Cahaba Announces Widespread Probe Reviews

on Friday, 12 February 2010. All News Items

Cahaba GBA, Medicare Administrative Contractor (MAC) for Alabama, recently announced two widespread probe reviews that will affect Alabama hospitals.  Per the announcements, the claims will be reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCD'S, correct billing and coding).  Results of the probe reviews will be posted on Cahaba’s website and will help Cahaba determine providers’ educational needs.

One probe review is for CPT codes 99291 and 99292, Critical Care, Evaluation and Management of the Critically Ill or Injured Patient; First 30-74 Minutes, and each additional Add on Code, TOB 13X.  This is a line item review.  Cahaba has previously published articles explaining the documentation requirements for critical care services and appropriate billing.  Documentation should support that the physician and/or hospital staff are actively engaged in the face-to-face critical care of a critically ill or critically injured patient.  For more information, please refer to the Cahaba articles Appropriate Documentation for Critical Care Services and Findings of Tennessee Probe Review of 99291 .

The second widespread probe review is of claims with diagnosis code 428.23 (Acute on Chronic Systolic Heart Failure) for Bill Type 11X (Short Term Hospitals) and CAH's (Community Access Hospitals).  This will be a full claim review.

The complete Cahaba announcements are available at these links:

Widespread Probe Review Announcement 99291, 99292

Widespread Probe Review Announcement Dx Code 428.23

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