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.

February 22^nd is National Heart Valve Disease (HVD) Awareness Day. One way to diagnose HVD is to perform an echocardiogram. You can read more about causes, risk factors, symptoms, and treatment of HVD  in a related article in this week’s newsletter. This article highlights one MAC’s Targeted Probe and Educate (TPE) review results for Transthoracic Echocardiography (CPT® code 93306).  

Palmetto GBA Jurisdiction J Part B TPE Review Results for Transthoracic Echocardiography July through September 2022

Palmetto GBA recently published their review results for CPT® code 93306: Echocardiography, Transthoracic, Real-Time with Image Documentation, for July through September 2022 claims. Jurisdiction J includes Alabama, Georgia, and Tennessee.

Review Results by the Numbers

• Thirty-seven providers received additional documentation requests (ADRs) for claims for this review.
• Palmetto GBA reviewed 1,480 claims.
• The state specific claim denial rate was 35% in Tennessee, 46% in Alabama and 50% in Georgia.
• Overall, 45% of the claims were denied.
• The total dollar denied amount was $101,664.11.
• Twenty-five providers were found to be “non-compliant” and will progress to a second TPE review of records.

   

  National Volume and Payment for CPT® 93306 July – September 2022 Claims

  In Palmetto GBA’s article Medicare Coverage of Echocardiography, they “identified CPT 93306 as an area of vulnerability” and noted “this code is a major risk.” As this is a TPE review target, is seems Palmetto GBA continues to identify CPT® 93306 as “an area of vulnerability” and “major risk.”

   

  Since the RTMD database now covers all 50 states and D.C. and inpatient discharges, outpatient hospital services and CMS 1500 Professional Services, I wanted to quantify this “major risk” at the national level.

   

  RTMD July-September 2022 Part B Professional Claims by Site of Service

  • Non-Hospital: 710,467 claims volume and $107,785,891 payment
  • 21-Inpatient Hospital: 569,770 claims volume and $30,110,417 payment
  • 22-Outpatient Hospital: 556,523 claims volume and $29,110,491 payment
  • 19-Off Campus-Outpatient Hospital: claims 85,517 volume and $4,624,688 payment
  • 23-Emergency Room Hospital: 12,983 claims volume and $674,203 payment

   

  The Total Volume was 1,935,260 and the Total Payment was $172,305,690. For this three-month time, a 45% claims denial rate equates to 870,867 non-paid claims with a loss in revenue of just over $77.5 million.

   

  Reasons for Claim Denial

• 26% of the denials were due to Palmetto GBA not receiving the documentation requested or the documentation was incomplete, and they were unable to make a reasonable and necessary determination.
• 24% of denials were due to the documentation that was submitted not supporting medical necessity of the services billed based on Palmetto GBA’s applicable Local Coverage Determination (LCD L37379).
• 19% of the denials were due to documentation containing an incorrect, incomplete, or illegible patient identification or date of service.
• 18% of the denials were due to a claim billed in error by the Provider.
• Finally, 11% of the denials were due to documentation not being signed by the rendering Provider.

   

  Specific to documentation not supporting medical necessity, Palmetto GBA noted in the article mentioned above, that “Echocardiography performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor such as having a positive family history, e.g., familial history of Marfan’s disease). Screening service for high-risk patients is considered good medical practice but is not covered by Medicare. When a screening test is performed, use the appropriate screening ICD-10 code to indicate the test is being done for screening purposes. When the result of the test is abnormal, subsequent diagnostic services may be billed with the test-result diagnosis; however, the initial screening test must be listed as screening, even though the result of the screening test may be a covered condition. Symptoms or an existing condition must be present in the medical record to meet medical necessity.”

   

  Moving Forward

  For Providers in Palmetto GBA’s Jurisdiction J or M, Take the time to read LCD L37379 and related Local Coverage Article (LCA) A56625 to identify covered indications and diagnoses for this procedure. Palmetto GBA has also made available an on-demand webinar Medicare Coverage of Echocardiography CPT® Code 93306, noting it should be of interest to the Part B Providers staff, managers, supervisors, medical record departments or third parties that respond on behalf to medical records requests from Palmetto GBA or any other CMS review contractor.

   

  For Providers in other MAC jurisdictions, search the Medicare Coverage Database to identify any applicable LCDs or LCA in place for CPT® 93306.

   

  References

• Palmetto GBA February 2, 2023 TPE Review Results for Transthoracic Echocardiography: https://palmettogba.com/palmetto/jjb.nsf/DIDC/6TOHQHVHCP~Medical%20Review~Targeted%20Probe%20and%20Educate
• Palmetto GBA Article Medicare Coverage of Echocardiography: https://www.palmettogba.com/palmetto/jjb.nsf/DIDC/B6KK2U3508~Specialties~Radiology#:~:text=Transthoracic%20Echocardiography%20(TTE)%2C%20Current,flow%2C%20valves%2C%20and%20chambers
• Palmetto GBA Medicare Coverage of Echocardiography OnDemand Webinar: https://palmettogba.com/palmetto/jjb.nsf/DIDC/2Y8EOPFEPO~Events%20and%20Education~Education%20On%20Demand