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 claims that include thyroid, parathyroid and/or thyroglossal procedures, billed on dates of service from July 1, 2018 through December 31, 2019. Below are the review results:

Background

Medicare severity diagnosis related group (MS-DRG) is a system used to classify various diagnoses and procedures for inpatient hospital stays so that Medicare can accurately reimburse the hospital under the inpatient prospective payment system (IPPS). In 2018, the Comprehensive Error Rate Testing (CERT) Medicare Fee-for-Service Improper Payment Report noted an improper payment rate of 49.1% for thyroid, parathyroid and thyroglossal procedure MS-DRGs.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and DRG coding review. Noridian completed a DRG coding review on claims in accordance with applicable statutory, regulatory, sub-regulatory and coding guidance.

Common Reasons for Denial

• Provider did not submit additional records requested.
  • CMS Internet-Only Manual, 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.
• Documentation did not support the claim as billed.
  • Internet-Only Manual Publication 100-08 Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 provides guidance on coding determinations. Publication 100-04 Medicare Claims Processing Manual, Chapter 23 requires providers to complete claims accurately so that Medicare contractors may process the claim correctly.

References/Resources

• Social Security Act (SSA) Title XVIII, §1812. Scope of Benefits
• SSA, Title XVIII, §1815(a). Providers must furnish information
• SSA, Title XVIII, §1833(e). Payment of Benefits
• SSA, Title XVIII, §1862(a)(1)(a). Exclusions from Coverage and Medicare as Secondary Payer
• SSA, Title XVIII, §1886. Payment to Hospitals for Inpatient Hospital Services
• SSA, Title XVIII, §1879. Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• Code of Federal Regulations (CRF) Title 42, 412.1(a)(1). Scope of Part
• CFR, Title 42, 412.2. Basis of payment
• CFR, Title 42, 424.5(a)(6). Basic conditions
• CFR, Title 42, 482.24(c)(1). Condition of participation: Medical record services
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual Chapter 23, Section 10.2. Inpatient Claim Diagnosis Reporting
• CMS IOM, , Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements
• 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 3.6.2.4. Coding Determinations
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.5. Denial Types
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 6, Section 6.5.3. DRG Validation Review
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 6, Section 6.5.4. Review of Procedures Affecting the DRG

Last Updated Oct 12, 2021