Cahaba GBA Medical Review Update May 2010

on Wednesday, 05 May 2010. All News Items

In April 2010, Cahaba GBA, Medicare Administrative Contractor (MAC) for Alabama, published notification of several upcoming probe reviews.  As a result of data analysis, Cahaba GBA will soon be conducting widespread medical reviews of the following.  The data from these reviews will assist Cahaba in determining the providers’ educational needs.  Once completed, the results of these probes will be posted on the Cahaba GBA website.

Review of DRG 392 Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders without MCC

  • Bill Type 11X Inpatient General Short-term Hospitals and CAH's
  • Reviewed for medical necessity (e.g. compliance with CMS guidelines, contractor LCD'S, correct billing and coding)
  • Full claim review

Review of CPT Codes 11055-11057, 11719-11721, and G0127 for Foot Care

  • Bill Type 13X
  • Reviewed for medical necessity (e.g., compliance with CMS guidelines and Publication 100-02, Chapter 1, Section 110 of the Benefit Policy Manual)

Review of CPT Code 83880, B-Type Natriuretic Peptide (BNP)

  • Bill Type 14X
  • Targeted pre-pay review to continue for all three states (Alabama, Georgia, and Tennessee) as a result of a prepay probe review of Georgia and Tennessee providers.
  • Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review.
  • Results of GA/TN prepay probe review can be viewed at https://www.cahabagba.com/part_a/whats_new/20100412_cpt83880.htm
  • Medical review decisions will be based on the Local Coverage Determination (LCD) for Pathology and Laboratory: B-type Natriuretic Peptide (BNP) Testing (L30012) which can be found at:Local Coverage Determinations (LCDs) and Articles.

Review of CMG's A2001-A2004, Miscellaneous

  • Bill Type 11X Inpatient Rehabilitation Facilities and Inpatient Rehabilitation Units.
  • Reviewed for medical necessity (e.g. compliance with CMS guidelines and Publication 100-02, Chapter 1, Section 110 of the Benefit Policy Manual).
  • Full claim review

Review of CMG's A0801-A0806, Replacement of Lower Extremity Joint

  • Bill Type 11X Inpatient Rehabilitation Facilities and Inpatient Rehabilitation Units.
  • Reviewed for medical necessity (e.g. compliance with CMS guidelines and Publication 100-02, Chapter 1, Section 110 of the Benefit Policy Manual).
  • Full claim review.

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