Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime

Background

In an effort to reduce the Part B CERT error rate, the MR Department conducted a service specific post payment review of CPT code Q4133 (Grafix Prime). The primary focus of these audits was to determine whether the medical necessity of the services billed was at the correct code per Medicare guidelines.

National Government Services (NGS) randomly selected 150 claims billed for CPT Q4133 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• Q4133 –– Grafix Prime per square centimeter

Results

Decision	Number of Claims
Allow	39
Deny	93
Nonresponse Denial	18
Claims Error Rate	74.0%

 

• 136 claims from Illinois with 33 allowed and 103 denied for a claims error rate of 75.7%
• 1 claim from Minnesota was allowed for a claims error rate of 0.0%
• 13 claims from Wisconsin with 5 allowed and 8 denied for a claims error rate of 61.5%

Key reasons services were denied

• Documentation did not support medically necessity due to one or more of the following: The documentation indicated use for other than what is approved by the FDA; amount or size of product used was not documented; size of product used and/or applications exceeded what is considered reasonable and necessary for the area treated, documentation did not include relative medical history and physical examination
• Documentation was insufficient or incomplete
• Failure to respond to the request for documentation

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available Grafix Prime guidelines and other CMS publications listed below
• Share this information with your coding personnel to ensure they are properly billing before sending the claim to Medicare.
• If you feel your application of this code is correct, ensure your documentation supports your usage.

Related Content

• Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled
  • Section 1833(e) – Payment of Benefits Social Security Act, Section 1833
  • Section 1862(a)(1)(A) – Exclusions from Coverage and Medicare as a Secondary Payer and Section 1862(a)(20) Social Security Act, Section 1862
• Code of Federal Regulations, Title 42 Public Health
  • 42 CFR, Section 419.2(b)(16) – Centers for Medicare & Medicaid Services, HHS, (§ 419 ) Basis of payment, (16) drugs and biologicals that function as supplies when used in a surgical procedure (including, but not limited to, skin substitutes and similar products that aid wound healing and implantable biologicals). Electronic Code of Federal Regulations (eCFR)
• CMS IOM, Publication 100-04, Claims Processing Manual, Chapter 17, Sections 10, 40, 70 and 90.2 – (10) Payment Rules for Drugs and Biologicals, (40) Discarded Drugs and Biologicals, (70) Claims Processing Requirements- General, (90.2) Drugs, Biologicals, and Radiopharmaceuticals
• Medicare Alpha-Numeric HCPCS File – Alpha-Numeric HCPCS, Centers for Medicare & Medicaid Services Alpha-Numeric HCPCS | CMS
• Annual HCPCS Level II Manual - Centers for Medicare & Medicaid Services HCPCS - General Information | CMS
• 21 CFR Part 1270 and 1271

Posted 8/12/2021