February 24, 2014

Drill Down: Medical Necessity: Percutaneous Transluminal Angioplasty (PTA)

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RAC Region C contractor Connolly posted a complex review for inpatient, outpatient hospital, and physician provider types regarding percutaneous transluminal angioplasty medical necessity.

The contractor references several Centers for Medicare & Medicaid Services (CMS) MLN Matters publications, among them MLN Matters # MM5432, Effective 1-11-07 - Intracranial Percutaneous Transluminal Angioplasty (PTA) with Stenting, which states:

Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Effective November 6, 2006, Medicare covers PTA and stenting of intracranial arteries for the treatment of cerebral artery stenosis ≥50% in patients with intracranial atherosclerotic disease when furnished in accordance with the Food and Drug Administration (FDA)-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. CMS determined that coverage of intracranial PTA and stenting is reasonable and necessary under these circumstances.

Providers billing FIs and A/B MACs should note this coverage applies to claims with:

  • A discharge date on or after November 6, 2006;

  • ICD-9-CM procedure codes of 00.62 and 00.65 both being present;

  • ICD-9CM diagnosis code 437.0 present; and

  • The IDE number present on a 0624 revenue code line.

Non-institutional providers billing Medicare carriers or A/B MACs should note this coverage applies to claims with:

  • CPT code 37799 (Unlisted procedure, Vascular surgery);

  • A QA modifier to denote Category B IDE clinical trial; and

  • The appropriate IDE number.

All other indications for PTA with or without stenting to treat obstructive lesions of the vertebral and cerebral arteries remain non-covered. The safety and efficacy of these procedures are not established.”

The medical documentation should reflect that this procedure was reasonable and necessary, by following the guidelines and criteria listed above along with using the appropriate ICD-9-CM codes and IDE numbers.

RAC Issues for the Week of February 24 – February 28, 2014:

RAC Region B CGI

DME

  • DME Home Glucose Testing Supplies - More than one spring powered device per 6 months is not reasonable and necessary, without regard to whether the beneficiary is insulin-dependent. This automated review will identify additional units of the device paid after the initial 1 unit in each 6 month period.

  • DME Glucose Monitor Unbundling - Certain blood glucose testing supplies are included in the allowance for the glucose monitor E0607 when provided at the same time. This automated review will identify claims paying those blood glucose testing supplies in addition to the purchase of the glucose monitor, for dates of service 7/1/2011-12/31/2012 only, and the overpayment for the supply will be recovered.

Professional

  • PF Observation Care Billed with Discharge Services on Same Day - J6 (NGS) - An issue exists where discharge services have been reported incorrectly with Observation Services on the same date of service. This automated review will identify the incorrect reporting of discharge services when billed on the same day as an Observation Service for a beneficiary.

RAC Region C Connolly

Inpatient

  • Medical Necessity: Percutaneous Transluminal Angioplasty - C004292013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Outpatient Hospital

  • Medical Necessity: Percutaneous Transluminal Angioplasty - OP - C004332013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

Physician

  • Medical Necessity: Percutaneous Transluminal Angioplasty - Carr - C004322013 - Percutaneous Transluminal Angioplasty (PTA) involves inserting a balloon catheter into a narrow or occluded blood vessel to recanalize and dilate the vessel by inflating the balloon. The objective of PTA is to improve the blood flow through the diseased segment of a vessel so that vessel patency is increased and embolization is decreased. PTA is covered for certain conditions as outlined in CMS medical policies. Medical documentation will be reviewed to determine if the percutaneous transluminal angioplasty was reasonable and necessary for the patient.

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article please go to editor@racmonitor.com

Margaret Klasa, DC, APN, Bc

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