Medical Review Pre-Payment Reviews: October 2024 to September 2025 Planned Reviews

Published 10/16/2024

Palmetto GBA Railroad Medicare’s Medical Review (MR) department is conducting pre-payment reviews.

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 are reviewing your claim and the additional documentation which you submit. The reason for record review is to confirm that services were rendered according to the Medicare guidelines for medical reasonableness and necessity. Providers can expect review completion within 30 days of MR’s receipt of the requested documentation for prepay claims.

A Remittance Advice (RA) will be generated after MR makes a determination on the claim. The RA will explain if the claim was allowed at the level billed, allowed but at an up-coded or down-coded level, or if the claim was denied. Railroad Medicare will also determine liability for denied services.

October 2024 Through September 2025 Planned Pre-Payment Reviews

Table 1.
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)
Echocardiography 93306 Echocardiography, transthoracic, real-time with image documentation
Ophthalmology Surgical Services 66894 Extracapsular cataract removal with insertion
Radiology 71045 X-ray exam chest 1 view
Radiology 71046 X-ray exam chest 2 views
Radiology 71260 Diagnostic imaging procedures of the chest
Radiology 77080 DXA, bone density, axial
Therapy 97110 Therapeutic exercises
Therapy 97112 Neuromuscular reeducation
Therapy 97113 Aquatic therapy/exercises
Therapy 97116 Gait training therapy
Therapy 97140 Manual therapy, 1/> regions
Therapy 97150 Group therapeutic procedures

CPT® codes, descriptors and other data only are copyright 2023 American Medical Association®. All rights reserved.

Resources on the Palmetto GBA/Railroad website:


Was this article helpful?