Drill Down: Cetuximab and Medical Necessity - April 7, 2014

April 7, 2014

Drill Down: Cetuximab and Medical Necessity

Written by Margaret Klasa, DC, APN, Bc Created on Tuesday, 08 April 2014 12:42

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RAC Region B contractor CGI posted a semi-automated review on March 26, 2014, for Outpatient provider types regarding the medical necessity for the drug Cetuximab. Per the contractor’s description of this issue, a semi-automated edit to identify potential incorrect billing occurring for Cetuximab claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations.
Payment will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period. Cetuximab is an epidermal growth factor receptor (EGFR) inhibitor used for the treatment of metastatic colorectal cancer and head and neck cancer.
The issue references Wisconsin Physicians Service Insurance Corporation’s Local Coverage Determination (LCD): Chemotherapy Drugs and their Adjuncts (L28576) which specifically lists the ICD codes for Cetuximab:
Cetuximab (Erbitux TM) (J9055) 10 mg
Colorectal Cancer 153.0-154.8
Head and Neck Cancer 140.0-149.9, 160.0-161.9, 195.0, 196.0
Non-Small cell lung cancer 162.2-162.9
Squamous Cell Skin Cancer of the head and neck 173.02, 173.12, 173.22, 173.32, 173.42
Squamous Cell Skin Cancer for Regional Recurrences or Distal Metastases 239.2 or V10.83.

Cetuximab is covered when:

• Used in combination with irinotecan, is indicated for the treatment of metastatic colorectal carcinoma in patients who are refractory to irinotecan-based chemotherapy.
  
• Administered as a single agent for the treatment of patients with metastatic colorectal carcinoma in patients who are intolerant to irinotecan based chemotherapy.
  
• The patient must not have K-RAS mutation when using this drug for the treatment of colorectal cancer.
  
• As a single agent or in combination with irinotecan after first progression except in patients receiving capecitabine or fluorouracil and leucovorin with bevacizumab.
  

Other sources referenced by the contractor for this issue include the Centers for Medicare & Medicaid Services (CMS) publications: CMS Pub 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 50 – Drugs and Biologicals and CMS Pub 100-04 Chapter 17 Section 90.2 – Drugs, Biological, and Radiopharmaceuticals.
RAC Issues for the Week of April 7 – April 11, 2014:
RAC Region B CGI
Outpatient

• Cetuximab Medical Necessity OP WPS - A semi-automated edit to identify potential incorrect billing occurring for Cetuximab claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations. Payment will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.
  

RAC Region C Connolly
DME

• Suction Catheters for Tracheostomy - CGS - C000362014 - Overpayments were identified where claims billed for suction catheters were not in accordance with billing requirements outlined in Local Coverage Determinations.
  
• Speech Generating Devices & Accessories - CGS - C004962013 - Medical documentation will be reviewed to determine if the Speech Generating Device and/or Accessories met coverage indications, limitations, and/or medical necessity as outlined in CGS LCD.
  

About the Author
Dr. Margaret Klasa is the medical director for Context⁴ Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.
Contact the Author
Margaret.Klasa@context4.com
To comment on this article go to editor@racmonitor.com

Read More of this Week's Enews

• Drill Down: Cetuximab and Medical Necessity

• False Claims Not Fair for Healthcare

• Hospices, RACs, ZPICs, UPICs, and the Whole Alphabet Soup

• Drawing Conclusions from the Record, Draws Contention

• The RACs, Hospitals, and Physician-Associated Services

March 25, 2014 Drill Down – Polysomnography Reported with Incorrect Diagnosis

 March 25, 2014

Drill Down – Polysomnography Reported with Incorrect Diagnosis

RAC Region B contractor CGI posted an automated review issue that was approved on March 6, 2014, for Outpatient providers targeting overpayments for polysomnography procedures when reported with the incorrect diagnosis. Per the contractor’s description of this audit issue, polysomnography, the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report, may be performed within the Critical Access Hospital setting.

This automated review will deny services reported with an incorrect diagnosis. The issue references CGS Administrator’s Local Coverage Determination (LCD) policies for the states of Kentucky and Ohio. The LCD policies list the specific CPT and ICD combinations allowed. The issue also references the Office of Inspector General (OIG) report titled Questionable Billing for Polysomnography Services that was published in October 2013 and the Centers for Medicare & Medicaid Services (CMS) publication 100-02 Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 70 - Sleep Disorder Clinics.

RAC Issues for the Week of March 24 – March 28, 2014:

RAC Region B CGI

Outpatient

·         CAH Polysomnography Services Correct Coding J15 CGS - Polysomnography, the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep with 6 or more hours of recording with physician review, interpretation and report, may be performed within the Critical Access Hospital setting. This automated review will deny services reported with an incorrect diagnosis.

Professional

·         PF Observation Care Billed with Discharge Services on Same Day - J6 (NGS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

·         PF Observation Care Billed with Discharge Services on the Same Day - J15 (CGS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

March 17, 2014 Drill Down – Excessive Units of Hospital Visits

March 17, 2014

Drill Down – Excessive Units of Hospital Visits

RAC Region B CGI posted an automated review issue that was approved on 2/10/2014 for providers regarding initial hospital procedure codes 99221-99223 and Subsequent procedure codes (99231-99233) which are considered “per diem” codes and cannot be used by the same specialty providers from the same group practice.

The issue references retired Local Coverage Article:  Initial Hospital Care Visits – Medical Policy Article (A48210):

A physician or qualified non-physician practitioners can admit patients to the hospital and may bill Medicare for an Initial Hospital Care visit.

The Initial Hospital Care visit codes (99221-99223) may be billed by the admitting provider (physicians or qualified non-physician practitioners (NP, PA, CNS or CNM), once per beneficiary per hospitalization. Providers may not bill for both an admission visit (using CPT codes 99221-99223) and a separate discharge visit on the same day.

The issue also references the Centers for Medicare & Medicaid Services publication, 100-04 Medicare Claims Processing Manual, Chapter 12 - Physicians/Non-Physicians Practitioners Section 30.6.9 Payment for Inpatient Hospital Visits – General as further guidance.

RAC Issues for the Week of March 17 – March 21, 2014:

RAC Region B CGI

Professional

·         Excessive Units of Hospital Visits – NGS - Both Initial Hospital Care codes (CPT codes 99221 - 99223) and Subsequent Hospital Care codes (CPT Codes 99231 - 99233) are "per diem" services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice.

PF Observation Care Billed with Discharge Services on the Same Day – J8 (WPS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

March 11, 2014 Drill Down – Hydration Therapy

 March 11, 2014

Drill Down – Hydration Therapy

Last week RAC Region C contractor Connolly posted an automated review for Outpatient Hospital providers incorrectly billing of Hydration Therapy. Per the issue description, providers are billing Hydration Therapy with diagnosis codes that are not considered reasonable and medically necessary per applicable Local Coverage Determinations (LCDs). Novitas’ Hydration Therapy LCD #L32738 lists specific ICD and CPT combinations:

Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:

Covered for:

250.80

275.42

276.0

276.50

276.51

276.52

458.9

535.00 - 535.01

535.10 - 535.11

535.20 - 535.21

535.30 - 535.31

535.40 - 535.41

535.50 - 535.51

535.60 - 535.61

535.70 - 535.71

536.2

558.9

578.0

643.10

643.13

643.20

643.23

643.80

643.83

780.2

780.4

780.97

787.01

787.03

787.91

V58.11

Report an encounter for radio-contrast dye(s), when hydration is needed in conjunction with angiography and/or CT scan with contrast, with the primary diagnosis of V15.89 (other specified personal history presenting hazards to health) and one of the secondary diagnoses from the list below.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 96360, 96361, J7030, J7040, J7042, J7050, J7060, J7070 and J7120:

Covered for:

585.3

585.4

585.5

RAC Issues for the Week of March 10 – March 14, 2014:

No new issues were posted on contractors’ websites.

Medical Director for Context Provides ICD-10 Expertise in "For The Record" Article

 In the news! Context 4 Healthcare's Medical Director, Margaret Klasa, DC, APN, Bc was quoted in the February 24, 2014 edition of For The Record, with recommendations for best practices in preparing for the impending ICD-10 conversion.

http://viewer.zmags.com/publication/a4f39eaf#/a4f39eaf/11

March 3, 2014 Drill Down – Pause and Improve

 March 3, 2014

Drill Down – Pause and Improve

The Centers for Medicare & Medicaid Services (CMS) has “paused” additional documentation requests by RAC contractors until such time as the new RAC contracts are in place. This pause will begin on February 21, 2014 for post-payment reviews and February 28, 2014 for pre-payment reviews.  At the same time CMS announced its 5 improvements to the RAC program that will be included in the next selection of the RAC contracts. These changes are small steps in an effort to address hospital concerns with the ever increasing administrative burdens caused by the RAC program.

RAC Program Improvements

Concern	Program Change
Upon notification of an appeal by a provider, the Recovery Auditor is required to stop the discussion period.	Recovery Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment. Providers will not have to choose between initiating a discussion and an appeal.
Providers do not receive confirmation that their discussion request has been received.	Recovery Auditors must confirm receipt of a discussion request within three days.
Recovery Auditors are paid their contingency fee after recoupment of improper payments, even if the provider chooses to appeal.	Recovery Auditors must wait until the second level of appeal is exhausted before they receive their contingency fee.
Additional documentation request (ADR) limits are based on the entire facility, without regard to the differences in department within the facility.	The CMS is establishing revised ADR limits that will be diversified across different claim types (e.g., inpatient, outpatient).
ADR limits are the same for all providers of similar size and are not adjusted based on a provider’s compliance with Medicare rules.	CMS will require Recovery Auditors to adjust the ADR limits in accordance with a provider’s denial rate. Providers with low denial rates will have lower ADR limits while provider with high denial rates will have higher ADR limits.

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/RAC-Program-Improvements.pdf

RAC Issues for the Week of March 3 – March 7, 2014:

RAC Region C Connolly

Outpatient Hospital

·         Incorrect Billing of Hydration Therapy - OP - C003932013 - Providers are billing Hydration Therapy with diagnosis codes that are not considered reasonable and medically necessary per applicable LCDs.

Physician

·         Incorrect Billing of Major Joint Replacement Procedures - Carrier - C004142013 - Overpayments were identified where ICD-9 codes billed were not in accordance with billing requirements outlined in Local Coverage Determinations.

 RAC Program Improvements

The CMS is pleased to announce a number of changes to the Recovery Audit Program in response to industry feedback. The CMS is confident that these changes will result in a more effective and efficient program, including improved accuracy, less provider burden, and more program transparency. These changes will be effective with the next Recovery Audit Program contract awards. Concern	Program Change
Upon notification of an appeal by a provider, the Recovery Auditor is required to stop the discussion period.	Recovery Auditors must wait 30 days to allow for a discussion before sending the claim to the MAC for adjustment. Providers will not have to choose between initiating a discussion and an appeal.
Providers do not receive confirmation that their discussion request has been received.	Recovery Auditors must confirm receipt of a discussion request within three days.
Recovery Auditors are paid their contingency fee after recoupment of improper payments, even if the provider chooses to appeal.	Recovery Auditors must wait until the second level of appeal is exhausted before they receive their contingency fee.
Additional documentation request (ADR) limits are based on the entire facility, without regard to the differences in department within the facility.	The CMS is establishing revised ADR limits that will be diversified across different claim types (e.g., inpatient, outpatient).
ADR limits are the same for all providers of similar size and are not adjusted based on a provider’s compliance with Medicare rules.	CMS will require Recovery Auditors to adjust the ADR limits in accordance with a provider’s denial rate. Providers with low denial rates will have lower ADR limits while provider with high denial rates will have higher ADR limits.