Knowledge Base Article

This week, during a school fall break, I went to the zoo with my grandchildren. This presented the perfect opportunity to teach my young granddaughter the famous phrase from the movie The Wizard of Oz, “Lions, and tigers, and bears. Oh my!” For those of us that deal with Medicare reviews, there are no literal lions, and tigers and bears, but we do sometimes have a reason to fear. Our refrain could be “MACs, and RACs, and CERT. Oh my!” Below is a discussion of the latest review issues and concerns from some of these types of reviewers.

There was not a lot of new medical review activity by Medicare Administrative Contractors (MACs) this month in the Targeted Probe and Educate (TPE) program. Some MACs remain silent on their review topics. Whether this means they are not conducting any reviews or are not sharing that information on their websites is unknown. Novitas, the MAC for Jurisdictions H and L, added new topics for reviews focused on DRG validation and partial hospitalization programs (PHP) for outpatient psychiatric services. DRG validation reviews generally focus on coding accuracy and the codes being supported by documentation in the medical record. WPS J5 reported on their TPE review of DRG validation with excellent results – no providers moved on to Round 2 so this review appears to be concluded for J5.

For the partial hospitalization program review, the PHP Checklist on the Novitas website indicates they expect to see:

• An initial psychiatric evaluation, including history and mental status examination,
• Physician certification/recertification and documentation of physician supervision,
• Description of illness requiring services, and psychiatric diagnosis to support medical necessity,
• Documentation that the services are designed to reduce or control psychiatric symptoms so as to prevent inpatient hospitalization and to improve or maintain the patient’s level of functioning,
• Progress notes for each service rendered, and
• Documentation to support a minimum of 20 hours per week of therapeutic services.

Novitas also released results of their Round 1 review of Hyperbaric Oxygen Therapy (HBO). Denials rate for HBO ranged from approximately 2% to 35% in JH and from approximately 20% to 56% in JL. Insufficient documentation is the reason for all denials. Records lacked documentation of medical necessity, treatments, physicians’ orders, tests/notes to support the diagnosis being treated, response to treatment or measurable signs of healing, and failed standard treatment of diabetic wounds.

Over the past few months, Recovery Auditors, still commonly referred to as RACs, have added new issues.

• In July, APC Validation was added to all RAC regions. This is a coding review to verify procedures are assigned CPT/HCPCS codes accurately and that “match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment.”
• HMS, the RAC for Region 4, posted a review of facet injections at the end of August. HMS quotes information from several Local Coverage Determinations (LCDs) – L34993, L34974, and L34892 – that describe the requirements for injections and blocks. For example, pain must have been present for 3 months or greater and a detailed pain history is essential and must provide information about prior treatment and responses, such as analgesics and physical therapy, for paravertebral facet joint injections.
• A new issue for Cotiviti RAC Regions 2 and 3 from September is the review of the medical necessity of transthoracic echocardiography (TTE) for hospital inpatients and outpatients, and patients in a skilled nursing facility (SNF). The medical necessity of this procedure will be based in large part on the requirements as described in several LCDs. Please refer to the LCD for your MAC region to determine the specific indications and requirement for TTE. For example, the Palmetto LCD includes such statements as:
• When there are no signs or symptoms of heart disease, the use of TTE is not covered for hypertension.
• The role of TTE in the emergency room assessment of individuals presenting with chest pain is not defined at this time. This use is not accepted as a standard-of-care. For TTE to be allowed, clinical findings supporting myocardial dysfunction must be present. When these findings are not present, this use is not covered.
• TTE is used annually in follow-up of chronic valvular disease to document the course over time. Generally, it is not medically necessary to repeat these examinations more frequently than annually. When the patient’s plan of care includes imminent valvular surgery, more frequent exams may be necessary.

Other RAC issues affecting outpatient hospitals are discussed in the Medicare Quarterly Provider Compliance Newsletters. The July newsletter explains that Vagus Nerve Stimulation is only considered reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. It is not covered for other types of seizure disorders or for resistant depression. The article goes on to list the specific ICD-10-CM diagnosis codes that are covered for vagus nerve stimulation. The October newsletter has an article on outpatient services overlapping or during an inpatient stay. Please refer to a June Wednesday@One article for information on how to avoid overlapping claims.

As you can see, there is a smorgasbord of issues for review as usual. Hospital providers have to constantly be on the lookout for lions, and tigers, and bears. Oh my!!