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National Government Services Part B Medical Review Newsletter December 2020

The National Government Services Medical Review department would like to welcome you to our newest service; a regular newsletter. It is our hope that you will find this newsletter helpful in providing you the resources you need to help you stay up-to-date on the MR activities performed here at NGS.

Our plan is to include:

    • Updates and News
    • Educational Resources
    • Helpful Tips and Reminders
    • Contact Information

What’s New?

Please note: TPE reviews remain suspended due to the PHE related to COVID-19. However, the NGS MR Department is currently performing service specific post-payment reviews for a random selection of claims billed to Medicare Part A and B.

Providers are encouraged to visit the Medical Review Focus Areas on our website. This dedicated area will identify which services are being selected, what documentation will be requested, and provide more details on these service specific post-payment reviews.

Medical Review Focus Areas:

Note: If the link above does not take you directly to the MR focus area topic, it is often due to it being your initial visit to the NGS website. If this occurs, you may see a red box that says Continue as a Guest. Select your Part B provider information. Once you do this and continue, you will be prompted to verify you read a short attestation statement. After completing this information once, you should not have to do it a second time as long as you choose Remember my choice when putting in your provider information. Once you do this, click on the Medical Policy & Review tab near the top.

JK Part B ‒ Service Specific Post-Payment Review Announcements

Ambulance Transport and Mileage

    • A0425 Ground mileage, per statute
    • A0428 Ambulance service, basic life support, non-emergent transport (BLS)

Nail Debridement: CPT Codes 11719, 11720, 11721

    • 11719 Trimming of nondystrophic nails, any number
    • 11720 Debridement of nail(s) by any method(s) 1 to 5
    • 11721 Debridement of nails by any method(s) 6 or more

Paring or Cutting of Benign Hyperkeratotic Lesions: CPT Codes 11055, 11056, 11057

    • 11055 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); single lesion
    • 11056 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to 4 lesions
    • 11057 Paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); more than 4 lesions

Botulinum Toxin: CPT Codes J0585, 64612, 64615

    • J0585 Injection, onabotulinumtoxina, 1 unit
    • 64612 Chemodenervation of muscle(s); muscle(s) innervated by facial nerve, unilateral (eg, for blepharospasm, hemifacial spasm)
    • 64615 Chemodenervation of muscle(s); muscle(s) innervated by facial, trigeminal, cervical spinal and accessory nerves, bilateral (eg, for chronic migraine)

Vitamin D Assay Testing: CPT Code 82306

    • 82306 Vitamin D; 25 Hydroxy, includes fraction(s), if performed

J6 Part B ‒ Service Specific Post-Payment Review Announcements

Psychotherapy, 60 Minutes with Patient: CPT Code 90837

    • 90837 Psychotherapy, 60 minutes with patient

Ambulance Transport Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN

    • A0425 Ground mileage, per statute mile
    • A0426 Ambulance service, advanced life support, non-emergency transport (ALS)
    • A0428 Ambulance service, basic life support, non-emergent transport (BLS)

Hyaluronan or Derivative: HCPCS Codes J7326, J7327

    • J7326 Hyaluronan or derivative, gel-one, for intra-articular injection, per dose
    • J7327 Hyaluronan or derivative, monovisc, for intra-articular injection, per dose

Attention Chiropractors - Have you Received a Comparative Billing Report?

In October, the NGS Medical Review Department began to mail CBRs to select chiropractors.

    • A CBR is a Comparative Billing Report
    • CBRs are free
    • The CMS defines a CBR as an educational resource and tool for possible improvement
    • CBRs are often used to alert providers if their billing statistics appear unusual compared to their peers
    • The CBR is an educational tool to support the effort of safeguarding the Medicare Trust Fund

NGS will also be mailing CBRs relating to observation and critical care services.

If you have receive a CBR and have questions or would like to request education, please contact the Medical Review department using the email address at the end of this newsletter.

Mental Health Providers

Recently the NGS Medical Review team surveyed Mental Health Providers in those areas most severely impacted by COVID-19. Providers expressed a need for further educational resources. Please see some helpful resources below:

Telehealth Video: Medicare Coverage and Payment of Virtual Services

CMS updated the Medicare Coverage and Payment of Virtual Services YouTube video that answers common questions about the expanded Medicare telehealth services benefit during the COVID-19 public health emergency. New information includes how CMS adds services to the list of telehealth services, additional practitioners that can provide telehealth services and the distant site services that RHCs and FQHCs can provide. Further, the video includes information about audio-only telehealth services, telehealth services that hospitals, nursing homes and home health agencies can provide, along with how to correctly bill for telehealth services.

CMS Takes Steps to Ensure Medicare Beneficiaries Have Wide Access to COVID-19 Antibody Treatment

Helpful Tips

    • NGS recommends responding to ADRs within 35‒40 days of the letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS.
    • Be sure to forward the requested documentation using the preferred method of submission.
    • If you are mailing in your ADR, please send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
    • Include all records necessary to support the services for the dates requested.
    • Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
    • Records must be complete and legible. Be sure to include both sides of double-sided documents.
    • The NGS self-service portal, NGSConnex, allows both Part A (including home health, hospice and FQHCs) and Part B providers to respond to ADRs electronically with no need to mail or fax a response to complete the ADR process. Further details are available on our website. If you are a current user of NGSConnex, click on the link for the NGSConnex User Guide for step-by-step instructions on how to submit ADR. If you are not a current user, sign up and get started!
    • All services must include necessary signatures and credentials of professionals. See the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”.
    • Visit the Medical Review Focus Areas on the NGS website for educational resources relating to these services being reviewed.

Contact Us

If you have received an ADR or CBR and have questions, you may contact the MR department at the following email address:

States Email Addresses
Connecticut, Maine, Massachusetts, New Hampshire, New York, Vermont, Rhode Island JKBcasemanagement@anthem.com
Illinois, Minnesota, Wisconsin J6Bcasemanagement@anthem.com

Posted 12/11/2020

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