Knowledge Base Article

MMP’s Protection Assessment Report (P.A.R.) combines current Medicare Fee-for-Service review targets (i.e., MAC, RAC, OIG) with hospital specific paid claims data made possible through a collaboration with RealTime Medicare Data (RTMD). Monthly, our newsletter spotlights current review activities. This month we provide updates and educate resources from the CERT, two MACs and Livanta, the National Medicare Review Contractor.

CMS Q1 2022 Program Scorecard

The U.S. government website PaymentAccuracy (link) publishes program scorecards “to assist the public in understanding what agencies are doing to overcome unique challenges and obstacles to ensure federal funds reach the right recipient.” More specifically, program scorecards are published for high-priority programs such as the Department of Health and Human Services Medicare Fee-for-Service (FFS) program.

The most recent Medicare FFS Program Scorecard published is for Q1 of the CMS fiscal year (FY) 2022 (link). Of note, actions being taken to recover overpayments includes:

• Recovery Audit Contractors reviewing inpatient claims for medical necessity and coding purposes,
• HHS implementation of the Review Choice Demonstration for Home Health Services in the last two states of North Carolina and Florida, and
• HHS providing additional funding to the MACs and the Supplemental Medicare Review Contractor (SMRC) to allow for additional claims review to determine if they had been billed appropriately. You can read more about current SMRC activities in a related article in this week’s newsletter.

Comprehensive Error Rate Testing (CERT) Announcement

The CERT Review Contractor has posted (link) their review year 2022 completion status. As of April 4, 2020, they have completed initial review of 34,400 claims out of 41,974 claims in the 2022 Annual Report (claims submitted to the MAC between July 1, 2020, and June 30, 2021).

Palmetto GBA JJ/JM MAC

New Address Information for CERT Review Contractor

Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, has published an article (link) to alert providers about the CERT Review Contractor’s move to a new location. The new address will be on letters beginning April 11, 2022. You will find the CERT Review Contractor’s new address, fax number, customer service toll free number and email in Palmetto’s article.

Cervical Discectomy Module

Palmetto GBA, has published a Cervical Discectomy module (link) focused on the roles of cervical spine, the differences between discectomy and fusion, and documentation requirements.

Spinal Cord Stimulatory Therapy Module

Palmetto GBA has also recently published a Spinal Cord Stimulator module (link) focused on the purpose of the spinal cord stimulator, coverage requirements for spinal cord stimulatory (SCS) therapy, and documentation requirements.

CERT: Inpatient Psychiatric Facility Checklist

Palmetto GBA posted a checklist (link) for providers to use when your claim(s) are selected for review by the CERT contractor. In this notice, they also provide links to their Psychiatric Inpatient Hospitalization Local Coverage Determination and related Billing and Coding article.

WPS J5/J8 MAC

New YouTube Video

WPS has released a new YouTube Video titled Transcatheter Aortic Valve Replacement (TAVR) CERT Findings (link). This video describes reasons for improper payments identified by the CERT Contractor for WPS claims and provides information on how to avoid these errors.

Therapy Assistants: What They Cannot Do

WPS published an article (link) noting they have identified that physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) have been providing services outside CMS guidelines. The article details what activities that Medicare does not allow PTAs or OTAs to complete.

Livanta National Medicare Review Contractor

Livanta’s focus as the National Medicare Review Contractor is on performing Short Stay Review (SSR) and Higher Weighted DRG (HWDRG) reviews. Monthly, they release a publication titled The Livanta Claims Review Advisor. The March 2022 edition (link) focuses on Exploring Short-Stay Claim Review Guidelines and provides information about:

• The history and background of short stay claim reviews,
• Short stay medical review,
• Step-by-Step guideline for short-stay determinations,
• Example scenarios for short-stay Part A denials, and
• Documentation features.

For those interested in receiving this publication, Livanta provides a link to subscribe at the bottom of the newsletter.