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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, and 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.

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

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