Newly approved Recovery Auditor issues – 05/11/2016

CGI posts two new issues

CGI posted two new issues in two categories to its CMS list for providers in Region B. (See link for individual state applicability.)

According to the CGI website, the new issue is:

For outpatient services:

• Bortezomib (Velcade) Non-Covered Diagnosis - Wisconsin Physician Services (WPS). Bortezomib (Velcade®) is a chemotherapy agent that is used in the treatment of multiple myeloma and certain other lymphomas. The purpose of this automated review is to identify claims that are billed without a covered diagnosis as specified within the LCD documents. An overpayment exists when a provider bills for a service of J9041, Injection, bortezomib, 0.1mg with an ICD diagnosis code that is not included in the list of covered diagnosis codes specified on the LCD.
• Cognitive Skills Limited to Specific Conditions- OP. The purpose of this automated issue is to identify claims that are billed with a non-covered diagnosis for development of cognitive skills based on instruction provided on the applicable Local Coverage Determination (LCD). An overpayment exists when a provider bills for a service of 97532, Development of cognitive skills to improve attention, memory, problem solving with an ICD diagnosis code that is not included in the list of covered diagnosis codes as specified on the LCD. Restrictions placed upon this code do not apply to vision impairment rehabilitation services as defined in PM AB-02-078. These include diagnosis codes: 368.41, 368.45, 368.46, 368.47, 369.01, 369.03, 369.04, 369.06, 369.07, 369.08, 369.12, 369.13, 369.14, 369.16, 369.17, 369.18, 369.22, 369.24, 369.25. Therapy services have specific documentation requirements, including specific diagnosis codes, that must be present, in order to justify the amount, duration and frequency of these therapy services. As of 10/01/2015 the following ICD-10 codes will apply to this edit: H53.411, H53.412, H53.413, H53.419, H53.461, H53.462, H53.469, H53.47, H53.481, H53.482, H53.483, H53.489, H54.0, H54.2, F07.0, F07.89, F07.9, F09, F48.2.

Cotiviti posts one new issue

Cotiviti posted one new issue to its CMS list for providers in Region C. (See link for individual state applicability.)

According to the Cotiviti website, the new issue is:

For Inpatient Hospital and Physician:     

• Lumbar Spinal Fusion IP/CARRIER C000122016. The goal of lumbar spinal fusion, also referred to as lumbar arthrodesis, is to permanently immobilize the spinal column vertebrae surrounding the disc(s) that are causing the discogenic low back pain. Medical Documentation will be reviewed to determine if Lumbar Spinal Fusion meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary as noted in Cahaba LCD L35624, Cahaba LCD L35942, First Coast LCD L32074, and First Coast LCD L33382.