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Part B Medical Review Articles

This section of our web site contains information written about subjects of Part B Medical Review and Part B Local Medical Review Policies. Please visit the Medical Review Part B Archived Updates Section for updates published before October 1, 2004.

Displaying Medical Review Part B Articles 1 to 25 of 94

Topic	Date	Description
Call Center Closing Times (Part B)	Thursday, September 04, 2008	To better serve the provider community, the Centers for Medicare and Medicaid Services (CMS) is allowing Provider Contact Centers across the nation to conduct customer service training during normal business hours. The Medicare Program is very complex with continuous changes and this initiative will help prepare Provider Customer Service Representatives (CSR's) to give quality answers to substantive Medicare related questions or inquiries. Pinnacle Business Solutions, Inc. the Medicare Part B Carrier for Arkansas, Louisiana and Rhode Island will be participating in this program. We have developed a comprehensive training plan that includes closing our Provider Contact Center for up to eight hours each month. Using Provider Contact Center call distribution data to determine the least possible impact for our customers, we have selected the following closure dates and times for August 2008 and September 2008.
Hurricane Gustav Updates	Friday, August 29, 2008	The employees of Pinnacle Medicare Services continue to extend their support and heartfelt concern to the victims of Hurricane Gustav. In an effort to assist our provider community/beneficiaries during this difficult time, all hurricane related updates will be posted in this section of our website.
Part B Draft Local Coverage Determination Update	Wednesday, August 27, 2008	The Part B Draft LCD Section of our website has been updated to include two policies that will be open for comment September 1, 2008 through October 31, 2008: Interspinous Process Decompression, AC-08-001; Posterior Tibial Nerve Stimulation (PTNS) for Urinary Control, AC-08-002.
Chemotherapy Protocals	Monday, August 25, 2008	This is a reiteration of an article previously released in 2000. Previously, the Carrier allowed coverage for chemotherapy protocols that were recommended by MD Anderson. This is to clarify our position. We will allow chemotherapy protocols for beneficiaries if MD Anderson or the equivalent initiates them and care is then transferred to a provider in the state. However, it is necessary to submit documentation that supports this transfer of care at the review level.
Billing for Deep Brain Stimulation (DBS)	Monday, August 25, 2008	DBS refers to high-frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes. These DBS electrodes are stereotactically placed within the targeted nuclei on one (unilateral) or both (bilateral) sides of the brain. This article addresses the three targets for DBS – the thalamic ventralis intermedius nucleus (VIM), subthalmic nucleus (STN) and globus pallidus interna (GPi) for Parkinson’s Disease (PD) and Essential Tremor (ET).
Part B Open Forum Meeting Update	Friday, August 22, 2008	The Carrier's Open Forum Meeting for discussion of draft policies is scheduled for September 9, 2008 at 1:00 p.m. Please view the Draft LCD Section of the web site for specifics. The comment period will begin September 1, 2008 and any policies open for comment will be posted as of that date. If you plan to attend, you must register via this section of the website. Also, please verify the address of the meeting as this may have changed.
ICD-9 for Anti-Cancer Drugs Update: August 2008	Friday, August 22, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as for documentation requirements. The Compendia List can be found on the CMS website at: http://www.cms.hhs.gov/CoverageGenInfo/02_compendia.asp The following revisions have been made to the allowable diagnoses for the specified drugs, effective January 1, 2008 or as otherwise specified:
Sacral Nerve Stimulation	Friday, August 22, 2008	Sacral nerve stimulation is defined as the implantation of a permanent device that modulates the neural pathways controlling bladder function. This treatment is one of several alternative modalities for patients with urge urinary incontinence who have not responded to more conservative treatment for at least six months. Such measures might include behavioral and pharmacological treatments that were ineffective or not well tolerated.
Documentation Requirements for External Counterpulsation (HCPCS G0166)	Friday, August 22, 2008	External Counterpulsation (ECP) is defined in Local Coverage Determination (LCD) AC-99-516, as a "non-invasive outpatient treatment for coronary artery disease refractory to medical treatment or surgical therapy." This service is reported using HCPCS code G0166, defined as External counterpulsation, per treatment session. National data was analyzed for G0166 for dates of service July through December 2006. The Carrier to Nation ratios for allowed dollars and services have been aberrant at several times the nation for numerous reporting periods and have been steadily increasing.
Revolving Audit for Subsequent Hospital Care (99232) by Specialty 25 (Physical Medicine and Rehab) in Arkansas	Thursday, August 21, 2008	Subsequent Hospital Care Evaluation and Management Services is a continued problem area from fiscal years (FY)2005 through 2007, and ranks 2nd among all identified problem areas for FY2008 (up from 3rd in 2007). During the preparation of the 2008 strategy, Medicare Data Analysis identified outlying specialties and codes, based on Comprehensive Error Rate Testing (CERT) errors, national aberrancies, and/or local data findings. Based on high denial rates on widespread probes completed in late 2005 and early 2006, service specific prepay complex review for the top specialties in each state was implemented in January 2006 and has continued into FY2007. The first and second quarter 2007 denial rates in AR were 73% and 55%.
Revolving Audit for Subsequent Hospital Care (99232-99233) by Specialty 38 (Geriatric Medicine) in Arkansas	Thursday, August 21, 2008	Subsequent Hospital Care Evaluation and Management Services is a continued problem area from fiscal years (FY) 2005 through 2007, and ranks 2nd among all identified problem areas for FY2008 (up from 3rd in 2007). During the preparation of the 2008 strategy, Medicare Data Analysis identified outlying specialties and codes, based on Comprehensive Error Rate Testing (CERT) errors, national aberrancies, and/or local data findings. Based on high denial rates on widespread probes completed in late 2005 and early 2006, service specific prepay complex review for the top specialties in each state was implemented in January 2006 and has continued into FY2007. The first and second quarter 2007 denial rates in AR were 73% and 55% respectively.
Implementation of New Provider Authentication Requirements for Medicare Contractor Provider Telephone and Written Inquiries	Friday, August 15, 2008	CR 6139, from which this article is taken, addresses the necessary provider authentication requirements to complete IVR transactions and calls with a Customer Service Representative (CSR). Effective March 1, 2009, when you call either the IVR system, or a CSR, the Centers for Medicare & Medicaid Services (CMS) will require you to provide three data elements for authentication: 1) Your National Provider Identifier (NPI); 2) Your Provider Transaction Access Number (PTAN), and 3) The last 5-digits of your tax identification number (TIN). Make sure that your staffs are aware of this requirement for provider authentication.
Complexity of Medical Decision Making in Evaluation and Management (E/M) Services	Tuesday, August 12, 2008	Pinnacle Business Solutions, Inc. (PBSI) is committed to decreasing the Comprehensive Error Rate Testing (CERT) error rate. Our goal is to assist providers, through education, to reduce billing errors, and enable providers to have their claims paid correctly. The appropriate level of service can only be determined based on the documentation in the medical record. The complexity of medical decision making is the primary indicator of the appropriate level of service. Documentation for E/M codes must contain the specified number of key components in the CPT definition of the code, based on the condition of the patient. The condition of the patient is indicated by the medical decision making aspect of the required components.
Edit Requiring CPT Codes 64470 – 64476 and 64622 – 64627 To Be Billed With Fluoroscopic Guidance, CPT 77003	Wednesday, August 06, 2008	Medicare Part B Local Coverage Determinations (LCD) AC-02-034, Paravertebral Facet Joint Nerve Block (Diagnostic Or Therapeutic) and AC-02-035, Paravertebral Facet Nerve Denervation state that CPT codes 64470 – 64476 and 64622 – 64627 require that a needle is placed in the proper position under fluoroscopic guidance since correct anatomic placement is essential. Effective for dates of service on or after January 1, 2008, these procedures, if billed without fluoroscopic guidance, will be considered trigger point injections and will be paid as CPT 20553: Injection(s); single or multiple trigger point(s), three or more muscle(s) Current Procedural Terminology2008 © 2007 American Medical Association. All Rights Reserved.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE FIRST IN A SERIES OF ARTICLES	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. These articles will help providers to register for access to CMS online computer services when directed to do so by CMS. This article contains: 11 questions and answers to get you started and Overview of the registration process for IACS-PC defined provider/supplier organization users.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE SECOND IN A SERIES OF ARTICLES ON THE IACS	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. This article contains: 3 questions and answers about the registration process for provider organizations. (See NOTE below.) Links to the Quick Reference Guides for completing the registration process for provider organizations. (See NOTE below.) Note: For purposes of the IACS-PC, "Provider Organizations" include individual practitioners who will delegate IACS-PC work to staff as well as their staff using IACS-PC.
Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC): THE THIRD IN A SERIES OF ARTICLES ON THE IACS-PC	Tuesday, August 05, 2008	Note: This article was revised on July 30, 2008, to reflect current processes and provide the Web address for the new IACS website which contains user reference guides. Please note that CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in IACS-PC. Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice. This article describes the 3 steps providers must take to access a CMS Enterprise Provider Application including how to request a provider application role in IACS-PC (See step 2). CMS will notify providers as internet applications become available, and provide clear instructions that specify which providers should register in Individuals Authorized Access to CMS Computer Services – Provider/Supplier Community (IACS-PC). Do not register until you are notified by CMS or one of its contractors to do so and only if you meet the criteria in the notice.
Medicare Contractor Annual Update of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)	Monday, August 04, 2008	This article is based on Change Request (CR) 6107 and reminds the Medicare contractors and providers that the annual ICD-9-CM update will be effective for dates of service on and after October 1, 2008 (for institutional providers, effective for discharges on or after October 1, 2008). You can see the new, revised, and discontinued ICD-9-CM diagnosis codes on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage, or at the National Center for Health Statistics (NCHS) website at http://www.cdc.gov/nchs/icd9.htm in June of each year.
Medicare Coverage of Bioengineered Skin Substitutes (Revised for Clarification and Explanation)	Thursday, July 31, 2008	The following article is written to clarify the articles previously published on August 27, 2007 and November 5, 2007. To be covered by Medicare, any metabolically active product used in ulcer treatment must be billed under the appropriate code and used according to the FDA labeling instructions. Documentation of criteria, frequency, and duration must be included in the medical record. The medical record must clearly document that conservative pre-treatment wound management has been tried and failed to induce healing. Compliance with the FDA approved labeling provisions is subject to monitoring by pre-payment medical review and post payment data analysis with subsequent medical review. Additional utilization guidelines beyond the FDA labeling, and information based on Medical Review results of prior claim review, are included in this article for provider use. This article provides information for coverage of bioengineered skin substitutes and their application. The short descriptors for the codes are in accordance with the AMA copyright agreement. Please refer to the current CPT book for full descriptions. Please remember that the HCPCS/CPT code(s) may be subject to Correct Coding Initiative (CCI) edits that limits their use with certain CPT codes and global periods. Providers are also reminded that the use must be consistent with State licensure and scope of practice limitations. Documentation should be readily available and submitted to the Contractor upon request.
Podiatrists and Optometrists Billing Nursing Facility Codes (CPT 99304-99307, 99307-99310)	Friday, July 25, 2008	Podiatrists and Optometrists cannot be reimbursed for initial nursing facility care CPT codes 99304 – 99306. According to the Code of Federal Regulations, 42 CFR 483.40 (b)(1), the physician admitting a resident to a nursing facility must "…Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section…" According to the Centers for Medicare & Medicaid Services (CMS), only a doctor of medicine or osteopathy legally authorized to practice medicine or surgery in the state may serve as a physician as described in this CFR. Reviewing the resident’s total program of care is beyond the scope of practice for a podiatrist or optometrist. In place of an initial nursing facility care code, podiatrists and optometrists may bill for a consultation visit for the initial visit (CPT 99251-99255), when the primary care physician has ordered podiatry or optometry services.
ICD-9 for Anti-Cancer Drugs Update: July 2008	Thursday, July 24, 2008	Pinnacle Business Solutions, Inc as a Medicare carrier has determined that the following anti-cancer drugs may be billed with the specified diagnosis codes only. Guidelines for coverage of anti-cancer drugs include FDA approval for specific indications and citation in the USPDI (United States Pharmacopeia Drug Information), AHFS (American Hospital Formulary Service Drug Information), and/or National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium providing support for the drug. Text analysis determines the support of a particular use. Please refer to the Local Coverage Determination AC-01-024 "Anti-Cancer Drugs" for additional information regarding indications and limitations of coverage and/or medical necessity as well as for documentation requirements.
Revolving Audit for Emergency Department Evaluation and Management Services (99284) by Specialty 08 (Family Practice) in Arkansas	Thursday, July 24, 2008	Emergency Department Evaluation and Management (E/M) services is a continued problem area from the 2006 and 2007 fiscal years, and ranks 8th among the identified problem areas for fiscal year 2008. During the preparation of the 2008 strategy, Medicare Data Analysis identified outlying specialties and codes for widespread probes, based on Comprehensive Error Rate Testing (CERT) errors, national aberrancies, and/or local data findings. Of the 100 services reviewed, 55 services (55%) were allowed as billed and 45 (45%) were denied as follows:
Psychotherapy Services in Arkansas (CPT Code 90804)	Thursday, July 24, 2008	Medical Review is currently auditing psychotherapy code 90804 in Arkansas. Psychiatric services are part of the Strategy for the 2008 fiscal year and a continuation from FY2007. A widespread problem of high utilization was identified by data analysis and was verified by prepay widespread probe review. Psychiatric services represented 1.3% of the total CERT errors for the Pinnacle Business Solutions, Inc. (PBSI) Medicare Coverage Area for sample dates April 1, 2005, through April 30, 2007.
Revolving Audit for New Patient Office Evaluation and Management Services (99205) by Specialty 13 (Neurology) in Arkansas	Thursday, July 24, 2008	New Patient Office Evaluation and Management services is a continued problem area from the 2007 fiscal year, and ranks 5th among all identified problem areas for fiscal year 2008. During the preparation of the 2008 strategy, Medicare Data Analysis identified outlying specialties and codes for widespread probes, based on Comprehensive Error Rate Testing (CERT) errors, national aberrancies, and/or local data findings. A widespread probe review was performed for CPT 99205 by specialty (SP) 13 in mid-2007. Probe review results revealed high denial rates. Of the 100 services reviewed, 4 services (4%) were allowed as billed. The remaining 96 services (96%) were denied as follows:
Subsequent Nursing Facility Evaluation and Management Services (99307-99309) by Specialty 11 (Internal Medicine) in Arkansas	Thursday, July 24, 2008	Medical Review is currently auditing Subsequent Nursing Facility Evaluation and Management (E/M) codes 99307- 9309 by Specialty (SP) 11 in Arkansas. A widespread probe was performed in 2007 with an error rate of 55% by claims, 54% by services, and 42% by dollar amount. An article was posted to the Medicare website in March 2007 educating the provider community on the probe findings. Data Analysis compared the time periods of June 1, 2007, through August 31, 2007, to December 1, 2007, through February 29, 2008. The data indicated a steady increase in the use of codes 99307-99309 by SP 11 and no one provider stands out as having contributed significantly to the overall increase.
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