Widespread Targeted Review Results for Alabama Providers Billing HCPCS Code 83880

Part A Medical Review has recently completed the 4th quarter widespread targeted prepay review of outpatient hospitals billing HCPCS 83880, B-type Natriuretic Peptide (BNP) testing in the hospital setting processed between October 1, 2007 and December 31, 2007.  Educational articles providing the results of previous reviews were posted on the “What’s New from Cahaba” Web page on August 2007 and October 2007.  The results of the current review are summarized below:

Providers Reviewed:               6
Claims Reviewed:                   31
Claims Approved:                   1
Claims Denied:                       30
Charges Reviewed:    $4,422.20
Charges Approved:     $197.00
Charges Denied:         $4,225.20
Error Rate:                             96%

* Error rate is based on the charges denied divided by the charges reviewed

The medical review decisions were based on the LCD for B-type Natriuretic Peptide (BNP) Testing (L20418).

Indications

Congestive Heart Failure (CHF) is a complex clinical syndrome characterized by dysfunction of the left, right or to the ventricles, which results in the impairment of the heart’s ability to circulate blood at the rate sufficient to maintain the metabolic needs of the peripheral tissues and various organs.  B-type natriuretic peptide (BNP) is synthesized, stored, and released primarily by the ventricular myocardium in response to volume expansion and pressured overload, which are hemodynamic parameters in CHF.  Used in conjunction with other clinical information, serum BNP concentrations parallel dyspnea in heart failure suggesting its usefulness as a neurohormonal index of progressive heart failure. 

Serum BNP when used in conjunction with other clinical information will be considered reasonable and necessary for the following:

  • Establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea
  • Predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after and acute coronary event. 

Limitations

Serum BNP will be considered non-covered in the following:

  • Monitoring the efficiency of treatment for CHF
  • Tailoring the therapy for heart failure

Therefore the primary outpatient site of service expected to perform a serum BNP is the emergency room. 

The majority of denials were due to one of the following reasons:

  1. Lack of medical necessity to support providing the service for 83880. (Denial Reason 54155):  This denial reason was due the documentation did not support clinical urgency for 83880.  The lab was ordered routine.  This service is considered reasonable and necessary for establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea or for predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute event.  In some instances the patient already had an established diagnosis of CHF.
  2. Lack of timely submission of requested documentation (Denial Reason 56900):  Claims were denied due to a lack of record submission in a timely manner.  According to The Medicare Program Integrity Manual, PUB 100-8, Chapter 3, § 3.4.1.2, if a coverage or coding determination cannot be made based upon the information on the claim, the Fiscal Intermediary (FI) may solicit additional documentation from the provider by issuing an Additional Documentation Request (ADR) and must notify the provider of the 30 day time-period to respond.  If the ADR-requested information is not is received within 45 days after the date of the request, then the claim must be denied. 

To eliminate 56900 denials, please review the following elements to ensure appropriate and timely record processing:

  • Access the Fiscal Intermediary Standard System (FISS) to identify claims selected for ADR.  Claims selected for ADR can be identified by accessing FISS Inquiry Option 12, and will appear in status location S B6001.  Pages 07 and 08 of the claim will contain the date your documentation is due, and the elements of documentation requested.
  • Print screen the ADR letter and attach the copy to the front of the requested medical documentation
  • Send requested information to the address on the ADR letter
  • Do NOT send certified mail or overnight mail
  • Include ALL requested documentation outlined in the ADR
  • Submit the above information via regular mail in a timeframe to ensure the FI receives the information by the 45th day after the date of the request.
  1. Services deemed not medically necessary based on the lack of documentation.  This item or services was denied because information required to make payment was missing. . (Denial Reason 55520):
  2. Lack of medical necessity to support providing the service for 83880. (Denial Reason 54155):  This denial reason was due the documentation did not support clinical urgency for 83880.  The lab was ordered routine.  This service is considered reasonable and necessary for establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea or for predicting the long term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute event.  In some instances the patient already had an established diagnosis of CHF.

As a result of this review, Part A Medical Review will continue the review of all outpatient hospitals (Bill Type 13X) billing 83880, identified by edit reason code 5133K.  Also, providers identified through data analysis as driving this aberrancy may warrant provider-specific medical review. 

Page last updated: March 3, 2008 Curved image to open content area.