Skip to Main Content
 
 
 
Web Content Viewer

News and Alerts

Web Content Viewer

National Government Services Part A Medical Review Newsletter June 2021

The National Government Services MR Department would like to welcome you to our newest service; a regular newsletter. It is our hope that you will find this newsletter helpful in providing you with the resources you need to stay up-to-date on the on the MR activities performed here at NGS for Medicare Part A and home health and hospice services.

What’s New?

MACs Resume Medical Review on a Postpayment Basis

Beginning August 2020, MACs resumed post-payment reviews of items and services with dates of service before March 2020. MACs may now begin conducting post-payment medical reviews for later dates of service. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to 3 rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate (posted 6/3/2021 in MLN Connects®).

NGSMedicare.com

On Friday, 5/14/2021, we launched a new combined homepage at NGSMedicare.com in response to feedback from our providers. The homepage allows you to log in to either NGSMedicare.com or NGSConnex from the same website address.  An article titled “Tips to Ensure an Optimal NGSMedicare.com Experience” offers suggestions for making use of the homepage and website the best encounter possible; it can be found under News and Alerts on the Education tab. Other exciting changes will be made on the website in coming weeks, to provide a better user experience and allow easier navigation for desired topics. Be on the lookout for additional communications regarding these changes.

Reminder: Update Your Browser Now

Starting July 2021, the NGSMedicare.com website will not support the Internet Explorer (IE) browser. To access either the secure, self-service provider portal, NGSConnex or the provider content website, you are required to use one of the supported browsers below:

Diabetic Self-Management Training and Medical Nutrition Therapy Information

As of Wednesday, 5/19/2021 calling the PCC to get information on DSMT and MNT got easier. When you call the PCC and complete authentication, you can now simply press zero (0) when prompted to reach one of our DSMT/MNT subject matter experts.

Two New Hospital Outpatient Services That Now Require Prior Authorization

Effective 6/17/2021, there are 2 new areas of hospital OPD services that will require prior authorization for procedures done on or after 7/1/2021. They are:

  • Cervical Fusion With Disc Removal
    • CPT 22551 fusion of spine bones with removal of disc at upper spinal column, anterior approach, complex, initial
    • CPT 22552 fusion of spine bones with removal of disc in upper spinal column below second vertebral neck, anterior approach, each additional interspace
  • Implanted Spinal Neurostimulators
    • CPT 63650 implantation of spinal neurostimulator electrodes, accessed through the skin
    • CPT 63685 insertion or replacement of spinal neurostimulator pulse generator or receiver
    • 63688 revision or removal of implanted spinal neurostimulator

For specific information related to the documentation requirements for these newly added procedures, as well as general information about the NGS prior authorization program, visit our website. Upon entering the site, choose the Medical Policy & Review > Medical Review > Prior Authorization Program for Certain Hospital Outpatient Department Services.

Reminder: Registration is Now Open for the 2021 MAC Collaborative Summit

This year, the home health and hospice summit will remain virtual and it is free to attend. The 2021 MAC Collaborative Summit, titled “Operation Collaboration: We are all in this Together” is scheduled for September 15–17, 2021. This year, an additional track has been added, specifically for Medicare A/B physicians and allowed practitioners who order and monitor home health and hospice services. A wide variety of topics are covered and presenters include representatives from MACs, The CMS, the UPIC, The National Home Health and Hospice Associations, as well as the Beneficiary Advocacy Groups. For a complete description of the sessions offered and the registration links, please visit the NGS website and click on the scrolling banner titled “2021 MAC Collaborative Summit”.

We hope to “see” you there!

Service Specific Post Payment Review Announcements

Please note: TPE reviews remain suspended due to the PHE related to COVID-19. However, the NGS MR Department is currently performing service specific post-payment reviews for a random selection of claims billed to Medicare Part A and B.

Providers are encouraged to visit the Medical Review Focus Areas on our website. This dedicated area will identify service areas under review, required documentation, and provides more details on these service specific post-payment reviews.

Upon entering the site, choose the Medical Policy & Review > Medical Review > Medical Review Focus Areas.

JK Part A

Continuing Edits

Physical Therapy Reevaluations

  • CPT 97164 – Reevaluation of physical therapy established plan of care

Wound Debridement

  • HCPCS 97597 – Active wound care management for selective wound debridement (typically recurrent debridement), performed with minimal anesthesia
  • HCPCS 97598 – Active wound care management for selective wound debridement (typically recurrent debridement), performed with minimal anesthesia, total wound(s) surface area greater than 20 square centimeters

Wheelchair Management

  • 97542 – Wheelchair management (e.g., assessment, fitting, training) each 15 minutes.

Group Psychotherapy

  • HCPCS: 90853 – Outpatient group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

Individual Psychotherapy

  • 90832 – Individual psychotherapy services rendered for 30 minutes by a licensed mental health provider, with patient
  • 90834 – Individual psychotherapy services rendered for 45 minutes by a licensed mental health provider, with patient

Trastuzumab/Herceptin

  • HCPCS: J9355 – Injection, trastuzumab (Herceptin), excludes biosimilar, 10 mg

Fosaprepitant Injection

  • HCPCS: J1453 – Injection, Fosaprepitant, 1 mg

New Edits

Cardiac Rehabilitation

  • Bill Type: 13x or 85x
  • CPT/HCPCS: 93797 or 93798

JK Home Health

Continuing Edits

Patient Driven Grouping Model (PDGM) Claims

  • Bill Type: 32x or 33x
  • Dates of Service: 1/1/2020 through 2/29/2020

Home Health Homebound Criteria

  • Bill Type: 32x or 33x

JK Hospice

Continuing Edits

General Inpatient (GIP) Services

  • Bill Type: 81x or 82x
  • Revenue code 0656 – 7 or more units

Completed Edits

Length of Stay > 730 days

  • Bill Type: 81x or 82x
  • The review summary results can be found at NGSMedicare.com under the Medical Review Focus Areas section

J6 Part A

Continuing Edits

Cardiac Rehabilitation Services

  • 93797 – (Physician services for outpatient cardiac rehabilitation; without continuous electrocardiographic [ECG] monitoring [per session]).
  • 93798 – (Physician services for outpatient cardiac rehabilitation; with continuous ECG monitoring [per session])

Physical Therapy Reevaluations

  • 97164 – Physical therapy reevaluation

Individual Psychotherapy

  • 90832 – Individual psychotherapy services rendered for 30 minutes by a licensed mental health provider, with patient
  • 90834 – Individual psychotherapy services rendered for 45 minutes by a licensed mental health provider, with patient

Group Psychotherapy

  • HCPCS: 90853 – Outpatient group psychotherapy including interpersonal interactions and support with several patients; typically 45 to 60 minutes in length.

Hyperbaric Oxygen (HBO) Services

  • HCPCS G0277 – HBO under pressure, full body chamber, per 30 minute interval

Trastuzumab/Herceptin

  • HCPCS:  J9355 – Injection, trastuzumab (Herceptin), excludes biosimilar, 10 mg

New edits

Intravenous Immune Globulin Services

  • HCPCS: J1459 – Injection, immune globulin (privigen), intravenous, non-lyophilized (e.g. liquid), 500 mg

Ambulance Services

  • HCPCS: A0427 – Ambulance service, advanced life support, emergency transport, level 1 (als1 – emergency)

J6 Home Health

Continuing Edits

Patient Driven Grouping Model (PDGM) Claims

  • Bill Type: 329
  • Dates of Service: 1/1/2020 thru 2/29/2020

Completed Edits

Claims with Value Code 17

  • Bill Type: 329
  • The review summary results can be found at NGSMedicare.com under the Medical Review Focus Areas section

J6 Hospice

Continuing Edits

General Inpatient (GIP) Services

  • Bill Type: 81x or 82x
  • Revenue code 0656 – 7 or more units

Completed Edits

Length of Stay > 730 days

  • Bill Type: 81x or 82x
  • The review summary results can be found at NGSMedicare.com under the Medical Review Focus Areas section

Have You Received a Comparative Billing Report from NGS?

  • A CBR is a Comparative Billing Report 
  • CBRs are free
  • The CMS defines a CBR as an educational resource and a tool for possible improvement
  • CBRs are often used to alert providers if their billing statistics appear unusual compared to their peers
  • The CBR is an educational tool to support the effort of safeguarding the Trust Fund

If you have receive a CBR from NGS and have questions or would like to request education please contact the Medical Review department using the email address at the end of this newsletter.

Additional information on CBR is available at our YouTube video: Part A Comparative Billing Reports or by reaching out to us at JKAcasemanagement@anthem.com or J6Acasemanagement@anthem.com.

Educational Resources

Home Health LUPA Threshold: Bill Correctly

In a recent report, the Office of Inspector General found that Medicare improperly paid some claims for home health services with five to seven visits in a payment episode. Review the Medicare  Home Health Benefit and Home Health Prospective Payment System booklets to properly bill for services slightly above the Low Utilization Payment Adjustment (LUPA) threshold.

For more information, visit the Home Health PPS webpage and view these additional resources  to stay informed on the latest policy and payment updates:

  • Home Health PPS final rule
  • CMS Internet-Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 Section 10.6
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 10 Section 10.1.17
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 6 Section 6.2

Remember, in CY 2020, the LUPA threshold changed:

  • from a fixed threshold of four visits
  • to a variable LUPA threshold that ranges from two to six visits based on the Health Insurance Prospective Payment System (HIPPS) payment code billed.

Additional information on the 2020 changes to the Medicare Home Health benefit can be found in the MLN® Booklet: Medicare Home Health Benefit

Helpful Tips

NGS recommends responding to Additional Documentation Requests (ADR) within 35‒40 days of letter date (CMS allows providers 45 days of the ADR date). See the ADR Timeline Calculator available on our website for help with determining the target date that the requested medical records must be received by NGS. Read the ADR carefully and submit all of the documentation requested. Include all records necessary to support the services for the dates requested.

  • If you are mailing in your ADR, please send each response separately and attach a copy of the corresponding ADR. It is acceptable to send multiple responses in a single mailing; however, each response must be individually bundled with a copy of the corresponding ADR within the mailing to facilitate proper handling and review of the ADR response.
  • Do not include additional correspondence with documentation submissions. Unrelated correspondence should be mailed separately.
  • Records must be complete and legible. Be sure to include both sides of double-sided documents.
  • All services must include necessary signatures and credentials of professionals. See CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, “Signature Requirements”

NGSConnex

Submitting Late or Additional Documentation via NGSConnex

If the claim selected is past the time limit to respond (45 days) or has already been responded to, the Respond to ADR button will be disabled. However, you can still use NGSConnex to submit the medical record documentation for an MR ADR. Simply select the Respond to ADR not in list button; if you use this option, you will need to manually enter all of the required data elements from the ADR. The only information that will auto-populate is the provider account information.  After entering all of the required information, it will allow you to attach and submit your medical record documentation.  Detailed instructions can be found in the NGSConnex User Guide.

Contact Us

If you have received an ADR or CBR from NGS, and have questions, you may contact the Case Management Team at the following email address

States Email Address
Connecticut, Maine, Massachusetts, New Hampshire, New York, Vermont, Rhode Island JKAcasemanagement@anthem.com
Illinois, Minnesota, Wisconsin J6Acasemanagement@anthem.com

Posted 6/23/2021
Last Modified: 6/29/21
National Government Services Part A Medical Review Newsletter June 2021
Complementary Content