Jurisdiction J Medical Review Updates

on Tuesday, 10 April 2018. All News Items | Case Management | Medicare Coverage | Documentation

Take a Tour of the Palmetto GBA Medical Review Webpage

By now most schools have made it past Spring Break and are well on the way to the home stretch towards summer vacation. This year, my oldest nephew’s baseball team in Clarkesville, TN (Go Hawks!) came to Alabama for a baseball tournament during Spring Break. During his stay in Alabama, as he is nearing the end of his Sophomore year in high school, the subjects came up of when was he planning to take the ACT and SAT and does he have any college tours planned. Before heading back to Clarkesville, my brother and nephew drove Samford University’s campus since this is where my brother attended college. It was a surprise to see that what was once a men’s freshman dorm was now the School of Divinity.

Times change and for Alabama, Georgia and Tennessee, the Medicare Administrative Contractor (MAC) has recently changed from Cahaba, GBA to Palmetto GBA. We have been hearing from clients that it did not take long for Palmetto to begin requesting records as part of the Targeted Probe and Educate Program. This article will take you on a “tour” of Palmetto’s Medical Review webpage in an attempt to keep you from being surprised by any changes.

First Tour Stop: General Information

Palmetto notes that “Medical review is the collection of information and clinical review of medical records…to ensure that payment is made only for services that meet all Medicare coverage, coding, and medical necessity requirements.” The goal of Medical review is “to reduce payment errors by identifying and addressing billing errors made by providers concerning coverage and coding.”

Additional Resources and links to “Latest Articles” are available on the General web page.  Latest Articles is where you will find the Active Medical Reviews being performed by Palmetto. Below is a table of Active Medical Reviews as of 3/1/2018.

Palmetto GBA Jurisdiction J (JJ): Active Medical Reviews
LOBCode TypeSpecific CodeEdit Topic
Part A DRG DRG 470 Major Joint Replacement or Reattachment of Lower Extremity without Major Complications or Comorbidities
Part A DRG DRG 885 Psychoses
Part A HCPCS J2505 Pegfilgrastim, 6mg
Part A-SNF RUG RU***,RV*** Ultra High/Very High RUG Codes
Part A-IRF CMG A0601-A0604, B0601-B0604, C0601-C0604, D0601-D0604 Neurological Motor
Part B CPT 99232-99233 Evaluation and Management (E/M), Subsequent Hospital Inpatient Care (Typically 35 Minutes per Day)
Part B CPT 99291-99292 Critical Care, First Hour Plus
Source: Palmetto GBA JJ Part A web page – Last Updated: 03/01/2018

Second Tour Stop: Notification

As of 4/1/2018, the following statement is the only thing on the Notification webpage:

“When Palmetto GBA identifies a service as being at risk, the potential error is validated with a review. Conducting a review ensures that medical review activities are targeted at identified problem areas. The sample of potential problem claims is used to validate the hypothesis that such claims are being billed incorrectly or in error. Current service-specific reviews may be viewed below.”


Third Tour Stop: Results

Palmetto GBA indicates that “upon the completion of the service-specific review sample, the claim review findings are analyzed and appropriate corrective action is taken when providers are found to be non-compliant based on the Progressive Corrective Action (PCA) philosophy. You may view information regarding the results of completed service-specific reviews below.

Note: Provider-specific review results are not published on the website. Providers are notified in writing at the beginning of the review and periodically until the conclusion of the review process.”

At this time, there are no results posted on this page. However, when you go to the JM Results webpage you can see the findings of reviews performed for the JM states (NC, SC, VA, and WV).  Palmetto does an excellent job of providing what they call “Granular Detail” as to why they denied a claim. Several of the current JJ Active Medical Reviews have already been under review in JM. The following table provides you a link to a sample of available specific review results.

Palmetto GBA Jurisdiction M: Active Medical Review Results
LOBCode TypeSpecific CodeLink to Medical Review Results
Part A DRG DRG 470 https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~Results~ARLLUT1283?open
Part A DRG DRG 885 https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~Results~ATRHGN2266?open
Part A HCPCS J2505 https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~Results~ATJP3E5612?open
Part A-SNF RUG RU***,RV*** https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~Results~ARLRGQ3053?open
Part B CPT 99232-99233 https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~Medical%20Review~Results~AVLRAY7176?open
Part B CPT 99291-99292 https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20B~Medical%20Review~Results~AT4PT33662?open
Source: Palmetto GBA JM Part A and Part B web pages – Last Updated: 04/01/2018

Fourth Tour Stop: Targeted Probe and Educate (TPE)

The TPE process was implemented by all MACs as of October 1, 2017. This webpage contains Articles about the review process, Q&A’s from a February 1, 2018 Palmetto GBA teleconference, a reminder about the Provider Contact and the Claims Selection Process.

Having attended two live Palmetto GBA Provider Outreach sessions in Birmingham prior to the MAC Transition, one thing that Palmetto stressed was the Provider Contact. In fact, they have bolded the following statement on their website: “It is imperative when responding to the TPE Additional Documentation Request (ADR) that you include the name and number of your designated contact person.” 

You can read more about the TPE Process in a related Wednesday@One Article.

End of the Tour: Education Events with Palmetto GBA Jurisdiction J (JJ)

As the tour of Medical Review winds down, I want to leave you with a few coming Palmetto GBA Education Opportunities. 

JJ Part A Website Navigation Basics Webcast

Date: April 12, 2018
Time: 10:00 AM – 11:00 AM
Webcast Detail: This session is designed to provide a basic overview of the Palmetto Jurisdiction J Part A website and navigation tutorial to assist providers in locating important resources and tools.
Link to Announcement: https://www.palmettogba.com/event/pgbaevent.nsf/EventDetails.xsp?EventID=AWVRT97085

Part A Ask the Contractor Teleconference (ACT): Specialty Clinical Topic: Hyperbaric Oxygen (HBO) Therapy

Date: May 15, 2018
Time: 11:00 AM – 12:00 PM
Teleconference Detail: Palmetto GBA Clinical Consultants will be providing information concerning Medical Review Targeted Probe & Educate (TPE) findings for HBO and how to improve your documentation.
Teleconference Number: (877) 789-3907
Confirmation Code: 86041469
Link to Announcement: https://www.palmettogba.com/event/pgbaevent.nsf/EventDetails.xsp?EventID=AXFQ524544

If you are a Provider that offers HBO Therapy, I strongly encourage you to listen to this teleconference. At this time medical review of HBO Therapy is not occurring in JJ. However, this has been a review area for some time in JM. I believe they are providing education in advance of making this a part of their Active Medical Review. The following table provides high level detail from Palmetto’s latest HBO Review Results.

Palmetto, GBA JM Prepayment  Review Results for Outpatient HBO, HCPCS G0277 for August – October 2017
StateVolume Claims ReviewedTotal Dollars ReviewedTotal Dollars DeniedCharge Denial Rate
NC 595 $5,371,347.48 $3,432,610.16 64%
SC 193 $1,731,422.19 $1,030,603.12 59.5%
VA 130 $3,436,849.80 $2,298,500.80 66.9%
WV 248 $1,038,515.11 $701,558.81 67.6%
Link to Results: https://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~JM%20Part%20A~Medical%20Review~Results~ATJLY50118?open

In addition to listening to the teleconference, I encourage you to read the JM Review Results to help understand the specific “Granular” denial findings and proactively review a sample of HBO records at your facility.  

Part A Inpatient Psychiatric Facility (IPF) Coverage and Documentation Webcast

Date: May 23, 2018
Time: 10:00 AM – 11:00 AM
Webcast Detail: This session is designed to provide overview of IPF coverage, billing and documentation requirements. Palmetto will also discuss Medical Review data related to DRG 885 Psychoses and valuable tips to prevent errors.
Reminder: This is a current Active Medical Review for JJ Part A Providers.
Link to Announcement:  https://www.palmettogba.com/event/pgbaevent.nsf/EventDetails.xsp?EventID=AXFRH20271

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. 

In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Risk Assessment (CRA) Tool. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.


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