Agencies that bill to Palmetto GBA can expect even more scrutiny of high-therapy claims with HIPPS code 5BGK*, as the Medicare administrative contractor (MAC) initiates a targeted review of these claims.
 
From Feb. 1 to April 1, Palmetto performed a service-specific prepay probe medical review on claims involving the code (HHL 2/3/14). The MAC completely or partially denied 62 of 190 claims involving 5BGK — denying nearly $223,000 of more than $767,000 million reviewed. The most common denial findings: Documentation contradicted MO Item(s) and face-to-face encounter requirements were not met.
 
Claims involving the affected code should be rare, because those patients would have a severe condition, experts say.
 
Palmetto, the MAC in 16 mostly southern states, announced its service-specific prepay probe review in January.