Comprehensive Error Rate Testing (CERT) Error Findings - Hyaluronan Injection

WPS Medicare recently received a CERT error finding for an intra-articular injection of the drug Hyaluronan (Orthovisc®) (Current Procedural Terminology (CPT) codes 20610 and J7324). According to the CERT reviewer, the medical records submitted did not support the diagnosis and medical necessity of the treatment according to Local Coverage Determination (LCD) requirements.

Per LCD L30149 - Intra-articular injections of Hyaluronan, documentation in the patient's medical record must show the patient failed to respond adequately to conservative nonpharmacological therapy (exercise or physical therapy, weight loss if appropriate) and a past history of treatment with analgesics and a radiological exam to support the diagnosis of osteoarthritis.

Additionally, if subsequent courses of treatment are given, medical records must support the effectiveness of the prior treatment and must clearly establish reduction of patient symptomatology and medication usage. Providers must indicate that documentation is available upon request and must respond timely to any request for the documentation. Medicare contractors will deny as not medically necessary any claim submitted without supporting evidence in the medical record.

Please visit the Policy portion of the website to review the Local Coverage Determination (L30149) which covers this topic.

Page Last Updated: Wednesday, 05-Oct-2011 13:47:04 CDT