Widespread Targeted Review Results – FI - HCPCS 83880, 13X Bill Type
Part A Medical Review has recently completed the 1st Quarter widespread targeted prepay review of outpatient hospitals billing HCPCS 83880, B-type Natriuretic Peptide (BNP) testing in the hospital setting processed between January 1, 2008 and March 31, 2008. Educational articles providing the results of previous reviews were posted on the What’s New from Cahaba Web pages on August 2007, October 2007, and February 2008.
The results of the current review are summarized below:
| Providers Reviewed | 3 |
| Claims Reviewed | 11 |
| Claims Approved | 0 |
| Claims Denied | 11 |
| Charges Reviewed | $1,677.00 |
| Charges Approved | $0.00 |
| Charges Denied | $1,677.00 |
| Error Rate | 100% |
| * 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) can be found on the Active LCDs page.
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 an 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 the following reason:
- Lack of medical necessity to support providing the service for 83880. (Denial Reason 54155): 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, Alabama 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: May 21, 2008
