Knowledge Base Article

In late summer, the corn stalks grow tall and full across our nation. I love the rustle of a cornfield as the stalks move in the summer breeze. But have you ever been lost in a cornfield or a maze? There is this moment of panic when you think you may not be able to find your way out. The maze of Medicare requirements and reviews can also create feelings of panic. For example, a recent OIG review focused on sleep study services; at least nine Medicare Administrative Contractors (MACs) have local coverage determinations (LCDs) or Articles for sleep studies; and sleep study services have also been the focus of reviews by a Recovery Auditor (Region D HDI) and the Supplemental Medical Review Contractor (SMRC).

Based on the findings from the recent Sleep Study Review, the OIG estimated overpayments of over $1 Million for the audit period for this particular independent sleep study provider. The LCD for the provider’s jurisdiction required that prior to sleep testing, the patient must have a face-to-face clinical evaluation by the treating physician that must include, among other requirements:

• the patient's sleep history and symptoms,
• a physical examination that documents body mass index, neck circumference, and
• a focused cardiopulmonary and upper airway evaluation.

Out of 130 lines of services, 50 had no documentation for the face-to-face clinical evaluation, attending physician's orders, technician's report, or interpretation report and 80 failed to include one or more of the following requirements of the face-to-face clinical evaluation: patient's sleep history and symptoms, Epworth sleepiness scale, body mass index, or neck circumference.

A previous OIG report on sleep studies from 2013 found that Medicare paid nearly $17 million for polysomnography services that did not meet one or more of three Medicare requirements – inappropriate diagnosis codes, duplicate studies for the same date of service, or invalid NPI numbers. According to the report, “Payments for services with inappropriate diagnosis codes composed a majority of these payments. Eighty-five percent of claims with inappropriate diagnosis codes came from hospital outpatient departments.”

The SMRC review from 2014 found that sixty-three percent (63%) of denials were because providers did not provide a History and Physical or other documentation to support medical necessity for polysomnography testing.

Providers need to be familiar with their MAC’s requirements for sleep testing. Hospital-based and independent sleep clinics should verify they are following the Medicare requirements and including appropriate documentation in their records. This is the best way to avoid the panic and ensure a good night’s sleep for you and your patients.

A summary of some Medicare medical review updates from last month are listed below.

Medicare Administrative Contractor (MAC) Review Updates

MAC J15 CGS

• Cataract Removal (HCPCS 66984, 66983, 66982)
• Error rate of 61.5% - 68.5%
• Review to continue

MAC JF Noridian

• Facet Joint Injections, CPT 64493
• Error rate 37% - 54%%
• Review to continue

MAC JE Noridian

• Brotezomib (Velcade), HCPCS J9041
• Error rate 10.7%
• Review to continue

MAC JM Palmetto

• Infliximab, HCPCS J1745
• Error rate 44% - 54%
• Review to continue
• HCPCS G0424, Outpatient Pulmonary Rehabilitation
• Error rate 26.3% – 55.3%
• Discontinued
• HCPCS Code J2505, Pegfilgrastim, 6 mg
• Error rate – 15.2% - 41.2%
• Discontinue in VA and WV, continue in NC and SC
• HCPCS Code J9035, Bevacizumab, 10 mg
• Error rate – 26.3% - 37.6%
• Discontinue in SC; continue in NC and VA/WV