Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, has conducted post-payment review of claims for Medicare electrodiagnostic (EDX) tests billed with a diabetes diagnosis with dates of service January 1, 2019, through December 31, 2019. 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.

In 2018, Noridian Healthcare Solutions, LLC (Noridian) as the current Supplemental Medical Review Contractor (SMRC), performed medical record review on supporting documentation to determine if the EDX testing was reasonable and necessary. An overpayment rate of 58% was found for the project. The SMRC also determined 75% of the EDX claims billed with a diabetes diagnosis code were denied.

Reason for Review

The SMRC was tasked with performing claim review on a sample of EDX test claims billed with a diabetes diagnosis for dates of service January 1, 2019, through January 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
  • CMS Internet-Only Manuals, Pub 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 was not supported
  • CMS Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. The medical record documentation submitted was insufficient to support medical necessity as listed in coverage requirements.           

References/Resources

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services.
• § 1833(e) Payment of Benefits.
• § 1835(2)(B) Procedure for Payment of Claims of Providers of Services.
• § 1861(s)(2)(C) Medical and Other Health Services.
• § 1861(aa)(2)(G) Rural Health Clinic Services and Federally Qualified Health Center Services.
• § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer.
• § 1879(a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1893(b) Medicare Integrity Program.

Title 42 of the Code of Federal Regulations (CFR)

• § 410.32(a) and (b) 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.

Internet Only Manual (IOM), Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02

• Chapter (Ch.) 6 § 20.4 Outpatient Diagnostic Services.
• Ch. 15 § 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
• Ch. 15 § 80.6 Requirements for Ordering and Following Orders for Diagnostic Tests.

IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04

• Ch. 4 § 10 Hospital Outpatient Prospective Payment System (OPPS).
• Ch. 23 § 20-20.4 Description of Healthcare Common Procedure Coding System (HCPCS).
• Ch. 30 § 50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN).

IOM, Medicare Program Integrity Manual (PIM), Pub. 100-08

• Ch. 3 § 3.2.3.2 Time Frames for Submission.
• Ch. 3 § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests.
• Ch. 3, § 3.3.2 Medical Review Guidance.
• Ch. 3 § 3.3.2.4 Signature Requirements.
• Ch. 3 § 3.6.2.2 Reasonable and Necessary Criteria.
• Ch. 3 § 3.6.2.4 Coding Determinations.
• Ch. 3 § 3.6.2.5 Denial Types.

Local Coverage Determination (LCD)

• L34594 Nerve Conduction Studies and Electromyography.
• L34859 Nerve Conduction Studies and Electromyography.
• L35048 Nerve Conduction Studies and Electromyography.
• L35081 Nerve Conduction Studies and Electromyography.
• L35098 Nerve Conduction Studies and Electromyography.
• L35897 Nerve Conduction Studies and Electromyography.
• L36524 Nerve Conduction Studies and Electromyography.
• L36526 Nerve Conduction Studies and Electromyography.

Local Coverage Article (LCA)

• A54095 Billing and Coding: Nerve Conduction Studies and Electromyography.
• A54969 Billing and Coding: Nerve Conduction Studies and Electromyography.
• A54992 Billing and Coding: Nerve Conduction Studies and Electromyography.
• A56035 Nerve Conduction Studies and Electromyography Revision to the Part A and Part B LCD.
• A56619 Nerve Conduction Studies and Electromyography.
• A57123 Nerve Conduction Studies and Electromyography.
• A57307 Nerve Conduction Studies and Electromyography.
• A57478 Nerve Conduction Studies and Electromyography.
• A57668 Nerve Conduction Studies and Electromyography.
• A58319 Nerve Conduction Studies and Electromyography Revision to the Part A and Part B LCD.

Last Updated Nov 4, 2022