Newly approved Recovery Auditor issues-02/17/2016

Performant Recovery posted three new issues in three categories to its CMS list for providers in Region A. (See link for individual state applicability.)

According to the Performant website, the new issues are:

For DME supplier:

• Vacuum Erection Devices–JA. Vacuum Erection Devices were paid under the DME Prosthetic benefit, which stipulates the device must be used to replace all or part of an internal body organ. Local Coverage Determinations in effect through June 30, 2015 describe medical necessity criteria. As of July 1, 2015, vacuum erection devises were statutorily excluded from coverage. Potential incorrect billing exists when the documentation does not support the Medicare criteria for coverage. 

For outpatient:

• Cardiac PET Scans–JA. This medical review will determine if the Cardiac PET Scan was medically necessary based on the indications noted in the CMS NCD Manual, Chapter 1, Part 4, §§220.6.1 and 220.6.8 and the Medicare Claims Processing Manual, Chapter 13, §§60.4, 60.9, and 60.11. 

For physician/non-physician practitioner:

• Cardiac PET Scans–JA. This medical review will determine if the Cardiac PET Scan was medically necessary based on the indications noted in the CMS NCD Manual, Chapter 1, Part 4, §§220.6.1 and 220.6.8 and the Medicare Claims Processing Manual, Chapter 13, §§60.4, 60.9, and 60.11. 

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 inpatient:

• Cardiac Valve and Other Major Cardiovascular Procedures, MS-DRGs 216, 217, 219, 220, 268, 269, 270, 271, 272, 273, and 274. The purpose of MS-DRG Validation is to determine that the principal diagnosis, procedures and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, and coded. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate the principal diagnosis, and secondary diagnoses and procedures affecting or potentially affecting MSDRG 216, 217, 219, 220, 268, 269, 270, 271, 272, 273, and 274.