Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327

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 J7327 (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.

NGS randomly selected 174 claims billed for CPT J7327 for post payment review in Jurisdiction 6 for Part B providers in the states of Illinois, Minnesota and Wisconsin.

• J7327 Hyaluronan or derivative, Monovisc, for intra-articular injection

Results

Decision	Number of claims
Allow	59
Deny	57
Partially Deny	17
Recode	4
Nonresponse	28
Rescinded	9

 

• 146 claims from Illinois with 50 allowed, 87 denied, and 9 reviews rescinded for a claims error rate of 63.5%
• 13 claim from Minnesota with 6 allowed and 7 denied for a claims error rate of 53.8%
• 15 claims from Wisconsin with 3 allowed and 12 denied for a claims error rate of 80.0%

 

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.
• 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 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

• CMS Publication 100-02 Medicare Benefit Policy Manual, Chapter 15, Section 30 – Physician Services and 50.6 Drugs and Biologicals
• CMS Publication 100-04 Medicare Claims Processing Manual, Chapter 26, Section 10.4 Provider of Service or Supplier Information
• CMS Publication 100-04 Medicare Claims Processing Manual, Chapter 30, Financial Liability Protections
• CMS Publication 100-08 Program Integrity Manual, Chapter 3, Section 3.3.1.1.F Advanced Beneficiary Notice (ABN)
• CMS 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 9/20/2021