Newly approved Recovery Auditor issues – 04/20/2016

CGI posts four new issues in two categories

According to the CGI website, the new issues are:

For professional:

• Verteporfin_Non-Covered Diagnosis. Verteporfin with Ocular Photodynamic Therapy is covered for treatment of subfoveal choroidal nepovascularization (CNV) in patients with the wet form of age-related macular degeneration (AMD). The LCD extends coverage for treatment of CNV associated with macular degeneration due to pathologic myopia or ocular histoplasmosis. Use of OPT with verteporfin for other types of AMD is non-covered.
• Inpatient EM During A SNF Stay_Initial Visits. Evaluation and Management services provided to patients in a Part A SNF stay are reported with CPT codes for Nursing Facility Care Services (99304-99306) based on the nature of work provided in a SNF setting. This review is looking for initial inpatient hospital E/M services (99221-99223) billed while the patient is under a Part A SNF stay. The Medicare manual states that physicians and qualified NPPs shall report initial nursing facility care codes (99304-99306) for their first visit with the patient. During the course of this automated review, the initial inpatient hospital care codes will be changed to the corresponding SNF code, and the claim will be re-priced.
• Critical Care Services Unbundled. The Critical Care service includes bundled services that are being billed separately.

For outpatient:

• Outpatient Azacitidine (Vidaza) Correct Coding – WPS. Azacitidine (Vidaza) HCPCS code J9025 is not supported by the diagnosis.