WPS has noted in its claims issue log that claims that contain routine diagnosis codes are incorrectly being denied if the diagnosis is in the second or subsequent position. This issue was identified on Oct. 22, but there was not a resolution date documented. WPS will adjust the claims automatically.
First Coast Service Options has identified that there is a correction for mammography claims (identified with reason code 32016). The claims are incorrectly rejecting diagnosis code Z12.31. This issue will be corrected and claims automatically reprocessed. There is the same issue that was reported for Palmetto GBA vaccine services, with this issue identified with reason code 32200. No provider action is required, as the claims will be corrected as well. The third issue involves HCPCS code J0717 (certolizumab pegol, 1 mg) billed with diagnosis code L40.50 – L40.59 (arthropathic psoriasis) with dates of service after Oct. 1, 2015. These claims also were incorrectly denied. The diagnosis codes are being added to the LCD and the claims will be adjusted.
CGS Medicare has listed in its issues log that LCDs for mammography, sleep studies, CT, MRI, and vascular studies are being incorrectly denied with reason code 55503. The LCDs were missing ICD-10-CM codes. CGS Medicare will reprocess. If a provider has a question about a diagnosis code and LCD, it can e-mail .
Action items that can be completed during this implementation period include the following:
- Review all medical necessity rejections for any topic identified by any Medicare Administrative Contractor (MAC).
- Ensure that your organization is not having the same issues.
- Communicate issues that are related to medical necessity to the payor to ensure that the problems are resolved.
- Monitor medical necessity issue trends.
- Review claims issue trends on the MAC website for early detection.
- It is important to resolve these issues quickly because there will be a financial impact.
Last week LCDs were in the news again. Cahaba, Novitas, and Palmento GBA all were working their way through medical necessity issues.
Novitas posted in its open claim issues log for Medicare Part A on its website. It lists that various LCDs need more specific diagnosis codes. The fix for this issue was to be in place by Oct. 23. One example of a recent change to an LCD was LCD35125 (wound care), in which all of the diagnosis codes have been removed. Novitas also was experiencing inappropriate medical necessity denials. Corrections are being made to the claims adjudication process. They will begin identifying and adjusting previously submitted claims by Dec. 27.
Cahaba was reporting higher-than-usual suspended workload that is being attributed to staff turnover. They expected the levels to return to normal by December.
Palmetto GBA also had medical necessity denials that were invalid. CT of chest/thorax was specifically mentioned, with the reason identified as the fact that the diagnosis is not covered, but in reality it is covered. Palmetto was in the process of adjusting claims affected by this issue. Palmetto also identified edits associated with reason code 32200 for claims associated with pneumococcus, hepatitis B, and influenza vaccine administration, with the claims being returned to provider (RTP). No provider action was needed and the issue was reported to the Fiscal Intermediary Shared System (FISS). There were edits associated with reason code 70034, which states that the indication that services are not covered was erroneous. Palmetto said it would be adjusting these claims automatically as well.
The bottom line for this transition period is to monitor medical necessity rejections and denials. If you identify a problem, determine what the root cause is (software, medical policy, etc.). Notify your MAC as soon as the problem is identified as a medical policy, as each issue no doubt impacts many organizations. Determine if you need to do anything or if the problem will be automatically fixed.
The goal is to ensure that you are getting the appropriate reimbursement for the services provided.
