Cahaba GBA Medical Review Updates

on Thursday, 01 July 2010. All News Items

Probe Notification:

Cahaba recently announced plans to conduct a widespread prepayment review of DRG 312-Syncope and Collapse for Bill Type 11X Inpatient General Short-term Hospitals.  This will be a full claim review for medical necessity (e.g., compliance with CMS guidelines, contractor LCD'S, correct billing and coding).  The results of the probe review will be posted to Cahaba’s website when complete and will assist Cahaba in determining providers’ educational needs.  The complete announcement can be viewed at Cahaba Probe Notification DRG 312.


Probe Review Results:

Cahaba has published results of a prepayment probe review of CPT codes 97597 and 97598, selective debridement, for type of bill 13X for Tennessee providers.  Some key findings of the probe were:

  • CPT 97001, physical therapy evaluation, was billed for a wound assessment.  Wound assessments are included in the billing of 97597/97598.  There must be a complete physical therapy evaluation as per the Physical Therapy Local Coverage Determination (LCD) to support the billing of 97001.
  • Daily treatment notes did not include documentation of wound measurements as required to validate the use of 97597/97598.
  • Documentation did not indicate the patient had an open wound or that selective debridement services were provided.
  • Whirlpool used for wound cleaning does not require the skills of a therapist and is not covered per the LCD.

Cahaba will continue targeted reviews for these CPT codes in Tennessee, Alabama, and Georgia.  Providers can read the complete findings at Cahaba Probe Review Findings 97597/97598.

Results of the prepayment probe review of Unna boot services, CPT code 29580, for type of bill 13x for Georgia and Tennessee providers is also available on the Cahaba website.  Cahaba’s LCD for Debridement Services states that CPT code 29580 is to be used for fractures and dislocations and is not to be billed for wound care services.  View the complete article at Cahaba Probe Review Findings Unna Boot.

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