Deeper Than the Headlines: Read the Fine Print
Transcript:
Hi, everybody. It's CJ Wolf here for another episode of deeper than the headlines.
This is a short, video that we do, and it's a series that we do, here at Healthicity where we take a headline that we see all the time, coders, auditors, compliance professionals. We see these headlines. We dive a little deeper to find out, well, what is this really about? Now the one headline that caught my attention today is not your typical headline. So it wasn't in a newspaper.
It wasn't a DOJ press release or an OIG press release of some sort. It was on a Medicare administrative contractor's website. So Medicare Medicare administrative contractors or MACs, these are those contracted entities throughout the country that process claims for Medicare. And so, each region of the country, maybe multiple states, might be represented by one MAC.
And MACs often do, a process called TPE.
Target stands for target, probe, and educate. Now, basically, what this means you can you can learn a little bit more about it if you if you if you need to. But if you don't know what it's about, these are Medicare administrative contractors or MACs that they'll target a certain service line or certain CPT code or HCPCS code. They'll do probe audits, then they educate providers.
So they're probably looking at maybe expensive services or services that that the data might look like. Ugh. This seems a little bit out of whack or out of line.
And so they're doing all sorts of services. And what's interesting is when Macs do these TPE audits, they often will educate and they'll publish the results publicly on their website. And then they might say, look. We had really bad results.
Right? We had eighty percent error rates. We're We're gonna continue this process, essentially, and they will do more audits, TPE audits, you know, in the next quarter. And they're they're trying to monitor to see if there's improvement.
So you can you can look to see what they're currently auditing, but you can also look to see what they've audited in the past, and sometimes you might catch it all in the middle. Sometimes you might even be involved, in the audit.
And so you get to know a little bit more about exactly what they're looking at. So the one I wanted to share was that. I had a client who who was involved in these TPE audits, and I was seeing why the MAC was denying these services. So the particular code that was being audited in this case was a was a HCPCS code. It was a j code.
And the MAC published so here's kind of the headline part of it. The MAC published that there was, like, a sixty percent error rate, sixty percent denial of use of this certain HCPCS code, which is a drug code. I'll tell it to you in a moment.
And they they then list the reasons. They'll say something like there was not appropriate documentation or, there weren't orders or it was miscoded. But these are kind of generic statements.
And they're good. They put them into categories, but we don't really know the details. And so that's what the whole point of these videos are deeper than the headlines is to kinda get into the details a little bit more. So the code is j zero seven one seven.
And this is a code for cetolizumab or you often hear you probably even see commercials for it on the TV, Cimzia, c I m z I a. Now this is a drug, really, useful drug. It's it's known as a biologic, and it often fits into this category of an anti TNF or a TNF blocker. TNF stands for tumor necrosis factor.
So these biologic drugs are can be useful for for many different, conditions.
SYNTHIA is typically used for rheumatoid arthritis, psoriatic arthritis, so this is arthritis that is from psoriasis, ankylosing spondylitis, or Crohn's disease. Now, of course, doctors can often, use these medications off label, when when medical literature, you know, in their their clinical judgment shows that, yeah, this can be used for other reasons. But what I found interesting in this particular case and this is where, I kinda in combining this headline from what the map was publishing with what I learned from a particular client because I was asked to audit and help, potentially prepare a an appeal for this for this provider.
And what they were denying for, not because there was no order, not because the service wasn't provided, not because there was the wrong units. Frequently with these j codes, you know, the code might be per one milligram. And, you know, if you if you overreport or underreport, that that could be a coding error. It was because of the product insert.
You ever seen a product insert?
The product insert, I'm trying to show you, is this it's that thin paper that gets folded a bunch of times that it has, like, the chemical symbols and and all sorts of stuff. These product inserts are important for, for clinicians to read all the possible side effects that can go on, you know, contraindications why you would not give the drug, things that most patients take for granted that doctors need to know all that fine print. Well, in that fine print, there is a little piece that says and and this is where you you might get some argument from from different people. I could not find for this Medicare administrative contractor an actual policy or an LCD that said physicians must do this.
But what they were doing on these audits is they were reviewing this product insert, and they were finding that in the medical records that were sent, they weren't doing something that was in that fine print. The fine print says that before you start CIMZIA, you should test a patient for hepatitis b, virus.
Now CIMZIA can have an effect where, if if you're not aware of somebody who either has hepatitis b or maybe they're susceptible to it, let's say they have hepatitis b already and you never knew, you could kind of reactivate that virus in a way, kind of oversimplifying here, but it could it it could have some some bad health outcomes if you don't test test for hepatitis b. But doctors use their judgment on, you know, when should I be testing for hepatitis b? Maybe I I know the patient. But, the reason that these were being denied during this target probe and educate audit was because there was no record sent in of the patient ever being tested for hepatitis b. So, you know, I work with the doctors, talk to the doctors, and and they give me their clinical reasoning for why they don't feel like it's medically necessary to do that on every single patient. And, essentially, that's what this audit was saying. Deny this drug because these are pretty expensive drugs.
We deny this drug and all the units you provided because you never tested for hepatitis b, virus.
So that's interesting. Now the the other kicker on all of this too is that if you get denied the drug and the drug is not medically necessary or appropriate, then the payer was also denying the administration of that drug. So these are usually from the the ninety thousand series of codes. Right?
And some commercial payers and, Medicare payers will have, a policy, that talks about, using the nine nine one of these codes is nine six four zero one, I think, and the other was, like, a nine seven, code.
But they were so that because the drug got denied, they were also denied this administration code.
So found that super interesting. That's a little bit of a detail that, you don't typically see, in the headlines, and it won't be published on their website that they're necessarily dying denying for that. At least I haven't seen it. They may have done sent they may have published that since then.
But they were having denial rates, you know, super high denial rates of sixty, seventy percent.
And with this one client I was working with, all of their claims got denied because they never tested hepatitis b.
So and that all came from just this little bitty product insert, not an LCD, not a a policy like that. So pretty interesting. Hope you enjoy these types of videos. We'll do more of them, where we go a little bit deeper than the headlines. Thanks for joining us.
Article referenced: https://www.palmettogba.com/palmetto/jmhhh.nsf/DIDC/BTPOD0A22I~Medical%20Review~Targeted%20Probe%20and%20Educate
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