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

Background

The Office of Inspector General (OIG), under report OEI-04-12-00420 titled: “Questionable Billing for Medicare Electrodiagnostic Tests” dated April, 2014, found that in 2011, Medicare paid approximately $486 million to 21,700 physicians who billed for electrodiagnostic tests for 877,000 beneficiaries. Per the OIG, 4,901 physicians had questionable billing for Medicare electrodiagnostic (EDX) tests totaling $139 million.

Further, per the OIG, in 2011, identified 334 physicians billed for an unusually high average number of electrodiagnostic tests for the same beneficiary on the same day. Those claims accounted for $20 million of the 2011 payments for EDX tests. In addition, it was noted that 907 physicians billed for an unusually high percentage of electrodiagnostic tests that did not include both Nerve Conduction Testing (NCT) and a needle electromyography (EMG) test. These claims accounted for $19 million of the 2011 payments for electrodiagnostic tests. Upon analysis of their data, the OIG also noted that physicians in the New York, Los Angeles, and Houston metropolitan areas had the highest total questionable billing for Medicare EDX tests in 2011.

Reason for Review

In response to the OIG report, CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review.  Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory and sub regulatory guidance.

Common Reasons for Denial

•  Medical Necessity – Services Performed per Coverage Requirement
  • The documentation did not support that both tests were performed together. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 identifies that claims shall be denied if the documentation submitted, based on the coverage requirement does not support medical necessity for the service performed. The coverage requirement with this project was that the needle Electromyography (EMG) was to be performed together with the associated Nerve Conduction Test (NCT) to confirm the clinical diagnosis. One test alone was not enough to determine a clear clinical diagnosis, both tests are needed to conclude to a more finite degree of diagnosis to provide the correct treatment for the beneficiary.
• 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.
• Documentation Requirement – Order for Service Billed
  • The documentation did not include the order or did not have supporting documentation for the ordering of the Electrodiagnostic services billed. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2 requires that the submitted documentation include a valid physician’s order or a valid intent to order for the services billed. The physician’s order or intent to order verifies that the service billed was performed for the diagnosis and level of service outlined in the order that was present in the documentation.
• Billing and Coding – Level of Service
  • The documentation identified the number of studies billed exceeded the number of studies performed within the submitted documentation. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 requires the submitted documentation to support the level of service billed.
• Medical Necessity – Level of Service Performed
  • The orders and/or the medical documentation did not support the level of service billed, so it was considered not medically necessary. CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 and 3.6.2.5 outlines that claims shall be denied if the documentation submitted does not support the service as medically necessary at the level of the service performed. The documentation must support with medical evidence that the level of service ordered, performed, and billed are one in the same.

 References/Resources

• Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits
• SSA, Title XVIII, §§1835(2)(B). Procedure for Payment of Claims of Providers of Services
• SSA, Title XVIII, §§1861(aa)(2)(G). Definitions of Services, Institutions, Etc.
• SSA, Title XVIII, §§1862(a)(1)(a). Exclusions from Coverage and Medicare As Secondary Payer
• SSA, Title XVIII, §§1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• SSA, Title XVIII, §§1893 (b). Medicare Integrity Program
• 42 Code of Federal Regulations (C.F.R.) §410.32(a). Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80. Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6-80.6.4. Requirements for Ordering and Following Orders for Diagnostic Tests
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.3. Use and Acceptance of HCPCS Codes and Modifiers
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.4. Deleted HCPCS Codes/Modifiers
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 40.3.6. Routine Notice Prohibition
• 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 3.3.2.4. Signature Requirements
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response of Insufficient Response to Additional Documentation. Requests
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2. Medical Review Guidance
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4. Coding Determinations
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5. Denial Types
• Local Coverage Determination (LCD) L35897: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• LCD L34859: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• LCD L35098: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• LCD L36524: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present
• LCD L36526: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present
• LCD L35081: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• LCD L34265: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-01/29/2018
• LCD L35048: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• LCD L34594: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• Local Coverage Article A54095: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• Local Coverage Article A54969: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
• Local Coverage Article A54992: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
• Local Coverage Article A54159: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
• Local Coverage Article A54990: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
• Local Coverage Article A54991: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present

Last Updated Jan 28, 2022