Knowledge Base Article

As our readers may have noticed over the last two weeks, we are providing information on the transition of Jurisdiction J from Cahaba GBA as the Medicare Administrative Contractor (MAC) to Palmetto GBA beginning in January and February of 2018. Numerous MMP clients are located in Jurisdiction J, so we believe providing information on the transition is beneficial to our clients and other providers in this Jurisdiction (Alabama, Georgia, and Tennessee).  Along these lines, the focus coverage policy for this month is B-type natriuretic peptide (BNP). I selected this policy because Cahaba GBA has been conducting pre-payment medical review of BNP in the outpatient/non-patient laboratory setting for several years with consistent error rates in the range of 99-100%.  These denials are mainly due to “the documentation submitted did not support clinical urgency for 83880” which would be expected for acute potential cardiac events.

Since our newsletter is read nation-wide, I do not want to forget our readers in other Jurisdictions.   It turns out it is easy to remember almost everyone when discussing coverage of BNP, because 7 of the 8 MACs (9 of 11 Jurisdictions) also have Local Coverage Determinations (LCDs) for BNP.  And with only one exception, the indications and limitations for coverage across these policies is consistent.  Here is a listing of the various Part A LCDs for BNP (CPT code 83880). You can easily view the specific policies by entering the Document ID # in the Quick Search section of the Medicare Coverage Database webpage.

Although stated somewhat differently between policies, the consensus for coverage of BNP is that it is covered:

• When used in combination with other medical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography; and
• To distinguish cardiac cause of acute dyspnea from pulmonary or other non-cardiac causes;
• To distinguish decompensated CHF from exacerbated chronic obstructive pulmonary disease (COPD) in a symptomatic patient with combined chronic CHF and COPD (Cahaba’s LCD does not include this indication, although Cahaba has stated in verbal discussion with providers that this would be a covered use of BNP.); or
• As a risk stratification tool (to assess risk of death, myocardial infarction or congestive heart failure) among patients with acute coronary syndrome (myocardial infarction with or without T-wave elevation and unstable angina) when obtained in the first few days after the onset of ischemic symptoms.

Providers also need to be familiar with the ICD-10 diagnosis codes that “support medical necessity.”  The list of codes supporting medical necessity varies between LCDs. It is likely the MAC will deny coverage utilizing automated edits when a claim is submitted without a “covered” diagnosis code.

BNP is not covered:

• As a stand-alone test, without being used in conjunction with standard diagnostic tests, medical history and clinical findings;
• For monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure;
• For adjustment of therapy in individual patients, or
• As part of cardiovascular risk assessment panels (screening).

Some policies quote the American College of Cardiology/American Heart Association 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult.  These guidelines were updated in 2017 and can be viewed on the ACC website. Some physicians argue the new guidelines support a standard of care to monitor and adjust therapy, determine prognosis and establish disease severity in CHF patients followed in an ambulatory setting based on the

“Class I recommendation (Level of Evidence: A) for measurement of B-type natriuretic peptide (BNP) or N-terminal (NT)-proBNP for establishing prognosis or disease severity in chronic HF.” 

However the full ACC/AHA article states, “Because of the absence of clear and consistent evidence for improvement in mortality and cardiovascular outcomes (43-62), there are insufficient data to inform specific guideline recommendations related to natriuretic peptide–guided therapy or serial measurements of BNP or NT-proBNP levels for the purpose of reducing hospitalization or deaths in the present document.”

The National Government Services (NGS) LCD for Jurisdictions K and 06 is significantly different, though extremely specific, from the other LCDs by allowing coverage for:

• To establish prognosis or disease severity in chronic CHF when needed to guide therapy,
• To achieve optimal dosing of guideline-directed medical therapy (GDMT) in select clinically euvolemic patients followed in a well-structured heart failure (HF) disease management program,
• To guide therapeutic decision-making in individuals who have amyloidosis.

Laboratory tests are not paid separately for inpatients or for outpatients having other outpatient services, and even when paid the Clinical Lab Fee Schedule payment rate for BNP is around only $46.  The Medicare issue with laboratory tests such as BNP is not the payment rate per test, but that millions of lab tests across the nation can add up to large reimbursement amounts for Medicare.

Hospitals need to evaluate whether their physicians are following the Medicare LCD guidelines for their Jurisdiction when ordering BNP testing on outpatients in a setting other than the Emergency Department.  Should another MAC besides Cahaba perform audits, what does your hospital have at risk?