RAC Review Issue

Recovery Audit Contractors (RACs) in at least two of the four jurisdictions are reviewing claims for PDT dating back to October 2007. We have seen recent activity by Diversified Collection Services (DCS) covering NY, PA, NJ, CT, DE, MD, DC and CGI Technologies and Solutions covering MN, WI, MI, IL, IN, OH, KY.

The purpose of the review is to identify overpayments associated with billing for Verteporfin and Ocular Photodynamic Therapy in the absence of fluorescein angiography or indocyanine-green angiography performed prior to each treatment.

DCS indicates that these reviews are automated which means the demand letter designates an overpayment and no records are requested for review. CGI lists these reviews as semi-automated indicating a need to respond to their inquiry after which a determination is made regarding a potential overpayment. If you receive a request from your RAC for records, it is very important that you respond promptly.

Both RACs reference the National Coverage Decision (NCD) published by CMS in April 2004. The NCD can be found at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads//ncd103c1_Part1.pdf. It states:

“Covered Indications

Effective April 1, 2004, OPT with verteporfin is covered for patients with a diagnosis of neovascular age-related macular degeneration (AMD) with:

• Predominately classic subfoveal choroidal neovascularization (CNV) lesions (where the area of classic CNV occupies ≥ 50% of the area of the entire lesion) at the initial visit as determined by a fluorescein angiogram. (CNV lesions are comprised of classic and/or occult components.) Subsequent follow-up visits require a fluorescein angiogram prior to treatment. . . . “

As with all RAC requests, we recommend a careful review of your documentation and a timely appeal.