February 24, 2014 Drill Down – Medical Necessity: Percutaneous Transluminal Angioplasty (PTA)

February 24, 2014

Drill Down – Medical Necessity: Percutaneous Transluminal Angioplasty (PTA)

RAC Region C contractor Connolly posted a complex review for inpatient, outpatient hospital and physician provider types regarding percutaneous transluminal angioplasty medical necessity.

The contractor references several Centers for Medicare & Medicaid Services (CMS) MLN Matters publications, among them MLN Matters # MM5432, Effective 1-11-07 - Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting, which states:

“Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis ≥50% in patients with intracranial atherosclerotic disease when furnished in accordance with the Food and Drug Administration (FDA)-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determined that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances.

Providers billing FIs and A/B MACs should note this coverage applies to claims with:

·         A discharge date on or after November 6, 2006;

·         ICD-9-CM procedure codes of 00.62 and 00.65 both being present;

·         ICD-9CM diagnosis code 437.0 present; and

·         The IDE number present on a 0624 revenue code line.

Non-institutional providers billing Medicare carriers or A/B MACs should note this coverage applies to claims with:

·         CPT code 37799 (Unlisted procedure, Vascular surgery);

·         A QA modifier to denote Category B IDE clinical trial; and

·         The appropriate IDE number.

All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain non-covered. The safety and efficacy of these procedures are not established.”

The medical documentation should reflect that this procedure was reasonable and necessary, by following the guidelines and criteria listed above along with using the appropriate ICD-9-CM codes and IDE numbers.

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

RAC Region B CGI

DME

·         DME Home Glucose Testing Supplies - More than one spring powered device per 6 months is not reasonable and necessary, without regard to whether the beneficiary is insulin-dependent. This automated review will identify additional units of the device paid after the initial 1 unit in each 6 month period.

·         DME Glucose Monitor Unbundling - Certain blood glucose testing supplies are included in the allowance for the glucose monitor E0607 when provided at the same time. This automated review will identify claims paying those blood glucose testing supplies in addition to the purchase of the glucose monitor, for dates of service 7/1/2011-12/31/2012 only, and the overpayment for the supply will be recovered.

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.

RAC Region C Connolly

Inpatient

·         Medical Necessity: Percutaneous Transluminal Angioplasty - C004292013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Outpatient Hospital

·         Medical Necessity: Percutaneous Transluminal Angioplasty - OP - C004332013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Physician

·         Medical Necessity: Percutaneous Transluminal Angioplasty - Carr - C004322013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

February 17, 2014 Drill Down – Non-Coronary Vascular & Lower Extremity Stents

 February 17, 2014

Drill Down – Non-Coronary Vascular & Lower Extremity Stents

RAC region C contractor Connolly posted an automated review for outpatient hospital providers regarding incorrect billing for non-coronary vascular and lower extremity stents for the states of Arkansas, Louisiana, Mississippi, Colorado, Texas, Oklahoma, New Mexico. Per the contractor’s description of this issue, overpayments were identified where ICD-9 codes billed were not in accordance with billing requirements outlined in Local Coverage Determinations (LCD).

Just as stents are used to open up a blocked cardiac blood vessel, stents can also be used in the peripheral blood vessels arterial as well as venous, provided certain criteria are met. Vascular stents are used to enhance primary blood flow in arteries and veins, usually at the site of a narrowed or blocked blood vessel. Stents also may be used as an adjunct to technically inadequate Percutaneous Transluminal Angioplasty (PTA). And can also be used in cases where PTA alone may not be expected to provide a sustainable result. Peripheral vascular stenting may be indicated for patients with symptomatic arterial and venous disease resulting in an obstructive process.

There are many conditions outlined in the LCDs referenced for this audit issue regarding non-coronary stenting and an example of one is listed below:

Stenting of vessels is covered only when all of the following conditions are met:

·         Angioplasty alone would not suffice.

·         The patient has undergone prior thorough medical evaluation and management of symptoms for which PTA and stent are therapeutic.

·         Surgical intervention would otherwise be considered as an alternative treatment for the patient.

·         Condition(s) exists for which there is evidence of superior outcome with renal artery intervention and medical therapy when compared with outcome of medical or surgical management.

The audit issue references LCDs for Novitas LCD #L32641 and Trailblazer #LCD L31440.

The Novitas LCD #L32641 states, “CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.”

The policy also lists utilization as well as documentation guidelines including the application of modifier Q0, Q1 and the FDA issued identifier for the stent

Medical necessity – meeting specific conditions and usage of the appropriate ICD-9 code(s) – is a key for compliance for this procedure to be payable by Medicare.  A quick review of the allowed modifiers and the FDA issued identifier is necessary to meet this contractor’s audit.

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

RAC Region A Performant

DME Supplier

·         High Frequency Chest Wall Oscillation Devices - Jurisdiction A - Potential incorrect billing occurred when claims for high frequency chest wall oscillation devices were billed without an indication supporting medical necessity as described in the NHIC Local Coverage Determination (LCD) L12870 and related article (A25231).

·         Spinal Orthoses: Thoracic Lumbar Sacral Orthoses (TLSO) and Lumbar Sacral Orthoses (LSO) - Jurisdiction A - Potential incorrect billing occurred when claims for spinal orthoses (TLSO and LSO) were billed without an indication supporting Medical Necessity as described in the NHIC Local Coverage Determination (LCD) L11470 and related article (A23663).

RAC Region C Connolly

Hospice

·         Hospice: Medicare Coverage Requirement Review - C004422013 - Hospice documentation will be reviewed to determine the appropriateness of payments for hospice care services for Medicare beneficiaries.

February 10, 2014 Drill Down – Is CMS is “Taking a Break” From the RACs?

 February 10, 2014

Drill Down – Is CMS is “Taking a Break” From the RACs?

Every relationship has its ups and downs and on February 3, 2014, the Centers for Medicare & Medicaid Services (CMS) and its RACs appear to be going through a rough patch. This relationship is clearly having issues and CMS in its recent rulings is sending the signal that it may want to take a break, slow things down with its RAC partnerships. Just as we approach Valentine’s Day, this may be a typical move to get out of buying your significant other a present but as far as CMS and the RACs as concerned, it may be time to evaluate things.

Trouble has been brewing in recent months and on February 3, 2014, the American Coalition for Healthcare Claims Integrity, representing RACs and other health payment contractors working for government agencies, sent a letter to members of Congress asking for reform of the administrative law judge process and to oppose further efforts to restrict the RAC program. CMS has delayed once again the enforcement of the two-midnight rule under which it would not reimburse under Part A for inpatient-level services provided to Medicare beneficiaries for treatment that does not span two midnights. This delay is now extended until October, 2014. CMS considers short stays to be payable as outpatient services. The American Hospital Association (AHA) and American Medical Association (AMA) argue that this policy undermines medical judgment, does not give enough time to restructure software systems, policies and procedures, and financially burdens providers.

On the other hand, the contractors’ association states that suspending the administrative law judge process and delaying the two-midnight rule has substantially shut down the RAC program and in the Feb. 3 letter to members of Congress, the association implied that CMS has stopped the entire RAC program. In regards to the two-midnight rule delay policy, “CMS is also continuing to suspend Medicare auditing by the Recovery Audit Contractor program,” the letter stated.

The American Coalition for Healthcare Claims Integrity in its letter to Congress states that RACs audit only 2% of Medicare billings and find errors in nearly half of them, and delays in the two-midnight rule will cost the Medicare Trust Fund more than $4 billion. “Last year, Medicare lost more than $35 billion to waste, fraud and abuse. The willingness of CMS to suspend the most effective Medicare integrity initiative in U.S. history in the face of this astounding volume of waste is unconscionable.”

In its letter to Congress, the association advises to immediately reinstate auditing with these guidelines:

·         “For Medicare admissions prior to Oct. 1, 2013, RACs will audit according to the old rule in effect at the time of service.

·         “For Medicare admissions between Oct. 1, 2013 and Sept. 30, 2014, RACs will audit according to the old and new two-midnight rule, apply the rule that favors the hospital while still identifying improper payments for the Trust Fund.

·         “For Medicare admissions after Oct. 1, 2014, RACs will audit according to the new rule.”

The AHA issued the following statement after CMS extended the two-midnight rule delay: “We are pleased that CMS has extended its enforcement moratorium on the two-midnight policy for an additional six months, as the AHA has urged.  This action clearly recognizes that there are still many unanswered questions about the policy.  At the same time, we continue to urge CMS to fix the critical flaws of the underlying policy by immediately engaging stakeholders to find a workable solution that addresses the reasonable and necessary inpatient-level services currently provided by hospitals to Medicare beneficiaries that are not expected to span two midnights.”

So is CMS telling the RACs “it’s not you, it’s me” or more like it is you after all? Judging from approved issues still being posted to RAC contractors’ websites, this relationship still has hope.

Source: http://properpayments.org/open-letter-to-congress-examine-suspension-of-rac-program/

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

RAC Region A Performant

DME Supplier

·         Speech Generating Devices - Jurisdiction A - Potential incorrect billing occurred when claims for speech generating devices were billed without an indication supporting Medical Necessity as described in the NHIC Local Coverage Determination (LCD) L11534 and related article (A33770).

RAC Region C Connolly

DME

·         CPM billed for patients who have not received a total knee replacement - C004802013 - Continuous Passive Motion devices are only covered 21 days after a total knee replacement. Claims will be reviewed to determine if overpayments exist where the patient did not receive a total knee replacement.

·         Negative Pressure Wound Therapy Pumps - C004792013 - Negative Pressure Wound Therapy Pumps are considered medically necessary when payer specific guidelines are met. Medical documentation will be reviewed to determine if the billing of Negative Pressure Wound Therapy Pumps and associated supplies were reasonable and necessary and if documentation guidelines have been met.

·         Medical Necessity - Osteogenesis Stimulators - C000102014 - Medical documentation will be reviewed to determine if the osteogenesis stimulator met coverage indications, limitations, and/or medical necessity as outlined in CGS LCD.

Inpatient Hospital

·         Medical Necessity: Sacral Nerve Stimulation For Urinary Incontinence – IP - Effective January 1, 2002, Medicare covers sacral nerve stimulation for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered. Medical documentation will be reviewed to determine if the sacral nerve stimulator was necessary for the patient.

Outpatient Hospital

·         Incorrect Billing of Non-Coronary Vascular & Lower Extremity Stents - OP - C003952013 - Overpayments were identified where ICD-9 codes billed were not in accordance with billing requirements outlined in Local Coverage Determinations.

·         Medical Necessity: Sacral Nerve Stimulation For Urinary Incontinence - OP -C003982013 - Effective January 1, 2002, Medicare covers sacral nerve stimulation for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered. Medical documentation will be reviewed to determine if the sacral nerve stimulator was necessary for the patient.

Physician

·         Medical Necessity: Sacral Nerve Stimulation For Urinary Incontinence – Carrier - Effective January 1, 2002, Medicare covers sacral nerve stimulation for the treatment of urinary urge incontinence, urgency-frequency syndrome, and urinary retention. Sacral nerve stimulation involves both a temporary test stimulation to determine if an implantable stimulator would be effective and a permanent implantation in appropriate candidates. Both the test and the permanent implantation are covered. Medical documentation will be reviewed to determine if the sacral nerve stimulator was necessary for the patient.