Palmetto Education Articles
Getting to the Heart of the Matter
To date, Palmetto GBA has posted twenty-three DRG and procedure specific articles on their CERT Topics webpage (JJ Part A CERT General Information or JM Part A CERT General Information). As September comes to a close and in honor of Atrial Fibrillation Awareness Month, today we highlight two recent additions to this growing list of articles.
DRGs 273 & 274: Percutaneous Intra-cardiac Procedure with MCC and without MCC respectively
Left Atrial Appendage Closure (LAAC) procedures are performed as a stroke prevention measure in certain patients with atrial fibrillation. National Coverage Determination (NCD) 20.34 outlines the indications for CMS to consider this procedure to be a medically necessary service.
The CERT denials of inpatient claims for LAAC article highlights the following reasons for denials:
- Missing documentation to support the need for the LAAC procedure. Reminder, CMS covers this procedure for patients with non-valvular atrial fibrillation.
- The submitted medical records were missing evidence of a formal shared decision making interaction with an independent non-interventional physician using an evidence-based decision tool on oral anticoagulation in patients with non-ventricular atrial fibrillation prior to LAAC.
DRG 266: Endovascular Cardiac Valve Replacement with MCC
Transcatheter Aortic Valve Repair (TAVR) procedures are performed to treat symptomatic aortic valve stenosis. NCD 20.32 outlines the indications for CMS to consider this procedure to be a medically necessary service.
The CERT denials of inpatient claims for TAVR article highlights the following two reasons for denials:
- Missing documentation to support the need for the TAVR procedure. Note, this procedure is used for the treatment of aortic stenosis when furnished according to the Food and Drug Administration (FDA) - approved indications.
- The submitted medical records were missing evidence that two cardiac surgeons had independently examined the patient face-to-face and evaluated the patient’s suitability for open aortic valve replacement (AVR) surgery. Both surgeons must document the rationale for their clinical judgment and that the rationale was available to the heart team.
Note: The requirement has changed from two cardiac surgeons independently examining the patient to a cardiac surgeon and an interventional cardiologist with the release of the June 2019 Decision Memo (CAG-00430R).
To date, out of the twenty-three articles, only Psychoses (DRG 885) and Renal Failure (DRG 682) have come under scrutiny in the Targeted Probe and Educate (TPE) Program. While not officially on the list, we have heard from a client that they have received requests for Spinal Fusion records. DRG 460 Spinal Fusion was one of the first of these articles posted. As a reminder to providers in one of the two Palmetto jurisdictions, Palmetto finalized Local Coverage Determination (LCD): Lumbar Spinal Fusion (L37848) this year that is effective for services performed on or after 05/06/2019.
MMP will continue to follow Palmetto’s websites for any future articles.
Article by Beth Cobb
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.
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.