MAC Prepayment Reviews - August 2012 Updates

on Tuesday, 14 August 2012. All News Items | MAC Reviews

As mentioned in our last Medicare coverage updates, we are now including information from three Medicare Administrative Contractors (MACs) in our newsletters in order to provide more complete Medicare information for all of our clients. Those MACs are:
  • Cahaba GBA, Jurisdiction 10 (J10) Part A MAC – Alabama, Georgia, and Tennessee
  • Palmetto GBA, Jurisdiction 11 (J11) Part A MAC - North Carolina, South Carolina, Virginia, and West Virginia.
  • Novitas Solutions, Jurisdiction 12 (J12) Part A MAC - Delaware, New Jersey, Pennsylvania, Maryland, and the District of Columbia.
Although MAC reviews are specific to their jurisdictions, providers may find some of the information from other MACs helpful, especially educational materials.

Cahaba GBA Prepay Review Updates

There are no review updates for Cahaba this month.
All Cahaba GBA review announcements, results, and education articles can be found under “What’s New” at https://www.cahabagba.com/part-a/

Palmetto GBA Prepay Review Updates

New Reviews

Claim TypeService CodeService DescriptionReason for ReviewType of ReviewDateStates
13x TOB HCPCS J9355 Trastuzumab Data analysis shows providers are billing multi-dose vials instead of amount administered prepay complex 8/2/2012 All J11 states
Inpatient hospital DRG 247 Percutaneous CV Procedure with Drug-Eluting Stent without MCC ranking of covered charges in top 10 DRGs probe 7/30/2012 NC, SC
Inpatient hospital DRG 291 Heart Failure, Shock with MCC ranking of covered charges in top 10 DRGs probe 7/30/2012 NC, SC

Review Results

  • Inpatient Service-Specific Complex Targeted Medical Review of DRG 191 (COPD with CC) in North Carolina (July 10, 2012)
    • Charge Denial Rate 30%
    • Main reason for denial was “need for service was not medically reasonable and necessary”
    • Other denials for lack of timely submission of records, no order for inpatient admission, and illegible or missing signatures
    • Review to be discontinued at this time
  • Inpatient Service-Specific Complex Targeted Medical Review of DRG 690 (Kidney and Urinary Tract Infections without MCC) in North Carolina (July 10, 2012)
    • Charge Denial Rate 24%
    • Main reason for denial was “need for service was not medically reasonable and necessary”
    • Other denials for lack of timely submission of records, no order for inpatient admission, and illegible or missing signatures
    • Review to be discontinued at this time
  • Inpatient Service-Specific Complex Targeted Medical Review of DRG 312 (Syncope with Collapse) in North Carolina (July 10 ,2012)
    • Charge Denial Rate 54%
    • Denial rate improved from probe review denial rate of 71%
    • Main reason for denial was “need for service was not medically reasonable and necessary”
    • Other denials for lack of timely submission of records and no order for inpatient admission
    • Review will be continued due to unacceptable denial rate

All Palmetto GBA review announcements, results, and education articles can be found under “What’s New” at http://www.palmettogba.com/palmetto/providers.nsf/DocsCatHome/Jurisdiction%2011%20Part%20A

Novitas Solutions Prepay Review Updates

Education

Novitas published an educational article on Total Joint Replacement - Understanding Documentation Requirements for Inpatient Admission on July 24, 2012. This article is in response to a high Comprehensive Error Rate Testing (CERT) error rate for DRG 470 - Joint Replacement or Reattachment of Lower Extremity without MCC. The article states “The areas of concern are total knee and total hip replacements. Reviews have found that the criteria to support the joint replacement is not met, therefore the procedure is determined to be not medically necessary and the inpatient admission and stay are therefore also denied as not medically necessary.” The article details the documentation required to support medical necessity for these procedures.

All Novitas Solutions review announcements, results, and education articles can be found at https://www.novitas-solutions.com/parta/whatsnew/index.html

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