Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Transforaminal Epidural Injection billed on dates of service from July 1, 2018, through June 30, 2019. Below are the review results:

Background

In 2018, the Comprehensive Error Rate Testing (CERT) Medicare Fee-for-Service (FFS) Improper Payment Report noted a 29.1% error rate for this service category. The error rate noted an 86.7% insufficient documentation error rate; with a 13.3% error rate related to medical necessity.

A previous SMRC contractor reviewed Transforaminal Epidural Injection (TEI) services and found a claim error rate of 40%. Further review was recommended.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on TEI claims. The claim sample consisted of Part B professional services in addition to Part B of A facility claims. Noridian completed medical record review on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Incomplete and/or Insufficient Documentation
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. Documentation was missing elements to support medical necessity.
• 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.
• Medical Necessity
  • 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.” Claims were denied when submitted documentation did not support identification and administration of medication and/or dosage limitations, etc.

References/Resources

Title XVIII of the Social Security Act (SSA)

• § 1833(e) Payment of Benefits
• § 1833(2)(E)(i) Payment of Benefits (Outpatient Hospital Radiological Services)
• § 1833(t)(B)(i) Payment of Benefits (Prospect Payment Service for Outpatient Part B Department Services)
• § 1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• § 1862(a)(1)(A) Exclusions of coverage
• § 1862(a)(7) Exclusion of Routine Physical examinations

Title 42 Code of Federal Regulations (CFR)

• § 410. Supplementary Medical Insurance Benefits
• § 414.40. Coding and Ancillary Polices – AMA HCPCS Professional Coding Guidelines
• § 424.5(a)(6). Basic Conditions of the Medicare Payment; Sufficient Information
• § 482.24. Signature Requirements

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

• Ch 6, § 20. Hospital Services Covered under Part B
• Ch 15, § 50-50.6. Drugs and Biologicals
• Ch 15, § 80.6.1. Definitions for Ordering for Diagnostic Testing
• Ch 16, § 20. Services Not Reasonable and Necessary

Medicare Claims Processing Manual (MCPM), Publication 100-04

• Ch 3, Modifiers
• Ch 4, § 20.4. Reporting of HCPCS Service Units
• Ch 4, § 20.6. Use of Modifiers
• Ch 7, § 50. Part B Billing, Inpatient Part B and Outpatient
• Ch 12, § 20.3. Bundled Services/Supplies
• Ch 12, § 70. Payment conditions for Radiology Services
• Ch 13, § 20. Payment Conditions for Radiology Services
• Ch 13, § 30. Computerized Axial Tomography Procedures
• Ch 23, § 20. Description of Healthcare Common Procedure Coding System (HCPCS)
• Ch 30, § 40.3.6. Advanced Beneficiary Notice of Non-Coverage
• Ch 30, § 50.6.1. ABN Standards Proper Notice Documents

Medicare Program Integrity Manual (MPIM), Publication 100-08

• Ch 3, § 3.2.3.8 and 3.2.3.8 B/C. No Response or Insufficient Response to Additional Documentation Requests
• Ch 3, § 3.3.2.4. Signature Requirements
• Ch 3, § 3.4.1.3. Diagnosis Code Requirements
• Ch 3, § 3.6.2.1 and 3.6.2.2. Coverage Determination and Reasonable and Necessary Criteria
• Ch 3, § 3.6.2.4. and 3.6.2.5. Coding Determinations and Denial Types
• Ch 3, § 3.6.2.5.A. Denial Types

Local Coverage Determination (LCD)

• L33906 Epidural. Effective Date October 1, 2015
• L34807 Lumbar Epidural Steroid Injections. Effective Date October 1, 2015
• L34980 Lumbar Epidural Injections. Effective Date October 1, 2015
• L34982 Lumbar Epidural Injections. Effective Date October 1, 2015
• L35148 Lumbar Epidural Steroid Injections. Effective Date October 1, 2015
• L35937 Lumbar Epidural Injections. Effective Date October 1, 2015
• L36521 Lumbar Epidural Injections. Effective Date June 16, 2016
• L36920 Epidural Injections for Pain Management Effective Date May 4, 2017

Local Coverage Article (LCA)

• A56469. Billing and Coding for Lumbar Epidural Steroid Injections (ESI). Effective Date October 1, 2018
• A56681 Billing and Coding: Epidural Injections for Pain Management. Effective Date July 11, 2019
• A57202 Billing and Coding: Lumbar Epidural Injections. Effective Date October 1, 2019
• A57203 Billing and Coding: Lumbar Epidural Injections. Effective Date October 1, 2019
• A56721 Billing and Coding: Lumbar Epidural Steroid Injection. Effective Date July 25, 2019
• A57494 Billing and Coding: Lumbar Epidural Injections. Effective Date October 17, 2019
• A56651 Billing and Coding: Epidural. Effective Date October 3, 2018
• A5755 Lumbar Epidural Injections. Effective Date November 1, 2019

Other

• National Correct Coding Initiative Coding Policy Manual for Medicare Services (Coding Policy Manual) revised January 12, 2018

Last Updated Oct 3, 2022