Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted a post-payment review of claims for Medicare Part B and Part B of A Endomyocardial Biopsy with Right Heart Catheterization services, billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

Right heart catheterization (RHC) is the introduction of a catheter(s) into the right atrium, right ventricle, and pulmonary artery. It generally includes hemodynamic measurements and cardiac output determination. It may also include, when medically indicated, shunt determinations, and/or blood sampling, and/or hydrogen arrival time.

RHC for the purpose of monitoring hemodynamic status during an electrophysiologic, other interventional cardiac procedure, or angioplasty is included in that procedure; it is not separately reimbursable. RHC performed solely for the purpose of inserting a temporary pacemaker, performing endomyocardial biopsy, or performing electrophysiologic studies is not covered by Medicare.

Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. Potential misuse of this modifier represents a potential vulnerability, and has been featured in work done by the Office of the Inspector General.

Reason for Review

The SMRC was tasked with performing claim review on a sample of RHC claims 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
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 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
  • Social Security Act 1862, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. The medical record documentation was not sufficient to support medical necessity for the procedure performed.
• The documentation did not support the services were rendered as billed
  • CMS Internet-Only Manuals, Medicare Program Integrity Manual, Pub 100-08, Chapter 3, Section 3.6.2.4. The documentation did not support the procedure was performed. The procedural documentation was not submitted for review.

References/Resources

Social Security Act (SSA) Title XVIII

• § 1138. Hospital protocols for organ procurement and standards for organ procurement agencies.
• § 1833(e). Providers must furnish information.
• § 1835(2)(A). Procedure for Payment of Claims of Providers of Services.
• § 1861(d). Definitions of services by a supplier.
• § 1861(s)(1). Definitions of services by a physician.
• § 1861(aa)(2)(G). Definitions of services for routine tests and additional tests.
• § 1862. Exclusion from Coverage and Medicare as a Secondary Payer.
• § 1879(a)(1). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
• § 1893(f)(7)(A)(B) (i-iv). Recovery of overpayments by post payment audits.

Code of Federal Regulations (CFR) Title 42

• 121. Organ procurement and transplantation network.
• 410.32. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• 411.15(k)(1). Particular Services excluded from coverage.
• 416.65. Covered Surgical Procedures.
• 424. Conditions for Medicare Payment.
• 482.24. Condition of Participation: Medical record services.

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

• Chapter (Ch.) 15, § 80.1. Clinical Laboratory Services.
• Ch. 15, § 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests.
• Ch. 16, § 20. Services Not Reasonable and Necessary.

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

• Ch. 12 § 20.3. Bundled Services/Supplies.
• Ch. 12 § 30(M). Correct Coding Policy. Mutually Exclusive Procedures.
• Ch. 16. Laboratory Services.
• Ch. 23 § 10. Reporting ICD Diagnosis and Procedure Codes.
• Ch. 23 § 20.3-20.4. Use and Acceptance of HCPCS Codes and Modifiers.
• Ch. 23 § 20.9.1.1-20.9.2. Instructions for Codes with Modifiers.
• Ch. 30 § 50 Form CMS-R-131. Advance Beneficiary Notice of Noncoverage (ABN).

Internet Only Manual (IOM), Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 1. Overview of Medical Review (MR) and Benefit Integrity (BI) Programs.
• Ch. 3. Verifying Potential Errors and Taking Corrective Actions.
• Ch. 3 § 3.2.3.8. No response or Insufficient Response to Additional Documentation Requests.
• Ch. 3 § 3.3.2.1. Documents on Which to Base a Determination.
• Ch. 3 § 3.3.2.4. Signature Requirements.
• Ch. 3 § 3.3.2.8. MAC Articles.
• Ch. 3 § 3.6.2. Verifying Errors.

Internet Only Manual (IOM), Medicare Contractor Beneficiary and Provider Communications Manual (MCBPC), Pub. 100-09

• Ch. 6 § 20.4. Provider Education.

Related Local Coverage Determinations (LCDs)

• L33557. Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015
• L33959. Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015

Related Local Coverage Articles (LCAs)

• A52850. Billing and Coding: Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015
• A56500. Billing and Coding: Cardiac Catheterization and Coronary Angiography. Effective October 1, 2018

Other

• National Correct Coding Initiative Policy Manual for Medicare Services. (Coding Policy Manual), revised January 1, 2019

Last Updated Sep 16, 2022