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May 29, 2018 - Updated 12.31.18

Targeted Probe and Educate Results – Round 1 (October 2017-April 2018)

The J15 Part A Medical Review department initiated probe review edits for specific providers in Kentucky and Ohio that were identified through data analysis as demonstrating high risk for improper payment. Education was offered to providers throughout, and upon completion of, Round 1 of the probe reviews.

The following edits were initiated during this period:

5PE10 Round 1 Cataract Removal (HCPCS 66984, 66983 and 66982)

  Kentucky Ohio
Probes Completed 6 8
Providers Compliant after Round 1 Completion 4 6
Providers Non-compliant after Round 1 Completion 2 2
Providers with Non-responses to ADRs for Round 1 0 0

Overall Claim Findings by State

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Top Denial Reasons

Required documentation was not submitted in response to the Additional Documentation Request (ADR):

  • Comprehensive ophthalmologic examination
  • Impairment in the ability to carry out activities of daily living (ADLs)
  • Record reflecting cataract is the primary cause of the decreased visual acuity and/or functional impairment, documentation to support visual impairment of 20/50 or worse, or additional testing showing visual acuity decreased by two lines with consensual light testing or glare testing

    Example: The VA and/or IOL measurements were submitted, but the comprehensive eye exam to reflect that the cataract is the primary cause of the decreased visual acuity and/or functional impairment was missing.
  • Operative report for correct eye, date of service and modifier

    Example: The wrong operative report for a previously billed eye and/or DOS was submitted or the incorrect modifier was billed.
  • Medical necessity for use of mechanical dilation with Malyugin Ring or Iris Hooks and proper coding of 66982 – Complex

    Example: Documentation did not support the medical necessity of utilizing a Malyugin Ring during the procedure and/or the simple procedure code 66984 was reported rather than the proper complex procedure code 66982.
  • Documentation does not support extra work/intensity during the procedure, or an underlying reason for dye use (such as a mature cataract) and is coded 66982 – Complex

    Example: The use of Trypan Blue in and of itself does not constitute sufficient extra work or intensity and the simple procedure code 66984 should be reported rather than the complex procedure code 66982.

How to Prevent Denials

Medicare coverage for cataract extraction and cataract extraction with intraocular lens implant is based on services that are reasonable and medically necessary for the treatment of beneficiaries with cataract(s). The CGS Local Coverage Determination (LCD): Cataract Extraction (L33954)External Website policy defines coverage and describes criteria necessary to justify the performance of cataract extraction(s) or other select lensectomies.

  • Please include office notes from the ophthalmologist that support the medical necessity of the cataract removal.
  • Do not forget to include beneficiary-specific documentation of ADL impairment (which may include, but is not limited to): reading, watching television, driving, or meeting occupational or vocational expectations.
  • Clear documentation of the best corrected visual acuity of 20/50 or worse at distant or near; or, additional testing shows one of the following:
    • Consensual light testing decreases visual acuity by two lines, or
    • Glare testing decreases visual acuity by two lines
  • Ensure documentation is submitted within 45 days of the ADR letter to prevent a 56900 claim denial.
  • Ensure the documentation submitted is for the correct dates of service, beneficiary and specific service billed.

Please also see the Additional Information section below.

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5PE11 Round 1 Spinal Injections (ESI) (HCPCS code 62323)

  Ohio
Probes Completed 4
Providers Compliant after Round 1 Completion 2
Providers Non-compliant after Round 1 Completion 2
Providers with Non-responses to ADRs for Round 1 0

Overall Claim Findings by State

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Top Denial Reasons

Required documentation was not submitted in response to the Additional Documentation Request (ADR):

  • Imaging Requirements – preoperative lumbar imaging/radiology reports
  • Preoperative H&P
  • Documentation of conservative pain treatments attempted prior to decision to utilize steroid injections
  • ADL impairment
  • Imaging-guidance

How to Prevent Denials

Medicare coverage for Lumbar Epidural Steroid Injections is based on services that are reasonable and medically necessary generally for the treatment of beneficiaries with pain arising from spinal nerve roots. The CGS Local Coverage Determination (LCD): Lumbar Epidural Steroid Injections (ESI) (L34807)External Website policy defines coverage and describes criteria necessary to justify the performance of ESI.

Please do not forget to include all aspects of the Indications for Coverage:

  • Initial injections – Documentation must be present to determine one of the following:
    • The patient failed four weeks of non-surgical, non-injection care (i.e., the four week period should clearly show treatments were attempted for that amount of time and failed); or,
    • Support the decision to forego the four week waiting period.
  • Imaging results must be included and not referenced in first injections.
  • Subsequent injections are considered covered if there was a previous successful injection and the specific subsequent injection documentation requirements are included.
    • Documentation should support that the prior ESI was successful and was for the same specific condition.
    • Include a documented response to the previous injection, including the percentage of relief provided.
    • It cannot be assumed that the subsequent injection is being performed because the pain returned/persisted and it was of such a severity that it, too, impacted ADLs.
  • Fluoroscopy and CT are the only two validated imaging guidance methods approved.
    • Results of imaging prior to the procedure to diagnose the disease and rule out red flag conditions, such as fractures or potential malignancies, must be present.
  • Documentation of ADL impairment caused by the patient's back pain is required.
    • Determine the necessity of each injection with a pre-procedure examination, including a focused physical, musculoskeletal and neurological exam to support that the patient was examined for any changes in condition since the last injection.
    • Include documentation of pain to support necessity, evaluation of ADL impairments, and documentation of an effective response (if it's not the first injection) of the prior injection to determine necessity for continued injections.
  • Ensure documentation is submitted within 45 days of the ADR to prevent a 56900 claim denial.
  • Ensure that the documentation submitted is for the correct dates of service, beneficiary and specific service billed.

Please also see the Additional Information section below.

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5PE12 Round 1 Cardiac Rehabilitation with continuous ECG Monitoring (HCPCS 93798)

  Kentucky Ohio
Probes In Progress Yes Yes

Top Denial Reasons

Required documentation was not submitted in response to the Additional Documentation Request (ADR):

  • Individualized Treatment Planned (ITP) signed and dated every 30 days
  • Cardiac Rehab (CR)/Intensive Cardiac Rehab (ICR) Program Component Requirements
  • ITP to include physician prescribed exercise plan (frequency, duration, intensity, mode) and cardiac rehab components to support the dates of services billed
  • Physician Validated Diagnosis
  • EKG monitoring strips for dates of services billed

How to Prevent Denials

Effective January 1, 2010, Medicare Part B pays for CR/ICR programs and related items/services if specific criteria is met by the Medicare beneficiary, the CR/ICR program itself, the setting in which is it administered, and the physician administering the program, as outlined in the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15External PDF, section 232.

You may also reference the CGS article, "Cardiac Rehabilitation: Coverage and Documentation Requirements ".

  • Submit a valid Individualized Treatment Plan (ITP) for the dates of services billed.
    • The ITP must be signed/dated by the physician every 30 days.
    • A signature/date provided by a certified physician assistant on the ITP is not acceptable; it must be completed by the physician.
    • Example: The initial individualized treatment plan (ITP) is completed on 1/1/18 and signed and dated by the physician on 1/1/18. Subsequent ITPs are completed every 30 days and signed and dated by the physician. Please ensure the date is legible and a signature log is provided if applicable. Dates of services billed prior to the completion of the qualifying ITP are not covered.
  • CR/ICR Program Component Requirements must include all of the following:
    • Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished
    • Cardiac risk factor modification, including education, counseling and behavioral intervention tailored to the patients' individual needs
    • Psychosocial assessment
    • Outcomes assessment
    • An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by a physician every 30 days.
  • A physician validated diagnosis:
    • An acute myocardial infarction within the preceding 12 months
    • Coronary artery bypass surgery
    • Current stable angina pectoris
    • Heart valve repair or replacement
    • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting
    • A heart or heart-lung transplant
    • For cardiac rehabilitation only: Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks
  • CGS expects that the physician's prescription for exercise will include:
    • Mode of exercise (typically aerobic)
    • Target intensity (e.g., a specified percentage of the maximum predicted heart rate, or number of METs)
    • Duration of each session (e.g., "20 minutes")
    • Frequency (number of sessions per week)
  • Ensure documentation is submitted within 45 days of the ADR to prevent a 56900 claim denial.
  • Ensure that the documentation submitted is for the correct dates of service, beneficiary and the specific service billed.

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Additional Information

Please submit all documentation as required in the LCD or NCD (if applicable) and in accordance with the Medicare Benefit Policy Manual. It is the responsibility of the provider to submit complete and accurate documentation per the regulatory guidelines for each claim. In order to meet the policy requirements for each claim submitted, please refer to the Additional Documentation Request (ADR) received and the references provided below:

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Next Steps

Providers found to be non-compliant at the completion of Round 1 will advance to Round 2 of TPE within 45 days of completion of the post probe educational session. CGS offers education for providers at any time, regardless of identification for TPE. Part A providers may submit questions or request education via the Part A TPE email box: J15AprobeandEducation@cgsadmin.com . Note: Please include your provider number (PTAN) in the subject line of the email.

CGS encourages providers to request education and conduct self-monitoring based on our posted Medical Review Activity and using tools such as Comparative Billing Reports (CBRs) offered through the myCGS portal.

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