Newly approved Recovery Auditor issues-02/10/16

CGI posted one new issue in one category 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:

• Cognitive Skills Limited to Specific Conditions- OP. This automated edit is to identify outpatient claims for Cognitive Skills Development where claims are incorrectly paid based off ICD-9 (ICD10- eff 10/1/2015) codes that are not payable based upon the PM AB-02-078 and LCD in effect at the time of administration.

Cotoviti posted nine new issue in two categories to its CMS list for providers in Region C. (See link for individual state applicability.)

According to the Cotiviti website, the new issues are:

For Skilled Nursing Facilities:     

• SNF Level of Care Review-C000572015. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care, which is covered under the program. Medical documentation will be reviewed to validate if the patient's stay met the level of care requirements for an inpatient SNF stay. Applicable Region C states–Palmetto.
• SNF Level of Care Review-C000562015. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care, which is covered under the program. Medical documentation will be reviewed to validate if the patient's stay met the level of care requirements for an inpatient SNF stay. Applicable Region C states–Novitas.
• SNF Level of Care Review-C000552015. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care, which is covered under the program. Medical documentation will be reviewed to validate if the patient's stay met the level of care requirements for an inpatient SNF stay. Applicable Region C states–First Coast.
• SNF Level of Care Review-C000542015. In the SNF, the term "non-covered care" refers to any level of care which is less intensive than the SNF level of care, which is covered under the program. Medical documentation will be reviewed to validate if the patient's stay met the level of care requirements for an inpatient SNF stay. Applicable Region C states–Cahaba.

For Outpatient Hospital:

• ESA Administration for NON-ESRD Conditions-OP-C000422015. CMS has determined that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. Applicable Region C states–Palmetto.
• ESA Administration for NON-ESRD Conditions-OP-C000412015. CMS has determined that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. Applicable Region C states–Novitas.
• ESA Administration for NON-ESRD Conditions-OP- C000402015. CMS has determined that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. Applicable Region C states–First Coast.
• ESA Administration for NON-ESRD Conditions-OP-C004872013. CMS has determined that ESA treatment is not reasonable and necessary for beneficiaries with certain clinical conditions, either because of a deleterious effect of the ESA on their underlying disease or because the underlying disease increases their risk of adverse effects related to ESA use. Applicable Region C states–Cahaba.
• Unclassified Drugs and Biologicals-C000432015. The medical documentation will be reviewed to validate if the following items: the NDC (National Drug Code) billed, the quantity of the drug that was administered, and that the unclassified drug or biological was paid in accordance with the CMS guidelines for Outpatient Payment for Unclassified Drugs and Biologicals. Applicable C Region states.