National Government Services Part B Medical Review Newsletter June 2021
We hope you are enjoying our newest service; a regular newsletter. Our goal is to help you stay up-to-date on the on the MR activities performed here at National Government Services.
A Message from Our Medical Review Staff
Please monitor your incoming mail and be sure to respond timely to Medical Review ADRs. ADRs are sent to the address CMS has on file for all correspondence. Contact us via email if you are having difficulty responding, we are here to help!
Have you received a Part B Medical Review Additional Documentation Request and are looking for the most efficient way to respond? If so, please watch our short YouTube Video Use NGSConnex to Respond to Post Pay Medical Review ADRs for guidance when responding to the request via NGSConnex.
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.
Service Specific Post Payment Review Announcements
Providers are encouraged to visit the Medical Review Focus Area on our website. This dedicated area will identify which services are being selected, what type of documentation is required, and provide more details on these service specific post-payment reviews.
Updated: Medical Review Focus Page for more information about your review:
See the Educational Resources within this letter to access our newly created webinars and videos.
Comparative Billing Reports
The Medical Review Department continues to mail CBRs to providers whose billing is identified as being significantly different compared to their peers. A CBR provides comparative data on how an individual health care provider compares to other providers by looking at utilization patterns for services, beneficiaries, and diagnoses billed. CBRs can serve as a helpful self-audit tool for providers. NGS has mailed CBRs for the following services:
JK Part B
- Chiropractic Services (98940‒98942)
- Hospital Outpatient Observation Services (99224‒99226)
- Subsequent Hospital Visits (99231‒99233)
- Chronic Care Management Service (99490 and 99487)
- Nursing Home Visits (99309‒99310)
- Urine Drug Test(s) (80307)
- Physical and Occupational Therapy (all applicable codes billed with GP modifier)
- Initial Hospital Visits (99221‒99223)
J6 Part B
- Chiropractic Services (98940‒98942)
- Hospital Outpatient Observation Services (99224‒99226)
- Subsequent Hospital Visits (99231‒99233)
- Nursing Home Visits (99309‒99310)
- Initial Hospital Visits (99221‒99223)
Questions? If you have received a CBR and have questions or would like to request education please contact the Medical Review Case Management team using the email address in the “Contact Us” section located at the end of this newsletter.
Educational Resources
- New! Educational Videos
- New! Medical Review Focus Webinars
Helpful Tips and Reminders
This month we are including helpful tips and reminders from our clinical staff. Our Medical Review staff has observed common errors involving documentation requirements during the review process. The following information pertains to the records submitted for post-pay review of specifically noted services below:
JK Part B
Prolia (Denosumab) Injection Reviews: The patient's medical record should contain documentation that fully supports the medical necessity for the administration of either formulation. Requirements specific to each formulation are as follows:
- Supplemental calcium and vitamin D are required (information should be current).
- Hypocalcemia must be corrected prior to initiation of Denosumab therapy.
Nail Debridement: CPT Codes 11719, 11720, 11721 and Paring or Cutting of Benign Hyperkeratotic Lesions: CPT Codes 11055, 11056, 11057
- 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
- 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion
- 11056 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions
- 11057 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions
The codes listed above for Debridement and Paring or Cutting should not be billed on the same date of service for the same toe. If the services occur on different toes, it is then appropriate to utilize the 59 modifier to indicate a different site. Medical review has observed many instances where the 59 modifier is being used incorrectly based on the information presented in the medical record.
When 11055‒11057 and 11720‒11721 are billed by the same provider for the same date of service, use of the 59 modifier will allow both codes to be paid on the original claim when it is not actually appropriate in most situations. It should only be used for services that do not overlap. Documentation must clearly show each procedure was performed on a separate toe.
Additional Educational Resources
- Modifier 59 is defined as a Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances.
- Modifier XS is defined as a Separate Structure, A Service That Is Distinct Because It Was Performed on A Separate Organ/Structure.
- MLN® Fact Sheet: Proper Use of Modifiers 59 & -X{EPSU}
Additional Information and Related Content
- NCCI listings can be found on the CMS National Correct Coding website.
J6 Part B
General Education: Please ensure the medical records and orders are authenticated with a valid, legible signature. You may submit a signature log with the documentation if a signature appears illegible. If a service requires an order, please ensure the order is submitted for review.
- Diagnostic Codes
- Must submit the referring providers signed MD order.
- Q4133 Grafix Prime
- Must submit Lot/Tissue number.
- Must use the most economical graft size available.
- Must document the amount of waste, if any.
- J0881 Darbepoetin Alfa
- Must submit lab results from initiation of therapy.
- Review guidelines to ensure labs are within range to support medical necessity for the use of Darbepoetin Alfa.
- 90837 Psychotherapy
- Must submit plan of treatment to include the type, amount, frequency, duration, modality, goals and mental status exam along with any updated treatment plan(s) to show progress towards goals to support continued need for services.
JK and J6 Part B
- J0585 Botox
- Must meet Local Coverage Determination L33646/Local Coverage Article A52848 medical necessity guidelines for covered diagnoses as well as documentation guidelines. Be sure to include:
- Documentation of the medical necessity for this treatment. For spastic conditions other than upper or lower limb spasticity, blepharospasm, hemifacial spasm, cervical dystonia or other focal dystonias, documentation should include a statement that the spastic condition has been unresponsive to conventional treatment;
- A covered diagnosis; dosage(s), site(s) and frequency(ies) of injection; documentation of the medical necessity for associated electromyography when used; and
- Description of the effectiveness of this treatment.
- Note: Due to the short life span of the drug once it is reconstituted, Medicare will reimburse the unused portions of Botulinum toxins. When modifier JW is used to report that a portion of the drug is discarded, the medical record must clearly show the amount administered and the amount discarded.
- Must meet Local Coverage Determination L33646/Local Coverage Article A52848 medical necessity guidelines for covered diagnoses as well as documentation guidelines. Be sure to include:
Contact Us
If you have received an ADR or CBR and have questions, you may contact the MR department at the following email addresses:
| States | Email Address |
|---|---|
| Connecticut, Maine, Massachusetts, New Hampshire, New York, Vermont, Rhode Island | JKBcasemanagement@anthem.com |
| Illinois, Minnesota, Wisconsin | J6Bcasemanagement@anthem.com |
Posted 6/24/2021