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. This month’s focus is on bariatric surgery.

Did You Know?

There has been a National Coverage Determination (NCD) for bariatric surgery (100.1) since 1979. Originally titled Gastric Bypass Surgery for Obesity, the NCD is now titled Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity (link). This name change reflects the fact that treatment for obesity alone remains a non-covered indication for bariatric surgery.

Why Does This Matter?

Bariatric surgery has come under scrutiny by more than one review contractor, for example:

Supplemental Medical Review Contractor (SMRC): Strategic Health Solutions, the first SMRC contractor, completed a review of claims for bariatric service codes for dates of service from January 1, 2014, through December 31, 2014. In their review results, they cited a 35% error rate. The main reason for denials was due to insufficient documentation, for example: documentation did not include information supporting prior unsuccessful medical attempts at weight loss prior to surgical intervention.

Recovery Auditors (RACs): Complex medical reviews of inpatient and outpatient bariatric procedures has been an approved RAC Issue (link) since February 1, 2017.

Office of Inspector General (OIG): More recently, the Office of Inspector General published the report Hospitals Did Now Always Meet Differing Contractor Specifications for Bariatric Surgery (link). The OIG undertook this audit due to findings from a prior review of claims in 2015 and 2016 where they found claims did not fully meet a MAC’s eligibility specifications as well as the variance in eligibility specifications by different MACs. The audit included hospital inpatient claims for bariatric surgery performed from January 2017 through July 2018.

The OIG found thirty-two claims that met the NCD requirements, however the claims did not meet the MACs local specifications in their Local Coverage Determination (LCD) or Local Billing and Coding Article (LCA). Noridian had the most restrictive eligibility specifications in their LCA. The top specification not met was a lack of documentation indicating the beneficiary had participated in a weight management program. Novitas and First Coast had the least restrictive LCDs. The OIG estimated that “Medicare could have saved $47.8 million during our audit period if Medicare contractors had disallowed claims that did not meet Medicare national requirements or Medicare contractor specifications for bariatric surgery.”

OIG Audit Recommendations

Based on the audit findings, the OIG recommended that CMS:

• Determine if any of the MACs eligibility specifications in their LCDs or LCAs should be added to the NCD and if so, take steps to update the NCD,
• Work with the MACs to determine if any of the LCD or LCA eligibility specifications should be requirements rather than guidance, and
• If the NCD is updated, provide education to hospitals on the NCD requirements for bariatric surgery.

CMS Response

CMS did not agree with the OIGs recommendations. Two CMS responses were highlighted in the Report Brief:

• CMS will continue to monitor scientific evidence related to bariatric surgery and evaluate if an update to the NCD is needed, and
• “The Social Security Act does not mandate that LCDs be uniform across all jurisdictions and there are valid reasons that variations at the local Medicare contractor level is appropriate.”

What Can You Do?

If your hospital provides bariatric surgery services, I encourage you to read this OIG Report and perform a record review to ensure documentation supports the NCD requirements and when applicable your MAC LCDs and/or LCAs.