Noridian Healthcare Solutions, LLC (Noridian), 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 and Part B of A claims billed with CPT 41899 (Unlisted procedure, dentoalveolar structures) billed on dates of service from January 1, 2019 through May 31, 2022. Below are the review results:

Background

The Office of Inspector General (OIG) published a report (A-06-16-05003) in March 2017 titled “Medicare Contractors’ Payments to Providers for Hospital Outpatient Dental Services Generally Did Not Comply with Medicare Requirements.”, noted from January 2011 through December 2014, Medicare contractors paid providers for hospital outpatient dental services that may be ineligible for Medicare payment. The OIG conducted audits of six Medicare contractors and found that 542 of the 600 dental services audited did not comply with Medicare requirements.

In September 2019, Noridian, as the SMRC, completed medical review and data analysis on outpatient dental services with an overall error rate of 91%. The SMRC found that the CPT code 41899 (Unlisted procedure, dentoalveolar structures) had a claim error rate of 92% with an overpayment error rate of 95%.

Reason for Review

The SMRC was tasked to perform data analysis and conduct medical record reviews on Part B and Part B of A claims billed with CPT 41899 with dates of service (DOS) January 1, 2019, through May 31, 2022. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Service provided is not a covered Medicare benefit.
  • The Social Security Act 1862, 42 CFR § 411.15(i) & (k) states “The following services are excluded from coverage: Dental services in connection with the care, treatment, filling, removal, or replacement of teeth, or structures directly supporting the teeth.” Dental extractions are an excluded dental service except when they are performed prior to radiation therapy for head and neck cancer. The medical record documentation did not support the dental procedure performed was an exception to the excluded dental services.
• No response to the documentation request.
  • Internet-Only Manuals (IOM), Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter (Ch.) 3, Section 3.2.3.8 states “During post-payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary.” Providers are required to respond to requests for documentation within 45 calendar days of the additional documentation request. The documentation was not submitted or not submitted timely therefore the claim was denied.
• Signature requirements were not met.
  • Medicare Program Integrity Manual (PIM), Pub. 100-08, Chapter 3, Sec 3.3.2.4 states “Medicare requires that services provided/ordered/certified be authenticated by the persons responsible for the care of the beneficiary in accordance with Medicare’s policies.” The treating practitioner’s documentation such as treatment note and operative notes, did not support signature requirements were met.

References

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services.
• § 1833(e) Payment of Benefits.
• § 1842(p)(4) Provisions Relating to the Administration of Part B.
• § 1861 Part E – Miscellaneous Provisions.
• § 1862(a)(1)(a) & (12) Exclusion from Coverage and Medicare as a Secondary Payer.
• § 1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1893 (f)(7)(A)(B)(i-iv) Medicare Integrity Program.

Title 42 of the Code of Federal Regulations (CFR)

• § 410.32(a) & (a)(2) Diagnostic x-ray test, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• § 411.15(i) & (k) Particular Services Excluded from Coverage.
• § 424.5 Basic Conditions.
• § 440.100 Dental Services.

Federal Register

• Interim Final rule with comments (IFC), Volume 85, No. 249, Medicare Program: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; New Categories for Hospital Outpatient Department Prior Authorization Process; Clinical Laboratory Fee Schedule: Laboratory Date of Service Policy; Overall Hospital Quality Star Rating Methodology; Physician-Owned Hospitals; Notice of Closure of Two Teaching Hospitals and Opportunity To Apply for Available Slots, Radiation Oncology Model; and Reporting Requirements for Hospitals and Critical Access Hospitals (CAHs) To Report COVID-19 Therapeutic Inventory and Usage and To Report Acute Respiratory Illness During the Public Health Emergency (PHE) for Coronavirus Disease 2019 (COVID-19). Effective January 1, 2021. Retrieved from 2020-26819.pdf (govinfo.gov).

Internet Only Manual (IOM), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01

• Ch. 5, § 70.2 Dentists.

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

• Ch. 1, § 70 Inpatient Services in Connection with Dental Services.
• Ch. 6 § 20.4 Outpatient Diagnostic Services.
• Ch. 15 § 150 Dental Services.
• Ch. 16 § 140 Dental Service Exclusion.

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

• Ch. 3 § 3.2.3.8 No response or Insufficient Response to 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)

• L34574 Dental Services. Effective October 1, 2015

Local Coverage Article (LCA)

• A56663 Billing and Coding: Dental Services. Effective July 4, 2019
• A52977 Billing and Coding: Routine Dental Services. Effective October 1, 2015
• A52978 Billing and Coding: Routine Dental Services. Effective October 1, 2015

Last Updated Jul 18, 2023