Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part A billed on dates of service from January 1, 2017 through December 31, 2017. Below are the review results:

Background

Prior CMS directed medical review activities focused on Medicare Severity Diagnosis Related Group (MS-DRG) codes for spinal fusion (MS-DRG 459 spinal fusion, except cervical spine, with major complication or comorbidity [MCC] and MS-DRG 460 spinal fusion, except cervical spine, without MCC). Medical review was performed and further medical review activities were anticipated.

Reason for Review

As a follow-up to the results of that project, the CMS requested the SMRC to perform medical record review activities on DRGs 459 and 460. The selection of providers for this project was determined through data analysis.

Common Reasons for Denial

• No Response to the Documentation Request
  • The documentation was not submitted or not submitted timely. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request.
• Medical Necessity
  • The documentation submitted did not support medical necessity for the service billed. The Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(a) provides the guidance that, “no payment may be made under part A or part B for any expenses incurred for items or services which, are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
• Insufficient Documentation
  • The documentation did not include all records requested. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 requires providers/suppliers to respond to requests for documentation within 45 calendar days of the additional documentation request. In addition, the Code of Federal Regulations, Title 42, Section 424.5(a)(6) indicates sufficient information must be furnished to the intermediary to determine whether payment is due and amount of payment.

References/Resources

• Social Security Act (SSA) Title XVIII, Section 1833(e).  Payment of Benefits.
• Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare As Secondary Payer.
• Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• Social Security Act (SSA) Title XVIII, Section 1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program.
• Social Security Act (SSA) Title XVIII, Section 1893(h)(4)(B). Medicare Integrity Program. 
• Code of Fedral Regulations (CFR) Title 42, Section 424.5(a)(6). Basic conditions.
• CFR Title 42, 482.24 (c)(1). Condition of participation: Medical record services. 
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary. 
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.1. Coverage Determinations.
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria.
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C. No Response or Insufficient Response to Additional Documenation Requests.
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on Which to Base a Determination.
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements.
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. Diagnosis Code Requirements.
• Local Coverage Determination (LCD) L33382: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. Effective 01/01/2017-09/30/2017.
• Local Coverage Determination (LCD) L33382: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. Effective 10/01/2017-12/31/2017.
• Local Coverage Determination (LCD) L35942: Fusion for Degenerative Joint Disease of the Lumbar Spine. Effective 10/01/2015-02/16/2017.
• Local Coverage Determination (LCD) L35942: Fusion for Degenerative Joint Disease of the Lumbar Spine. Effective 02/17/2017-01/28/2018.

Last Updated Jan 28, 2022