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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 focus on the new service to be added to the Prior Authorization for Certain Hospital Outpatient (OPD) Services effective July 1, 2023.

Did You Know?

CMS implemented the Prior Authorization for Certain Hospital Outpatient Department (OPD) Services through the Calendar Year (CY) 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center (OPPS/ASC) Final Rule (CMS-1717-FC).

Initially, effective July 1, 2020 blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation required a prior authorization when performed in the hospital OPD. For claims on or after July 1, 2021, implanted spinal neurostimulators and cervical fusion with disc removal were added to the list.

New for 2023, CMS finalized the addition of facet joint interventions requiring prior authorization for claims on or after July 1, 2023. This service category includes facet joint injections, medial branch blocks, and facet joint nerve destruction. A list of the specific CPT codes that will require prior authorization are listed in Table 103 of the CY 2023 OPPS/ASC Final Rule (CMS-1772-FC).

Why it Matters?

Reviewing facet joint records has been a target by several different entities.

Medicare Administrative Contractors

Noridian Jurisdiction E (JE) Part B MAC has conducted a Targeted and Probe and Educate (TPE) review of CPT 64635 (Destruction by Neurolytic Agent, Paravertebral Facet Joint Nerve). Dates of service reviewed were January 2020 through March 2020. The claims error rate was 75% with the top denial reasons being:

• Failure to return records,
• Documentation does not support the medical necessity as listed in the Coverage Requirement, and
• Duplicate billing.

Noridian indicated in their review results that “Local Coverage Determination L34993 provides an overview of the coverage requirements for these services. Documentation must support the history of pain which has not been responsive to conservative measures. Documentation must also support the conservative measures that have been tried and failed. The LCD also further clarifies that documentation must support a clinical assessment which supports that the pain is a result of the facet joint and that there is no other pathology that may be causing the pain.

Documentation must reflect the patient pre and post procedure pain rating, procedure report, and the injectate used is within the LCD requirements.”

Other Part B MACs that have reviewed or are currently reviewing facet joint injections include Novitas JH and JL and WPS J8.

Office of Inspector General (OIG)

CMS notes in the OPPS/ASC final rule that the OIG has published multiple reports indicating questionable billing practices, improper Medicare payments, and questionable utilization of facet joint interventions. Based on their findings, the OIG recommended that CMS and its contractors provide additional oversight on claims for facet joint injections to prevent additional improper payments.

Supplemental Medical Review Contractor

Just last month on October 10th, the Supplemental Medical Review Contractor (SMRC) posted their review findings of Project 01-304: facet joint injections. The October 2020 OIG report was referenced in the review results. Claims reviewed included hospital outpatient and critical access hospitals with dates of service in CY 2019. The claims error rate was 92% and common denial reasons included:

• Documentation submitted was insufficient or incomplete,
• Documentation submitted did not support medical necessity as listed in National and Local Coverage Determinations, and
• No response to the documentation request by the provider.

What Can I Do?

You can begin to prepare for the July 1, 2023 addition of Facet joint procedures to the Prior Authorization for Certain Hospital OPD Services now by:

• Identifying applicable Medicare Coverage Documents (Local Coverage Determinations (LCDs) and Local Billing and Coding Articles (LCAs)), and
• Ensuring key stakeholders are aware of the need for prior authorization effective July 1, 2023 (i.e., Outpatient Department Nurse Manager, Scheduling, Physicians performing these procedures) and educate them on applicable documentation requirements found in the LCDs and LCAs.

CMS recently published the following information about expanding the use of (bivalent) COVID-19 vaccines and new bivalent vaccine CPT codes in the Thursday, October 27, 2022 edition of MLN Connects (link).

The CDC recently expanded the use of updated (bivalent) COVID-19 vaccines to children ages 5 through 11 years. This followed the FDA’s authorization of updated COVID-19 vaccines from Pfizer-BioNTech for children ages 5 through 11 years and from Moderna for children and adolescents ages 6 through 17 years. People with Medicare, Medicaid, Children’s Health Insurance Program coverage, private insurance coverage, or no health coverage can get COVID-19 vaccines, including the updated Moderna and Pfizer-BioNTech COVID-19 vaccines, at no cost, for as long as the federal government continues purchasing and distributing these COVID-19 vaccines.

CMS issued 4 new CPT codes effective October 12, 2022:

Code 91314 for Moderna COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 25MCG/.25ML

Code 91315 for Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product:

• Long descriptor: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use
• Short descriptor: SARSCOV2 VAC BVL 10MCG/0.2ML

Code 0144A for Moderna COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose
• Short descriptor: ADM SRSCV2 BVL 25MCG/.25ML B

Code 0154A for Pfizer-BioNTech COVID-19 Vaccine, Bivalent - Administration – Booster Dose:

• Long descriptor: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose
• Short descriptor: ADM SARSCV2 BVL 10MCG/.2ML B

Visit the COVID-19 Vaccine Provider Toolkit (link) for more information, and get the most current list of billing codes, payment allowances, and effective dates (link).

See the full news alert (link)

Source: Thursday October 27, 2022 MLN Connects: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2022-10-27-mlnc

Question

What is the code assignment for a patient with Type 2 DM with Nephropathy and CKD?

Answer

Assign only one code, Type 2 DM with CKD (E11.22) because CKD is more specific than nephropathy per advice found in Coding Clinic, 3rd Quarter 2019, page 3.

References

Coding Clinic, 3rd Quarter 2019, page 3

Did You Know?

On September 28, 2022, the United States District Court for the District of Columbia vacated (link) the previously applied differential payment rates for 340B-acquired drugs in the Calendar Year (CY) 2022 Outpatient Prospective Payment System (OPPS) final rule.

Why it Matters?

As a result of this of this ruling, CMS will revert to paying the default rate (generally ASP plus 6%) under the Medicare status for 340B-acquired drugs.

CMS noted in the Thursday, October 13, 2022 edition of MLN Connects (link) that “CMS is uploading revised OPP drug files that will apply the default rate (generally ASP plus 6%) to 340B-acquired drugs for the rest of the year. CMS also will reprocess claims our contractors paid on or after September 28, 2022, using the default rate.”

What Can You Do?

To receive payments for claims prior to September 28, 2022, providers will need to submit adjustment claims to recalculate their payments. Medicare Administrative Contractors (MACs) nationwide have posted information about this issue on their websites. For example, Noridian JF, the MAC for Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming has posted the following information in their October 27, 2022 daily email (link):

Provider/Supplier Action Required:

“Although MACs shall not reprocess 2022 date of service claims prior to 09/28/22 as contractor-initiated adjustments, MACs shall process provider-submitted adjustments to 2022 date of service claims that were paid prior to September 28, 2022. The adjustments can be submitted using type of bill (TOB) XX7 with condition code D9 and remarks indicating “340B adjustment”.

Did You Know?

Division D, Sections 101 and 102 of the Continuing Appropriations and Ukraine Supplemental Appropriations Act, 2023 has extended the temporary low-volume hospital payment adjustment and Medicare Dependent Hospital (MDH) Program that were set to end October 1, 2022.

Why it Matters?

CMS released MLN Matters Article MM12970 (link) on October 21, 2022. This article details information about the above-mentioned Act that extends the temporary changes through December 16, 2022.

What Can You Do?

Per CMS, provider actions needed includes:

• Sending a written request to your MAC by November 16 to get the applicable low-volume hospital payment adjustment, and
• Read this MLN article and related transmittal to determine if you are eligible for continued MDH status.

Did you Know?

November is Lung Cancer Awareness Month and annually the American Cancer Society has designated the third Thursday of November as the Great American Smokeout®.

Why it Matters?

The American Cancer Society indicates that this event is important because “about 34 million American adults still smoke cigarettes, and smoking remains the single largest preventable cause of death and illness in the world. Smoking causes an estimated 480,000 deaths every year, or about 1 in 5 deaths.”

What Can You do About It?

For health care providers, know what resources are available for your patients.

Counseling to Prevent Tobacco Use

This service falls in the benefit category of additional preventive services and National Coverage Determination (NCD 210.4.1) Counseling to Prevent Tobacco Abuse details the covered indications for this service. Specifically, CMS covers this service for outpatient and hospitalized patients with Medicare Part B who meet the following criteria:

• The patient uses tobacco, regardless of whether they exhibit signs and symptoms of tobacco-related disease,
• The patient is competent and alert when counseling is delivered, and
• The counseling is provided by a qualified physician or other Medicare-recognized practitioner.

Counseling Frequency

Medicare covers two cessation attempts per year and each attempt may include a maximum of four intermediate or intensive sessions, with the patient getting up to eight sessions per year. There is no copayment, coinsurance, or deductible for the patient.

Lung Cancer Screening with Low Dose Computed Tomography (LDCT) (NCD 210.14)

Lung Cancer Screening also falls in the benefit category of additional preventive services. Screening is covered for patients with Medicare Part B who meet all the following categories:

• The patient is 50 – 77 years of age,
• The patient is asymptomatic,
• The patient has a smoking history of at least 20 pack-years (1 pack-year = smoking 1 pack per day for 1 year, 1 pack + 20 cigarettes),
• Is a current smoker or quit smoking within the last fifteen years, and
• The physician orders the lung cancer screening with LDCT.

Screening Frequency

Medicare will cover this service annually. Of note, before the first lung cancer LDCT screening, the physician must counsel the patient as a shared decision-making visit. Like counseling to prevent tobacco use, the patient has no copayment, coinsurance, or deductible.

Resource:

CMS MLN Educational Tool Medicare Preventive Services (link)

Compliance Education Updates

MLN Educational Tool: Medicare Preventive Services

This MLN tool (link) was updated in September. Updates include pneumococcal shot resources, thirteen new bone mass measurement codes and three new hepatitis B screening codes.

MLN Educational Tool: Medicare Payment Systems

This MLN tool (link) was also updated in September to include updates for FY 2023 for:

• The Acute Care Hospital Inpatient Prospective Payment System (IPPS),
• The Hospice Payment System,
• The Inpatient Psychiatric Facility Prospective Payment System (IPF PPS),
• The Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS),
• The Long-Term Care Hospital Prospective Payment System (LTCH PPS), and
• The Skilled Nursing Facility Prospective Payment System (SNF PPS).

MLN Booklet: Chronic Care Management Services

This Booklet (link) has been updated. Substantive content changes are in dark red font and includes:

• Beginning 2022, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can bill Chronic Care Management (CCM) and Transitional Care Management (TCM) services for the same patient during the same period,
• In 2021 CMS added five codes to report staff-provided Principal Care Management (PCM) services under physician supervision, and
• Beginning 2022 CMS replaced G2058 with 99439.

COVID-19 Updates

October 13, 2022: Update to COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

This CMS document (link) was updated on October 13th. The waiver related to the Director of Food and Nutrition Services was terminated on 10/1/2022 per the FY 2023 SNF Prospective Payment System Final Rule (1765-F).

Other Updates

September 23, 2022 Award of Medicare Administrative Contractor (MAC) Contract for Jurisdiction M

On September 23rd, Palmetto GBA, the incumbent MAC for Jurisdiction M (JM) was again awarded the contract for the administration of Medicare Part A and Part B Fee-for-Service claims in the states of North and South Carolina, Virginia, and West Virginia. The claims volume in JM equates to more than $26.4 billion in Medicare benefit payments annually. Palmetto GBA will provide Medicare services to more than three hundred hospitals, approximately 75,000 physicians, and 3.2 million beneficiaries.

CMS Implements Temporary Increase in Payment under Medicare for Qualifying Biosimilars

Section 11403 of the Inflation Reduction Act provides for a temporary increase in the add-on payment for qualifying biosimilars from the current ASP plus an add-on of 6% of the reference biological product’s ASP to ASP plus 8% for a 5-year period. CMS noted in the Thursday, October 6th edition of MLN Matters (link) that “the goal of the temporary add-on payment for providers is to increase access to biosimilars, as well as to encourage competition between biosimilars and reference biological products, which may, over time, lower drug costs and lead to savings to beneficiaries and Medicare.”

If you are interested in learning more about biosimilars, there are two FDA resources:

• FDA Biological Product Definition Fact Sheet (link), and
• A Curriculum Materials for Health Care Degree Programs / Biosimilars (link). The “FDA’s curriculum materials are intended to help educate students in health care professional degree programs, for medicine, nursing, physician assistants, and pharmacy, as well as practicing professionals, to improve understanding of biosimilar and interchangeable biosimilar products and the regulatory approval pathway in the United States.”

CMS Request for Information (RFI): Developing a National Directory of Health Care Providers and Services

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

• Helping patients locate providers that meet their individual needs and preferences, and
• A modern NDH “should enable healthcare providers, payers, and others involved in patient care to identify one another’s digital contact information also referred to as digital endpoints, for interoperable electronic data exchange.”

On October 7, 2022, CMS published an RFI in the Federal Register (link) seeking comments on the establishment of a National Directory of Healthcare Providers & Services (NDH). CMS believes an NDH would serve multiple purposes for the end user, for example:

Medicare MLN Articles & Transmittals

Inpatient Prospective Payment System Hospitals in the 9th Circuit: Updated Fiscal Years 2019 and 2020 Supplemental Security Income Medicare Beneficiary Data

• MLN Release Date: September 29, 2022
• What You Need to Know: Data for the Ninth Circuit’s jurisdiction has been updated based on Supreme Court decision in Azar v. Empire Health Foundation. This includes hospitals in Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada, Oregon, and Washington. Data for all other hospitals is unchanged.
• MLN MM12906: (link)

New Fiscal Intermediary Shared System Edit to Validate Attending Provider NPI

• MLN Release Date: October 6, 2022
• What You Need to Know: Make sure your billing staff knows about a new consistency edit that validates the attending provider NPI and that organizational NPIs cannot be used in place of individual NPIs, unless exception conditions are met.
• MLN MM12889: (link)

Medicare Deductible, Coinsurance & Premium Rates: Calendar Year 2023 Update

• MLN Release Date: October 13, 2022
• What You Need to Know: CMS advises to make sure your billing staff know about the calendar year 2023 rate changes. I would also encourage you to make sure your case management and social services staff are aware of this information too.
• MLN MM12903: (link)

Revised Medicare MLN Articles & Transmittals

Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter As Certain Colorectal Cancer Screening Tests

• MLN Release Date: April 29, 2022 – Revised September 29, 2022
• What You Need to Know: The article was revised to add the Other Amount Indicator “B2” for co-insurance reduction amount to the claim, modify edits that affects the co-insurance reduction amount, and report the applied coinsurance amounts in the c-insurance field.
• MLN MM12656: (link)

International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determinations (NCDs)-January 2023 Update – 2 of 2

• MLN Release Date: August 12, 2022 – Revised October 5, 2022
• What You Need to Know: This article was revised to reflect a revised Change Request (CR) 12842. The update for NCD 150.3 (Bone Mineral Density Studies) was removed due to ICD-10 diagnosis codes that were added in error and restore ICD-10 diagnosis C91.92 that was removed in error to NCD 110.23 (Stem Cell Transplantation).
• MLN MM12842: (link)

October 2022 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal Release Date: Transmittal 11610 released September 23, 2022 is being rescinded and replaced by Transmittal 11661 dated October 23, 2022
• What You Need to Know: This transmittal has been updated to add HCPCS J1952 to table 2, attachment A, and correct the associated number of new codes identified in the policy section B.3.a from 10 to 11.
• Transmittal 11661: (link)

Coverage Updates

Cochlear Implantation Final Decision Memo (CAG-00107R)

On September 26, 2022, CMS published a final decision memo (link) for NCD 50.3 Cochlear Implantation. CMS has concluded there is sufficient evidence for cochlear implantation be “be covered for treatment of bilateral pre- or post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence cognition.” Patient’s must also meet specific criteria detailed in the Decision Memo.

MMP has been sending out the Wednesday@One since 2012. Over the past decade, I have often shared with our readers my love of fall. Fall means the return of college football, front yards filled with inflatable pumpkins and ghosts, and this year I am seeing the addition of exceptionally large decorative black spiders crawling up the outside walls of homes and strings of glowing witch hats lighting front porches.

Even with pots of chili still to be cooked and caramel apples still to be consumed, it is never too early to prepare for the New Year. Along with the October 1st start of the CMS 2023 Inpatient Prospective Payment System (IPPS) Fiscal Year, this article highlights recent news to help you prepare for the coming year.

2023 Dollar Amount in Controversy Required for Administrative Law Judge (ALJ) Hearing or Federal District Court Review

The fifth level of appeal for Medicare Fee-for-Service appeals is an ALJ hearing or Federal District Court review. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), requires an annual reevaluation of the dollar amount in controversy (AIC) required to advance to this level of appeal.

On September 30, 2022, the annual adjustment that will be effective on January 1, 2023 was published in the Federal Register (link). The calendar year (CY) 2023 AIC threshold amounts are:

• ALJ hearing requests filed on or after January 1, 2023 remains the same as CY 2022 at $180.
• Federal District Court requests filed on or after January 1, 2023 will increase from the CY 2022 amount of $1,760 to $1,850.

You can learn more about the appeal process in the CMS MLN Booklet Medicare Parts A & B Appeals Process (link).

Inflation Reduction Act

President Biden signed the Inflation Reduction Act (IRA) into law on August 16, 2022. On October 5th, CMS released a Fact Sheet (link) where CMS notes that “this law means millions of Americans across all 50 states, the United States territories, and the District of Columbia will save money from meaningful benefits.” Insulin cost sharing is one of the benefits that will start in 2023 and includes:

• Starting January 1, 2023, people enrolled in a Medicare prescription drug plan will not pay more than $35 for a month’s supply of each insulin that they take and is covered by their Medicare prescription drug plan and dispensed at a pharmacy or through a mail-order pharmacy. Also, Part D deductibles will not apply to the covered insulin product.
• Starting July 1, 2023, people with traditional Medicare who take insulin through a traditional pump will not pay more than $35 for a month’s supply of insulin, and the deductible will not apply to the insulin. This will apply to people using pumps covered through the durable medical equipment benefit under Part B.

COVID-19 PHE Extended

The Secretary of Health and Human Services, Xavier Becerra, renewed the COVID-19 public health emergency this past Thursday, October 13th (link). As a reminder, PHE declarations last for the duration of the emergency or 90 days and may be extended by the Secretary. Ninety days from October 13th will be January 11th, 2023. Specific to the COVID-19 PHE, HHS has indicated that they will provide a 60-day notice prior to the termination of the COVID-19 PHE. Sixty days prior to January 11, 2023 is Saturday, November 12th, 2022.

Social Security Benefits in 2023

In an October 13th Press Release (link), the Social Security Administration announced that “approximately 70 million Americans will see a 8.7% increase in their Social Security benefits and Supplemental Security Income (SSI) payments in 2023. On average, Social Security benefits will increase by more than $140 per month starting in January.”

Calendar Year 2023 Medicare Deductible, Coinsurance & Payment Rates

Since writing about the updated Medicare deductible, coinsurance and payment rates in last week’s newsletter (link), CMS has published MLN Matters article MM12903 (link) which includes background information regarding a Medicare beneficiary’s “spell of illness” and Medicare coverage in a skilled nursing facility (SNF) as well as the 2023 payment rate changes.

As we wait for the release of the CY 2023 Outpatient Prospective Payment System (OPPS) Final Rule, the 2022 CERT Report, and the possible notification of the end of the COVID-19 PHE, I wish all our readers a happy fall y’all.

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 focus on seven of the recent review results posted by the Supplemental Medicare Review Contractor (SMRC).

Project 01-034 Transforaminal Epidural Injections

Background: 2018 CERT Improper Payment Report noted a 29.1% error rate for this service. Also, a previous SMRC contractor found a claim error rate of 40% with 30% of the claims error being due to no response to documentation request.

• Dates of Service (DOS) Reviewed: July 1, 2018 - June 30, 2019.
• Claims Error Rate: 65%

Common Denial Reasons: Incomplete/insufficient documentation, no response to documentation request, and documentation submitted did not support identification and administration of medication and or dosage limitations.

Project 01-058: Traditional Telehealth

Background: Under COVID-19 waivers and flexibilities, Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including the patient’s place of residence starting March 6, 2020.

• DOS Reviewed: March 6, 2020 - May 13, 2021
• Claims Error Rate: 88%

Common Denial Reasons: documentation did not support the use of appropriate real-time telecommunication technology and documentation did not support the signs and symptoms to warrant billing an E&M visit.

Project 01-302 Cataract Surgery

Background: This surgery had been a topic of the OIG for many years. They have reviewed surgery in both the outpatient facility and ambulatory surgery center setting. CMS data reflects a potential vulnerability.

• DOS Reviewed: CY 2019
• Claims Error Rate: 51%

Common Denial Reasons: No response to the documentation request, documentation submitted did not support the required documentation needed for cataract surgery, and the documentation did not include a signed physician order or documentation to support intent to order.

Project 01-304 Facet Joint Injections

Background: The OIG has found significant billing errors in this area in the past and an October 2020 OIG report found that due to coverage limitations Medicare improperly paid out $748,555.

• DOS Reviewed: CY 2019
• Claim Error Rate: 92%

Common Denial Reasons: Documentation submitted was insufficient or incomplete. Documentation submitted did not support medical necessity as listed in National and Local Coverage determinations. No response to the documentation request.

Project 01-305 Inpatient Psychiatric Facility

Background: The OIG found on 87% error rate on claims reviewed dated fiscal years 2014 – 2015. A CERT report published in February 2016 and updated in July 2020 highlighted DRG 885 (Psychoses) as the eighth top service with the highest improper payment rate.

• DOS Reviewed: January 16, 2019 through December 31, 2019
• Claim Error Rate: 26%

Common Denial Reasons: documentation submitted lacked evidence that category requirements were met. No response to the documentation request. Documentation submitted did not include the required certifications or recertifications for the inpatient psychiatric stay.

Project 01-308 Outpatient Therapy

Background: The Bipartisan Budget Act (BBA) of 2018 created a medical review (MR) expense threshold of $3,000 or physical therapy (PT) and speech-language pathology (SLP) combined and $3,000 for occupational therapy (OT). The SMRC was directed to perform data analysis on outpatient therapy claims below the 2019 therapy threshold and recommend codes to be selected for review, recommend a sampling strategy, and identify MR strategy for the project.

• DOS Reviewed: CY 2019
• Claim Error Rate: 39%

Common Denial Reasons: No response to the documentation request. Certifications for the Plan of Care (POC) not present. Documentation did not support the initial POC was certified by the physician / NPP. Lack of evidence of delayed certification attempts to obtain the certification. Documentation did not support the units billed.

Project 01-310 Endomyocardial Biopsy with Right Heart Catheterization

Background: Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure. Potential misuse of this modifier represents a potential vulnerability and has been featured in work done by the OIG.

• Dates of Service Reviewed: CY 2019
• Claim Error Rate: 60%

Common Denial Reasons: No response to the documentation request. Documentation was not sufficient to support the medical necessity of the procedure performed. Documentation did not support that the procedure was performed.

Moving Forward What Can You Do?

• First, make sure your hospital has a process in place to respond to documentation request from the SMRC,
• Read the entire review results that can be found on the SMRC website (link), and
• Identify services that have a related National or Local Coverage Determination (NCD/LCD) that you are providing at your hospital and share this information with key stakeholders.