Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), has conducted post-payment review of claims for Medicare Part B echocardiography billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

An echocardiogram (ECHO) is an ultrasound of the heart. It is a type of medical imaging using ultrasound (high-frequency sound waves) to generate images of the heart’s valves and chambers and helps evaluate the pumping action of the heart.

Medicare does not cover ECHOs performed with equipment that provides limited evaluations. Such evaluations typically do not provide a permanent image and complete interpretation is not performed. These tests have demonstrated value in screening-type evaluations, although they are then considered part of the physician’s exam, similar to a BP measurement and are not separately payable under Medicare.

Symptoms or an existing condition must be present to meet coverage criteria and support payment for an ECHO. ECHOs performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor such as having a positive family history, e.g., familial history of Marfan’s disease). We note that screening for high-risk patients is not covered by Medicare.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of echocardiography claims. The SMRC performed medical record review on supporting documentation to determine if the echocardiography was reasonable and necessary.

Common Reasons for Denial

• No Response to the Documentation Request
  • The requested records were not received. Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). This requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. The requested documentation was not submitted to support reasonable and necessary criteria for echocardiography.
• Medical Necessity of the service performed
  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination. Refer to Social Security Act 1862, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. The diagnosis billed on the claim must be reasonable and necessary with a covered indication, describe the patient’s condition, and be supported within the medical record.
• Incomplete and/or Insufficient Documentation
  • The documentation submitted was incomplete and/or insufficient. Refer to Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C; 42 CFR 424.5(a)(6), Social Security Act 1833(e), and Social Security Act 1862(a)(1)(A). The submitted documentation did not contain medical records and/or findings for the echocardiography completed.

References

Title XVIII of the Social Security Act (SSA)

• § 1815(a). Payment to Providers of Services
• § 1833(e). Payment of Benefits
• § 1842(p)(4). Provisions Relating to the Administration of Part B
• § 1861(ddd). Preventive Services
• § 1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed

42 of the Code of Federal Regulations (CFR)

• § 410.32. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
• § 410.64. Additional Preventative Services
• § 411.15(k)(1). Particular services excluded from coverage
• § 424.5. Basic Conditions
• § 482.24(c)(1). Conditions of Participation: Medical Record Service

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub.) 100-03

• Chapter (Ch) 1, Part 4, §220.5. Ultrasound Diagnostic Procedures

IOM, Medicare Benefit Policy Manual (MBPM), Pub.100-02

• Ch 6, § 20.4. Outpatient Diagnostic Services
• Ch 15, § 80. Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests
• Ch 16, § 20. Services Not Reasonable and Necessary

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch 13, §10.1. Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch 13, §20. Payment Conditions for Radiology Services
• Ch 23, § 20.9. National Correct Coding Initiative (NCCI)
• Ch 30, § 30.2. Healthcare Provider or Supplier Knowledge and Liability

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch 3, § 3.2.3.2. Time Frames for Submission
• Ch 3, § 3.2.3.3. Third-party Additional Documentation Request
• Ch 3, § 3.2.3.8(A). Additional Documentation Requests
• Ch 3, § 3.3.2.4. Signature Requirements
• Ch 3, § 3.6.2.1. Coverage Determinations
• Ch 3, § 3.6.2.2. Reasonable and Necessary Criteria
• Ch 13, § 13.5.4. Reasonable and Necessary Provisions in LCDs

Local Coverage Determination (LCD)

• L33577, Transthoracic Echocardiography (TTE)
• L33768, Transthoracic Echocardiography (TTE)
• L34338, Transthoracic Echocardiography (TTE)
• L37379, Echocardiography

Local Coverage Article (LCA)

• A56625, Billing and Coding: Echocardiography
• A56781, Billing and Coding: Transthoracic Echocardiography (TTE)
• A57182, Billing and Coding: Transthoracic Echocardiography (TTE)
• A57306, Billing and Coding: Transthoracic Echocardiography (TTE)

Last Updated Apr 21, 2023