RAC Drill Down Utilization Guidelines: A Must-Read

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Original story posted on: April 8, 2013

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On April 3, 2013, the RAC Region A contractor Performant once again posted a semi-automated audit for EMG and Nerve Conduction Studies, now focused on the utilization guidelines.

The target of the RAC audit this time is the excessive use of units of testing, based on the American Association of Electrodiagnostic Medicine's white paper which provides a table of conditions and applicable units, cross-referencing limb studies by EMG, nerve conduction, and neuromuscular junction testing.

For example, if a patient is consistently being tested for the same condition that exceeds these units listed in this table, there may be a medical necessity violation due to overutilization. Or if a provider is consistently testing every patient for referred pain, weakness, or paresthesia, this will also become a target and medical necessity issue. Both the referring provider and the NCS-EMG provider are responsible for the determination of the relevance and medical necessity of the study.

Below is a snapshot of the table that can be found on Performant's website for Novitas LCD (L29547).

Another issue to keep on the radar, recently posted for both Ambulance Services and Physician/Non Physician Practitioners, is the use of the GZ modifier. This is a semi-automated review type. The GZ modifier is used by a provider when an item or service is expected to be denied as not reasonable and necessary. Potential incorrect billing occurred when the GZ modifier was reported and the provider did not obtain a signed Advanced Beneficiary Notice (ABN). Payment will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.

Other RAC Issues for April 1–5, 2013:

RAC Region A Performant

Physician/Non Physician Practitioner Claim Types

  • Nerve Conduction Studies (NCS) - Maximum Units – J12 Potential incorrect billing occurred for claims reporting CPT codes 95900, 95903, and 95904 for units in excess of what is medically necessary, based on information found in Novitas Local Coverage Determination (LCD) L29547. Payment will be recouped when no additional supporting documentation is received from the provider for complex review within the 45-day response period.
  • Inappropriate Payment For GZ Modifier – J14 The GZ modifier is used by a provider when an item or service is expected to be denied as not reasonable and necessary. Potential incorrect billing occurred when the GZ modifier is reported and the provider did not obtain a signed Advanced Beneficiary Notice (ABN). Payment will be recouped when no additional documentation is received from the provider for complex review within the 45-day response period.

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 and Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

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Margaret Klasa, DC, APN, Bc

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