Medical Review Postpayment Reviews: October 2024 to September 2025 Planned Reviews
Palmetto GBA Railroad Medicare’s Medical Review (MR) department is conducting postpayment reviews at this time.
Postpayment review means that MR will request documentation for claims that have already been processed and paid. These reviews are being performed on services where a high error rate and/or potential overutilization has been identified through data analysis.
An Additional Documentation Request (ADR) letter, asking for the records for a specific claim, will be sent on each claim selected for review. MR clinicians will review your claim and the additional documentation which you submit. Providers can expect review to be completed within 60 days of MR’s receipt of the requested documentation for postpayment claims.
Upon review of the documentation, MR clinicians will make a determination that either affirms the original payment or denies the payment (in part or in full.) The RRB SMAC will recoup any funds for claims that were paid previously but are denied through this process.
October 2024 Through September 2025 Planned Postpayment Reviews
| Type of Service | CPT®/HCPCS Code | Code Description |
|---|---|---|
| Ambulance | A0425 | BLS/ALS mileage, per statue mile (in combination with transport codes) |
| Ambulance | A0427 | ALS1, emergency |
| Ambulance | A0429 | BLS, emergency |
| Ambulance | A0431 | Rotary wing air transport |
| Ambulance | A0436 | Rotary wing air mileage, per statute mile (in combination with air transport code) |
| Laboratory | G0480 | Drug test definitive, 1–7 classes |
| Laboratory | G0481 | Drug test, definitive, 8–14 classes |
| Laboratory | G0482 | Drug test, definitive, 15–21 classes |
| Laboratory | G0483 | Drug test, definitive, 22 or more classes |
| Laboratory | 80305 | Drug test, presumptive; direct optical observation |
| Laboratory | 80306 | Drug test, presumptive; instrument-assisted |
| Laboratory | 80307 | Drug test, presumptive; chemistry analyzers |
| Laboratory | 88305 | Tissue exam by pathologist |
| Laboratory | 88307 | Tissue exam by pathologist |
| Laboratory | 88309 | Tissue exam by pathologist |
| Laboratory | 88312 | Special stains; group 1 |
| Radiology Services | 71045 | X-ray exam chest 1 view |
| Radiology Services | 71046 | X-ray exam chest 2 views |
| Radiology Services | 77080 | DXA, bone density axial |
| Radiology Services | R0070 | Transport portable X-ray |
| Radiology Services | R0075 | Transport portable X-ray multiple |
| Radiology Services | Q0092 | Set-up portable X-ray equipment |
CPT® codes, descriptors and other data only are copyright 2023 American Medical Association®. All rights reserved.
Resources on the Palmetto GBA/Railroad website: