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 and B of A polysomnography claims billed on dates of service from January 1, 2018 through December 31, 2018. Below are the review results:

Background

In June of 2019, the Office of the Inspector General (OIG) released a report titled “Medicare Payments to Providers for Polysomnography Services Did Not Always Meet Medicare Billing Requirements A-04-17-07069.” From January 1, 2014 through December 31, 2015, Medicare paid freestanding facilities, facilities affiliated with hospitals and physicians approximately $800 million for selected polysomnography (a type of sleep study to diagnose and evaluate sleep disorders) services which consisted of Current Procedural Terminology (CPT) codes 95810 and 95811. Previous OIG reviews for polysomnography services found that Medicare paid for services that did not meet Medicare requirements. These reviews identified payments for services with inappropriate diagnosis codes without the required supporting documentation.

Reason for Review

CMS tasked the SMRC to perform medical record review on the validation of polysomnography to support the performed services were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Common Reasons for Denial

• Facility Accreditation and/or Technician/Technologist Credentials
  • Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(2) requires services to be furnished by providers or suppliers qualified to receive Medicare payment. Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual Chapter 3 Section 3.6.2.5 supports denial of claims not billed in compliance with the local coding, payment or billing requirements. Local coverage guidance exists for all jurisdictions regarding sleep facility accreditation and/or technician/technologist credentialing requirements.

• No Response to the Documentation Request
  • CMS Internet-Only Manuals, 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. The documentation was not submitted or not submitted timely.

• Incomplete/Insufficient Information
  • Social Security Act 1833(e) and Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6) require suppliers/providers to provide sufficient information to support that the basic conditions were met for Medicare payment. This is further outlined in Internet-Only Manuals, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8.

References/Resources

• Social Security Act (SSA) Title XVIII, §§1815(a). Payment to Providers of Services
• Social Security Act (SSA) Title XVIII, §§1833(e). Payment of Benefits
• SSA, Title XVIII, §§1862 (a)(1)(A). Reasonable and Necessary
• SSA, Title XVIII, §§1862 (a)(1)(c). Exclusions from Coverage and Medicare as Secondary Payer – Part B services
• SSA, Title XVIII, §§1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• 42 C.F.R. §410.28, Subpart B. Hospital or CAH diagnostic services furnished to outpatients: Conditions
• 42 C.F.R. §410.32, Subpart B. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• 42 C.F.R. §424.5, Subpart A. Basic Conditions
• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 50. Sleep Disorder Clinics
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 30. Physician Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 70. Sleep Clinics
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests
• CMS IOM, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.4.1. Sleep Testing for Obstructive sleep Apnea (OSA)
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.2. Consistency Edits for Institutional Claims
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter23, Section 20.3. Use and Acceptance of HCPCS Codes and Modifiers
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. Requested records not received
• 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 3.6.2.2. Reasonable & necessary criteria
• Local Coverage Determination (LCD) L33405. Polysomnography and Sleep Testing. Effective October 1, 2015
• LCD L34040. Polysomnography and Other Sleep Studies. Effective October 1, 2015
• LCD L35050. Outpatient Sleep Studies. Effective October 1, 2015
• LCD L36593. Polysomnography. Effective June 13, 2016
• LCD L36839. Polysomnography and Other Sleep Studies. Effective February 2, 2017
• LCD L36861. Polysomnography and Other Sleep Studies. Effective June 5, 2017
• LCD L36902. Polysomnography and Sleep Testing. Effective March 6, 2017
• Local Coverage Article A53019. Polysomnography and Sleep Studies. Effective October 1, 2015
• Local Coverage Article A53252. Independent Diagnostic Testing Facility. Effective October 1, 2015
• Local Coverage Article A54718. Polysomnography and Sleep Studies. Effective November 5, 2015
• Local Coverage Article A55307. Polysomnography and Sleep Studies. Effective October 1, 2015
• Local Coverage Article A55430. Polysomnography and Sleep Studies. Effective March 6, 2017
• Local Coverage Article A55478. Abbreviated Daytime Sleep Study. Effective June 5, 2017
• Local Coverage Article A55491. Polysomnography and Sleep Studies. Effective June 5, 2017
• Local Coverage Article A55548. Sleep Lab Credentialing: Polysomnography and Sleep Studies. Effective June 5, 2017
• Local Coverage Article A55831. Polysomnography and Sleep Testing. Effective October 1, 2017
• Local Coverage Article A55929. Polysomnography and Sleep Testing. Effective March 15, 2018
• Local Coverage Article A55931. Polysomnography and Sleep Testing Coding. Effective March 15, 2018
• Local Coverage Article A55958. Polysomnography and Sleep Testing. Effective April 5, 2018

Last Updated Aug 11, 2021