Purpose

This bulletin is written as an educational tool to discuss the specific findings of the pamidronate service specific re-probe. 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 and may be indicated in the following conditions:

• Treatment of hypercalcemia associated with malignancy, with or without bone metastases;
• Osteolytic bone metastasis of breast cancer;
• Osteolytic lesions of multiple myeloma;
• Pagets Disease;
• Osteogenesis imperfecta in pediatric patients.

A random service specific probe review of pamidronate was completed in October, 2004 that resulted in a denial rate of 52%. An educational article was published (Provider Notice 05-014) to assist providers with correct billing, coding and medical documentation in order to decrease the denial rate.

A random service specific re-probe was then conducted for claims with dates of services from 2/16/05 through 5/9/05. The denial rate for the re-probe was 62%. The results of the re-probe have been summarized according to diagnosis. This article presents the results related to the malignancy diagnoses.

Of the claims reviewed for use in hypercalcemia associated with malignancy, with or without bone metastases, the pamidronate was denied on 62% of those claims. The denials were related to a lack of documentation to support that the medication regimen with pamidronate was medically reasonable and necessary. The following is a summary of the documentation that was missing from the clinical record:

• The initial history and physical examination including diagnosis;
• Consultation reports and/or other diagnostic studies to support medical necessity were insufficient in detail or were lacking;
• The medication administration records necessary to verify medication dosage and route; and/or
• Results of billed diagnostic tests were not included.

• Diagnoses not covered by Medicare; and/or
• The billing of self-administered medications, for example acetaminophen or benadryl.

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 your facility receives from Highmark Medicare Services. Additional information can be found on the Highmark Medicare Services web site. Please send all of the documentation that is requested.

It is very important that providers contact third parties such as physicians or other providers, health care facilities, or suppliers and request a copy of the medical documentation necessary to fully support the services billed to Medicare. It is the responsibility of the provider submitting the claim for payment to obtain all the requested documentation, regardless of where the records are kept.

Providers should send the following information:

1. Physician orders
2. History & Physical , history of prior treatment and other clinical data to support the medical necessity/ rationale for the use of the drug to validate the diagnosis on the claim
3. Treatment and medication record that includes the dosage, route and method of administration
4. Progress notes indicating the patients response to the treatment
5. Results of all testing/services billed
6. Clinic/treatment room records
7. Itemized bill

The information needed to support Pamidronate claims with the diagnosis of hypercalcemia associated with malignancy, with or with without bone metastases, osteolytic bone metastases of breast cancer and osteolytic lesions of multiple myeloma are:

• A documentation of the malignancy;
• The patients response to pamidronate therapy; and
• The diagnosis which most accurately reflects the reason for use of pamidronate

Long-term administration of Pamidronate must be supported in the medical documentation through the physicians 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.

Highmark Medicare Services, Local Coverage Determination LCD 05-007 Pamidronate Disodium

Highmark Medicare Services, Provider Notice 05-014- Pamidronate Disodium

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

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

If you have any questions regarding this bulletin, please contact the Provider Service Center at 1-800-560-6170.