Hyaluronan or Derivative - Service Specific Targeted Review

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments. This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on Comprehensive Error Rate Testing (CERT) contractor identified errors.

This article is to notify providers of the initiation of a Service Specific Review on:

  • HCPCS J7318 - Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg
  • HCPCS J7321 - Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose
  • HCPCS J7322 - Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
  • HCPCS J7323 - Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
  • HCPCS J7324 - Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
  • HCPCS J7325 - Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg
  • HCPCS J7326 - Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
  • HCPCS J7327 - Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose
  • HCPCS J7328 - Hyaluronan or derivative, GELSYN-3, for intra-articular injection, 0.1 mg
  • HCPCS J7329 - Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg
  • HCPCS J7331 - Hyaluronan or derivative, SYNOJOYNT, for intra-articular injection, 1 mg
  • HCPCS J7332 - Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg

One-Time Notification to Providers

If your facility is selected for this post payment review, you will be notified of the selected claims per an individual letter. Federal law requires that providers submit medical record documentation to support claims for Medicare services upon request. Providers are required to send supporting medical records to the MAC. Authorization for the collection of this informational is included in Federal Law a Social Security Act §§ 1815(a), 1833(e), and 1862(a)(1)(A) and in the Federal Regulation at 42 Code of Federal Regulations (CFR) § 424.5(a)(6).

Provider Action Required

  • Review the requested information in the Additional Documentation Request (ADR)
  • Locate and submit all requested items in the ADR
  • Refer to individual letter for timeline and submission methods

Noridian MR Determination

MR will review the claim documentation within 60 days of its receipt and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Overall results of the service specific review will be posted to the Noridian website at the end of each quarter and at the end of the review. Noridian will not post provider specific results on the website.

 

Last Updated Tue, 06 Jul 2021 17:31:01 +0000