Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326

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 J7326 (Hyaluronan or derivative). 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 randomly selected 175 claims billed for CPT J7326 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• J7326 Hyaluronan or derivative, Gel One, for intra-articular injection

Results

Decision	Number of Claims
Allow	77
Deny	48
Partially Deny	17
Recode	7
Nonresponse	25
Rescinded	1

 

• 121 claims from Illinois with 51 allowed and 70 denied for a claims error rate of 57.9%
• 30 claim from Minnesota with 14 allowed and 16 denied for a claims error rate of 53.3 %
• 24 claims from Wisconsin with 12 allowed, 11 denied and 1 review rescinded for a claims error rate of 47.8%

Key Reasons Services Were Denied

• Documentation did not support medically necessity due to one or more of the following: The submitted documentation lacked a physician's order; evidence that the patient failed conservative nonpharmocologic therapy and simple analgesics; relative medical history and physical examination, results of pertinent diagnostic tests or procedures, documentation to support repeat injections.
• Failure to respond to the request for documentation
• Documentation does not support a separately identifiable evaluation and management service

Recommendations

• Send the requested records within the requested time frame to avoid a denial for no documentation
• Familiarize yourself with available Hyaluronan or derivative 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

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30 – Physician Services and 50.6 Drugs and Biologicals
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 26, Section 10.4 Provider of Service or Supplier Information
• CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections
• CMS IOM Publication 100-08, Program Integrity Manual, Chapter 3, Section 3.3.1.1.F Advanced Beneficiary Notice (ABN)
• CMS IOM Publication 100-08, Program Integrity Manual, Chapter 13, Section 13.5.1 Reasonable and Necessary Provisions in LCD's
• LCD L33394 Drugs and Biologicals
• LCD L33622 Pain Management
• LCA A52420 Billing and Coding: Hyaluronans Intra-articular Injections
• Title 42 of the Electronic Code of Federal Regulations, Section 410.33 Independent diagnostic testing facility

Posted 9/15/2021