MAC Medical Review Updates June 2017

on Tuesday, 20 June 2017. All News Items | MAC Reviews

A Smorgasbord of Review Topics

A Smorgasbord of Review Topics

There are lots of “good eating” holidays in the summer from Memorial Day to Mother’s Day to Father’s Day, the Fourth of July and finally Labor Day. Barbecues, pot-luck dinners, restaurant buffets and family picnics all offer a smorgasbord of good food. This month the medical review activities of the Medicare Administrative Contractors (MACs) offer up a smorgasbord of review topics.

For our Medicare Administrative Contractor (MAC) medical review update this month, I want to look at a variety of topics instead of delving into the details of one issue. As you can see from the table at the bottom of this article, the MACs were quite active this month on the medical review front. There are some interesting ‘multi-MAC’ review topics, some intriguing post-probe review decisions, and as always, challenges in finding all the desired information on certain MAC websites.

Cardiac Rehabilitation

This review topic is being looked at by at least two MACs. CGS (J15 MAC) published results of their service-specific complex review, which will be continued, and NGS (J6 MAC) had a new announcement on their website, although it is not dated. The main reason for denial was the lack of one or more of the required components for cardiac rehab services such as:

  • Physician-prescribed exercise
  • Cardiac risk factor modification
  • Psychosocial assessment
  • Outcomes assessment
  • An individualized treatment plan

For excellent information on the requirements for cardiac rehab services, I recommend CGS’s educational article or the NGS announcement.


The NGS JK jurisdiction completed several pre-pay probe reviews of drugs and I was surprised that despite fairly significant error rates, NGS did not progress any of these topics to a targeted medical review. Of specific note, there were reviews of injections of: Alteplase (J2997) with a payment error rate of 42.27%, Pegfilgrastim (J2505) with a payment error rate of 58.41%, and Botulinum Toxin (J0585) with a payment error rate of 53.90%. Some of the denial reasons were missing documentation such as:

  • Medication administration record with drug name, dosage, frequency of injection, site, route and date/time of administration;
  • Documentation to support medical necessity of services such as medical history, physician progress notes, pertinent diagnostic tests/procedures, or treatment plan/plan of care;
  • Physician\practitioner’s signed order for medication billed;
  • For alteplase, documentation indicating it was administered for restoration of function to the central venous access device; and
  • For botulinum toxin, documentation showing patient had an inadequate response to conventional treatment prior to initiation of the botulinum.

Hyperbaric Oxygen Therapy

Palmetto GBA published the results of the 1st quarter service-specific targeted review for HBO. I have previously addressed this review topic in a Wednesday@One article, due to the high errors rates from Palmetto’s probe review. Only one state in Palmetto’s jurisdiction showed slight improvement in the targeted review, while the other states error rates increased over the probe review results. The main reasons for denial of HBO services are:

  • Documentation provided does not support the medical necessity for HBOT,
  • Lack of a treatment plan,
  • Treatment plan does not include goals for the therapy,
  • Treatment plan does not include progress updates and patients response to therapy,
  • There is no valid order for services provided.


Another review topic that may be being reviewed by more than one MAC is blepharoplasty. CGS (J15) released results of a complex medical review for blepharoplasty services with charge denial rates of 36.8% and 60.0%. The top denial reasons were no documentation of medical necessity and failure to submit requested records. WPS, both jurisdictions J5 and J8, published interim results for two outpatient hospital service edits. One of the edits is for “Questionable Covered Services” but the WPS article does not specify which services these are. In the References section of the article, the Blepharoplasty LCD is one of LCDs referenced. This may indicate Blepharoplasty is one of the review topics under Questionable Covered Services for the WPS reviews.

All 12 MACs have Local Coverage Determinations addressing the coverage of Blepharoplasty. The CGS LCD cites the following as covered indications:

  • To correct visual impairment caused by dermatochalasis, blepharochalasis, blepharoptosis, or brow ptosis. Documentation must support patient complaints which justify functional surgery and address the signs and symptoms commonly found in association with ptosis, pseudoptosis, blepharochalasis and/or dermatochalasis. These include (but are not limited to):
    • Significant interference with vision or superior or lateral visual field, (e.g., difficulty seeing objects approaching from the periphery);
    • Difficulty reading due to superior visual field loss; or,
    • Looking through the eyelashes or seeing the upper eyelid skin.
  • Repair of anatomical or pathological defects, including those caused by disease, trauma, or tumor-ablative surgery to reconstruct the normal structure of the eyelid, using local or distant tissue.
  • Relief of eye symptoms associated with blepharospasm.

Refer to the complete CGS LCD or you local MAC’s LCD for more information.

Bone Mass Measurement

A new topic not previously addressed by any MAC is that of Bone Mass Measurement (BMM). WPS, J5, released results of a service-specific audit of BMM with a charge error rate of 33%. As a reminder, the coverage guidelines for BMM can be found in the Medicare Benefit Policy Manual, Chapter15, section 80.5 and claims guidelines in the Medicare Claims Processing Manual, Chapter 13, section 140. To summarize, Medicare covers screening of BMM every 2 years for estrogen deficiency (post-menopausal), vertebral abnormality (such as osteoporosis, osteopenia, or vertebral fracture), glucocorticoid therapy (with specific dosage, frequency, and duration requirements), and primary hyperparathyroidism. Testing to monitor osteoporosis treatments is only covered for dual-energy x-ray absorptiometry (axial) tests (CPT 77080). When medically necessary, Medicare may pay for more frequent BMMs such as for monitoring patients on long-term steroid therapy of more than 3 months or to confirm baseline BMMs to permit monitoring of beneficiaries in the future.

WPS denied bone mass measurements when:

  • Documentation did not support services were performed as billed
  • Documentation did not support the ordering provider’s rationale for the vertebral fracture assessment (VFA)
  • Missing documentation (i.e. physicians order or intent, BMM interpretation.)
  • Missing medication dosing and frequency
  • Bone mass measurement preformed did not match the order and the explanation for separate tests was not provided

As you can see, there is a little something for everyone on the MAC’s smorgasbord. Enjoy!

MACService DescriptionService CodeDateError/Denial RateStatus
NGS J6 Cardiac Rehabilitation Services CPT 93798 unk   New
NGS JK Alteplase Injection HCPCS J2997 6/7/2017 42.27% discontinued
NGS JK Chemotherapy Admin. per IV Infusion - Additional Hours CPT 96415 6/7/2017 28.48% discontinued
NGS JK Pegfilgrastim Injection HCPCS J2505 6/7/2017 58.41% discontinued
NGS JK Trastuzumab HCPCS J9355 6/7/2017 15.63% not stated
NGS JK Injection of Botulinum Toxin HCPCS J0585 6/1/2017 53.90% discontinued
NGS JK Transluminal Balloon Angioplasty, Percutaneous; Venous CPT 35476 6/7/2017 15.29% discontinued
Palmetto JM Pegfilgrastim HCPCS J2505 5/26/2017 NC - 28.2% continue
Palmetto JM Bevacizumab, 10 mg HCPCS J9035 5/26/2017 NC- 15.2%
VA - 25.0%
Palmetto JM HBO HCPCS G0277 6/5/2017 NC - 57.1%
SC - 90.3%
VA - 77.0%
WV - 100%
CGS J15 Cardiac Rehab HCPCS 93798 5/22/2017 KY - 54.7%
OH - 39%
CGS J15 Spinal Injections HCPCS 62311 5/22/2017 55.80% continue
CGS J15 Cataract Removal HCPCS 66984, 66983, 66982 5/22/2017 KY - 32.1%
OH - 41.1%
CGS J15 Major Joint Replacement DRG 470 5/22/2017 KY - 19.8% discontinued
CGS J15 Blepharoplasty HCPCS 15820-15823 5/22/2017 KY 36.8%
OH - 60.0%
WPS J5 High Dollar Claims Interim Results NA 5/30/2017 39% continue
WPS J5 Outpatient Hospital Services Edits - Interim results various codes 5/30/2017 19% continue
WPS J5 Outpatient Hospital Diagnostic Procedure - Bone Mass Measurement HCPCS codes 77078, 77079, 77080, 77081, 77083, and G0130 5/22/2017 33% continue
WPS J8 High Dollar Claims Interim Results NA 5/30/2017 43% continue
WPS J8 Outpatient Hospital Services Edits - Interim results various codes 5/30/2017 33.50% continue


Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie 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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