CMS adds implantable automatic defibrillators, other items and procedures, to proposed Recovery Audit topics
CMS is proposing new topics for review under the Recovery Audit (RA) program. The new topics, released April 10, include:
- Exact duplicate claims
- Implantable automatic defibrillators
- Group 3 support surfaces
- Percutaneous implantation of neurostimulator electrode array
CMS noted additional details such as affected regions, review type, affected codes, and provider type for each topic. Provider types affected by the proposed reviews include physicians/non-physician practitioners, outpatient hospitals, ambulatory surgical centers, durable medical equipment (DME) suppliers, and DME by physician. All topics proposed in the April 10 update would affect all states.
Implantable automatic defibrillators audits would involve RA review of documentation to support medical necessity. CMS notes that this would be a complex review and would affect CPT® codes 33240, 33241, 33242, 33243, 33249.
Group 3 support surfaces reviews would scrutinize Medicare payment for the use of an air-fluidized bed in a patient’s home. RA reviews would evaluate whether the item was reasonable and medically necessary based on documentation. CPT code E0194 would be affected.
Percutaneous implantation of neurostimulator electrode array audits would examine whether providers correctly billed for HCPCS codes 64553 and 64555. The documentation must support that the code accurately represents the service performed and that all coverage criteria were met.
Exact duplicate claims—any claims paid across more than one claim number for the same beneficiary, CPT/HCPCS code, and service state by the same provider—would affect all CPT/HCPCPS codes.
Organizations should review providers’ documentation and ensure that the medical record supports the medical necessity of all services, procedures, and items. Providers, coders, and CDI specialists should be encouraged to review the documentation requirements for proposed RA topics.