Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327

National Government Services Part B Medical Review Department analyzes national and local data to identify possible improper payment for Medicare services. MR will be conducting a service specific review of HCPCS code J7326 and J7327 (Hyaluronan or derivative).

In an effort to reduce the Part B CERT error rate, the MR Department will be conducting a service specific post payment review of the services mentioned. The primary focus of these audits will be to determine whether the medical necessity of the services billed is at the correct code per Medicare guidelines.

NGS has randomly selected claims billed for HCPCS J7326 and J7327 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, per dose
• J7327 Hyaluronan or derivative, monovisc, for intra-articular injection, per dose

 If a claim is selected for review, the provider will receive an ADR letter. Providers with claims selected for review must submit the requested documentation within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in a denial of the billed services.

The Hyaluronan or derivative procedure codes HCPCS J7326 and J7327 medical record must include:

• Physician/nonphysician practitioner’s office and progress notes
• History and physical examination notes
• Relevant medical history
• Procedure reports
• Pertinent diagnostic reports
• Operative reports
• Orders
• Medication records
• History of previous pharmacologic therapy
• Prior injection history
• Documentation of any significant improvements in pain and or functional capacity
• The medical record must clearly reflect the medical necessity for repeated injections.

It is important to submit all documentation, which supports the medical necessity of HCPCS J7326 and J7327. The medical record must be legible and the name of the beneficiary, the date of service, and the signature of the billing provider clearly identified. Please ensure all documentation to support medical necessity of the billed service is submitted for review.

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 10/14/2020