765 Deny without modifiers TA, T1-T9, FA, F1-F9	11-02-2013	N/A
Part B	JN	All Specialties	Surgical Treatment of Nails 11730/11732 Utilization Parameter	11-02-2013	N/A
Part B	JN	All Specialties	Total Calcium 82310 Phosphorus 84100 utilization parameter	07-04-2008	09-10-2008
Part B	JN	Excluding Specialties 13 & 26	Transcranial Magnetic Stimulation For Major Depressive Disorder Deny 90867, 90868, 90869 if not specialty 13 or 26	07-07-2014	N/A
Part B	JN	All Specialties	Transplantation Immune Cell Function Assay (IMMUKNOW) Deny 86352 non-covered	29-01-2013	N/A
Part B	JN	All Specialties	Tysabri J2323 utilization parameter	09-06-2010	09-12-2011
Part B	JN	All Specialties	Vertebroplasty, Vertebral Augmentation Deny 22510-22515, 22520-22525 billed without 72291-72292	31-03-2014	01-01-2015
Part B	JN	All Specialties	Vertebroplasty, Vertebral Augmentation utilization parameter	31-03-2014	01-01-2015
Part B	FL/US Virgin Islands	Specialties 50, 89, 97	Vestibular Function Tests	30-09-2014	N/A
Part B	JN	All Specialties	Viscosupplementation Therapy for Knee J7321, J7323, J7324, J7325 and J7327 utilization parameter of codes overtime	01-01-2010	11-06-2015
Part B	JN	All Specialties	Viscosupplementation Therapy for Knee J7325 utilization parameter (units billed)	01-01-2010	N/A
Part B	JN	All Specialties	Viscosupplementation Therapy for Knee  J7326 and J7327 lifetime utilization parameter	11-06-2015	N/A
Part B	JN	All Specialties	VISCO and Imaging Modalities, Deny 77012, 77021, 76881, 76882 or 76942 billed on the same date of service with J7321, J7323, J7324, J7325, J7326 or J7327	26-11-2014	01-01-2015
Part B	JN	All Specialties	Wound Debridement Services 97597 utilization parameter	08-06-2012	N/A