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 we provide medical review updates and educate resources from the Medicare Administrative Contractors (MACs)

CGS Administrators, LLC J15 MAC

Review of Implantable Automatic Defibrillator CERT Errors Education Session

CGS is offering this education session on Monday September 26, 2022, from 10:00 AM – 11:00 AM CDT (link). During this session they will discuss an increase in CERT errors related to the “formal shared decision-making encounter using an evidence-based decision tool prior to implantation” as outlined in National Coverage Determination (NCD) 20.4.

First Coast Service Options, Inc. JN MAC

TPE Rehabilitation Services (Outpatient) Review Results

First Coast recently published review results for outpatient rehabilitation services (CPT® 97110, 97112 and 97140) (link). In addition to CPT specific review results, First Coast provides a link to a documentation checklist to help providers when responding to medical documentation requests for therapy and rehabilitation services.

National Government Services (NGS), Inc. J6/JK MAC

Prior Authorization Exemption Status Inquiry Tool Alert

This month NGS announced (link) that they have developed this tool as a way to unnecessary prior authorization requests by exempt providers.

Noridian Healthcare Solutions, LLC JE/JF MAC

Noridian JE Medical Record Review Results

On August 31st, TPE medical record review results were posted on the Noridian JE (link) and Noridian JF (link) websites.

Noridian JE Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 48.78%,
• Lumbar Epidural Injection (CPT® 64483): Error rate 34.43%, and
• Dual-energy X-ray absorptiometry (DXA) (CPT®77080): Error rate 26.43%.

Noridian JF Medical Record Review Results

• Cataract Removal (CPT® 66984): Error rate 55.64%, and
• Total Knee Arthroplasty (CPT® 27447): Error rate 44.83%.

Review Results for both jurisdictions were for dates of service April 1, 2022, through June 30, 2022. Articles for review topics includes top denial reasons, links to educational resources, and education specific to documentation requirements and medical necessity.

Novitas Solutions, Inc. JH/JL MAC

Forms Catalog for Medicare Part A

Novitas Solutions has recently modified their Forms Catalog for Medicare Part A webpage (link). Examples of forms you will find on this webpage includes:

• Link to the Advanced Beneficiary Notice (ABN) Form (CMS-R-131),
• Hospital-Issued Notices of Noncoverage (HINNs), and
• Prior authorization request for certain hospital outpatient department services.

Palmetto GBA JJ/JM MAC

MACtoberfest®

Annually, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, hosts their provider education event MACtoberfest. This virtual three-day conference includes a Medicare Part A and Part B track. Registration is now open and you can learn more about this event on their website (link).

New Local Coverage Determination (LCD)

Palmetto published LCD L39270 Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin’s and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin (link). This policy is effective for services performed on or after September 4, 2022. There is a National Coverage Determination (NCD) 110.23 Stem Cell Transplantation. Palmetto notes in their LCD, “This policy describes additional locally covered indications for allo-HSCT for primary refractory or relapsed Hodgkin's and non-Hodgkin's lymphomas with B-cell or T-cell origin that are medically necessary in patients for whom there are no other curative intent options.”

WPS J5/J8 MAC

WPS recently published Quarter 2 Targeted Probe and Educate (TPE) review results for WPS J5 (link) and WPS J8 (link).

WPS J5 TPE Review Results

• Infusion Services (CPT® 96413 or 96415): Trending error rate 99%. The top reason for denial cited by WPS was the documentation did not support frequent monitoring.
• Routine Foot Care: Trending error rate 24%. The top reason for denial being documentation did not support the presence of severe systemic conditions.
• Outpatient Therapy (CPT® 97110): Trending error rate 52%. The top denial reason was documentation did not support the skills of a licensed professional therapist.
• Group Psychotherapy (CPT® 90853): Trending error rate 49%. The top denial reason was claim billing did not meet the National Correct Coding Initiative (NCCI) guidelines.

WPS J8 TPE Review Results

• Wound Care (CPT® 11042): Trending error rate 43%. The top denial reason was that documentation did not contain initial wound measurements.
• Infusion Services (CPT® 96361): Trending error rate 53%. Denials occurred due to documentation supporting intravenous fluids for the purpose of keeping a vein open. “According to CPT coding guidelines providers should not bill codes 96360 and 96361, when the purpose of the fluids is to keep open a vein.”
• Basic Life Support (BLS) Ambulance transports (HCPCS A0429): Trending error rate 29%. Denials occurred cue to the Assignment of Benefits (AOB) being incomplete or missing.