01-060 E/M No Response Providers DME Part II Findings of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare Part B billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:
|Project ID||Project Title||Error Rate|
|01-060||E&M No Response Providers DME Part II||59%|
In 2020, the SMRC completed medical review project 01-021 No Response Providers for DME/DTS Part I, which reviewed the ordering and dispensing of diabetic test strips (DTS) and lancets. The results of this review identified numerous referring providers that did not respond to supplier requests for additional documentation. Failure to respond to a supplier’s request for additional documentation may represent a potential vulnerability.
For purposes of this project, the SMRC performed medical record review of traditional Evaluation and Management (E/M) services for those referring provider National Provider Identifiers (NPIs) that did not respond to supplier requests for additional documentation.
Reason for Review
The SMRC was tasked with performing claim review on a sample of Evaluation and Management (E/M) Services from January 1, 2019, through December 31, 2019. The SMRC conducted medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.
Common Reasons for Denial
- No Response to the Documentation Request
- The requested records were not received. Refer to IOM, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 22.214.171.124, Social Security Act (SSA) Title XVIII, Section 1815(a), 1833(e), and 1862(a)(1)(A). This 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 CPT code on Review
- The documentation submitted supported the key elements and/or reasonable necessity of a higher/lower level of service. Refer to Internet Only Manual (IOM), Pub 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6; 1995 Documentation Guidelines for Evaluation and Management Services; 1997 Documentation Guidelines for Evaluation and Management Services; IOM, Pub 100-08, Medicare Program Integrity Manual Chapter 3, Section 126.96.36.199 and Section 188.8.131.52; IOM, Pub 100-04, Medicare Claims Processing Manual Chapter 23. The documentation submitted did not support the level of E/M service billed. Claims were adjusted to the appropriate level of service.
Social Security Act (SSA), Title XVIII
- § 1815(a) Payment to Providers of Services.
- § 1833(e) Payment of Benefits.
- § 1861(s)(2)(w) Medical and other Health Services.
- § 1861(ww)(1) Initial Preventative Physical Examination.
- § 1861(s)(2) (FF) and 1861(hhh) Medical and other Health Services.
- § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer.
- § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
- § 1893(b) Medicare Integrity Program.
Code of Federal Regulations (CFR) Title 42
- § 410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions.
- § 411.15(k)(1) Particular services excluded from coverage.
- § 424.5(a)(6) Basic Conditions.
- § 424.535 Revocation of enrollment in the Medicare Program.
- § 411 Exclusions from Medicare and Limitations on Medicare Payment.
- § 410.16 Initial Preventive Physical Examination: Conditions for and limitations on coverage.
- § 410.15 Annual Wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage.
- § 410.20 Physician Services.
- § 410.74 Physician Assistants’ Services.
- § 410.75 Nurse Practitioners’ Services.
- § 410.134 Provider Qualifications.
- § 482.24(c)(1). Condition of Participation: Medical Record Services.
Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Pub. 100-02
- Ch. 6, § 20.4 Outpatient Diagnostic Services.
- Chapter 15 Covered Medical and Other Health Services.
- Ch.15, § 50.4.3 Examples of Not Reasonable and Necessary.
- Ch. 15, § 60. Services and Supplies.
- Ch. 15, § § 60.1-60.3. Incident to Physician’s Professional Services.
- Ch. 16, § 10. General Exclusions form Coverage.
Internet Only Manual (IOM), Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1 General Billing Requirements.
- Ch. 12, § section 30.6 Evaluation and Management Service Codes – General (Codes 99201 – 99499).
- Ch. 23 Fee Schedule Administration and Coding Requirements.
Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3, § 184.108.40.206 Documents on which to Base a Determination.
- Ch. 3, § 220.127.116.11 Time Frames for Submission.
- Ch. 3, § 18.104.22.168 No Response or Insufficient Response to Additional Documentation Requests.
- Ch. 3, § 22.214.171.124(A) Additional Documentation Requests.
- Ch. 3, § 126.96.36.199 Signature Requirements.
- Ch. 3, § 188.8.131.52 Coverage Determinations.
- Ch. 3, § 184.108.40.206 Reasonable and Necessary Criteria.
- Ch. 3, § 220.127.116.11 and 18.104.22.168 Denial Types.
- Ch. 5, §5.9 Documentation in the Patient’s Medical Record.
- Ch. 5, §5.11 Evidence of Medical Necessity.
- Ch. 6, §6.8 Medical Review of Evaluation and Management (E/M) Documentation.
- Ch. 13, § 13.5.4 Reasonable and Necessary Provisions in LCDs.
- CMS 1995 Documentation Guidelines for E&M services.
- CMS 1997 Documentation Guidelines for E&M services.
- Evaluation and Management Coding, E/M Codes-AAPC.
- Evaluation and Management Services Guide Booklet.
- Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List effective January 1, 2019.
Last Updated Dec 2, 2022