Early this morning, long before dawn, this email caught my attention and reminded me of the many times I’ve received similar requests for assistance. Does this sound familiar to you?
 
Since November of 2012 we have been receiving ADRs from our MAC, Novitas, wrote a Monitor Monday listener. We receive roughly one ADR a day; they are targeting joint replacement (DRG 470) and cardiac devices (AICDs and pacemakers).  I have researched LCDs and NCDs concerning these DRGs and I have been able to find more consistent guidelines regarding the cardiac devices.  However, the information regarding total joints is not thorough.  I have found a CMS Special Edition (SE 1236), First Coast Service Options LCD L32078 and a Novitas Bulletin dated 02/07/2013 that discuss guidelines for DRG 470.  All three of these references are slightly different.  For instance the SE 1236 and the Novitas Bulletin never mention hip or knee revisions.  Do you have any information that CMS follows which is consistent for joint replacement?
 
I also contacted my MAC by email to ask that they provide me with information concerning their pre-pay ADR policy.  I want to know if they have any limits on the number of ADRs they can issue over a certain time frame or if they will look at observation admissions.  Novitas responded to my email saying they “do not have a policy on Pre Pay ADRs”. 
 
Signed a faithful RACmonitor Monitor Monday listener.
 
Dear Faithful Listener:
 
Here’s the response from Steven J. Meyerson, MD, vice president of the regulations and education group for Accretive Physician Advisory Services:
 
The ADR limits apply to RACs. Prepayment RAC reviews are supposed to fall within the existing ADR limits. There are no ADR limits for MACs. The number of records will depend on the number of claims and their review plan. LCDs apply only to the MAC that issues them. LCDs issued by “foreign” MACs can serve as a guide for your documentation. There is a general requirement that services must be medically necessary so even without an LCD (or NCD) the MAC can deny payment based on lack of documentation to support medical necessity.

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