This bulletin has been updated. Please refer to Provider Notice 07-001.

Purpose

This bulletin is written as an education tool to assist providers with correct billing, coding and medical documentation related to the use of pamidronate disodium. The notice is also intended to decrease the paid claims error rate, and to avoid provider denials.

Pamidronate disodium is a bone-resorption inhibitor which either directly blocks the dissolution of calcium phosphate in bone, or which inhibits osteoclast activity. Pamidronate disodium may be indicated in the following conditions:

• Hypercalcemia associated with malignancy;
• Paget’s Disease;
• Osteolytic bone metastasis of breast cancer;
• Osteolytic lesions of multiple myeloma; or
• S elect cases of disabling osteoporosis.

Review Findings

The outcome of the 3^rd Quarter, 2004, pamidronate service specific review is demonstrated by the pie chart below.

A total of 68% of claims were either fully or partially denied.

The majority of the denials were related to insufficient documentation in the following areas:

• Initial history and physical examination including diagnosis was not provided;
• Documentation was not provided to support the presence of osteolytic lesions;
• Progress notes that provided information of failed treatments prior to the use of pamidronate was not provided
• Consultation reports and/or other diagnostic studies that supported medical necessity were not provided or were insufficient in detail
• The medication administration records that verified medication dosage and route were not provided or were insufficient in detail and
• D iagnostic tests were billed but results were not included in the medical records provided.

Additionally, some of the claims were denied because:

• the ICD-9-CM code listed on the claim did not meet the guidelines for medical necessity per LCD 04-008; or
• S elf-administered medications were billed.

Highmark Medicare Services is alerting providers to the risk of claim denials due to these findings. In order to avoid denials, please notify all appropriate individuals in your facility to be alert for the Additional Development Requests (ADR) that come from Highmark Medicare Services. Additional information regarding ADRs can be found on the Highmark Medicare Services web site at: http://www.highmarkmedicareservices.com.

Please follow the directions and send all the documentation that is requested.

Providers should send the following information:

1. Physician's orders that are signed and dated;
2. History/progess/consultations notes (both historical and current) as well as and other clinical data, including signs and symptoms of disease to support the drug and/or service. The progress notes should also indicate the response to treatment
3. Signed medication record with dosage/method of administration and progress notes indicating the response to treatment;
4. Results of all testing/diagnostic studies billed;
5. Signed clinic/treatment records; and
6. an itemized bill.

In claims listing a diagnosis of hypercalcemia, a malignancy must be documented in the records provided.

In claims listing osteoporosis as a diagnosis, all of the following criteria must be met and documented:

1. Severe disabling osteoporosis;
2. T scores below –5.0
3. Compression fractures of the axial skeleton, or peripheral fractures
4. Pain and difficulty with activities of daily living (ADL) and/or ambulation, secondary to osteoporosis;
5. Allergy to shellfish and/or salmon derivatives or a failed trial of calcitonin; or a contraindication of the use of calcitonin;
6. Inability to take oral biphosphonates or a failed 12-month trial of oral biphosphonates; and
7. S evere deterioration of the patient’s condition and the degree of osteogenesis is so pronounced that a trial of biphosphonates is not medically warranted.

Long-term administration of Pamidronate must be supported in the medical documentation through: the physician’s history and physical; and progress/consultation notes (both historical and current) to support the medical necessity for continued administration, for example, exacerbations, failed treatments, abnormal labs, X-rays, CT scans, MRI results.

NOTE: A revision of the pamidronate policy is underway and expected to be completed by late February, 2005. Some requirements will change. Please visit Highmark Medicare Services' website to view the revised policy

Billing Guidelines
Bill types: 11x, 13x, 71x, 75x and 85x

Coding Guidelines
Revenue Code 636

References

LCD Pamidronate 04-008

Highmark Medicare Services – The Need for Accurate, Complete, and Timely Responses to Additional Development Requests (ADR) 03-095

If you have any questions regarding this Notice, please contact the Provider Service Center at 1-888-543-5118 (non-claim related inquiries).

Clinical inquiries and questions related to documentation reviewed by Medical Review should be directed to Highmark Medicare Services Local Provider Education and Training (LPET).