Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted post-payment review of claims for Medicare carotid artery screening/testing billed on dates of service from January 1, 2019, through December 31, 2019. Below are the review results:

Background

The Centers for Medicare and Medicaid Services (CMS) tasked Noridian Healthcare Solutions, LLC (Noridian), as the current Supplemental Medical Review Contractor (SMRC), to conduct data analysis and related medical review activities on carotid artery testing/screening. Medicare Part B covers carotid artery testing in certain circumstances for select indications. Non-invasive vascular studies done for screening purposes (i.e., without signs or symptoms of disease) are considered not reasonable and necessary and are therefore non-covered by Medicare.

Reason for Review

CMS tasked the SMRC to perform data analysis and conduct medical review on carotid artery screening/testing claims. Noridian completed medical review on a sample of claims related to carotid artery screening/testing services. The SMRC conducted 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 Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C, 42 CFR 424.5(a)(6), 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 requested documentation was not submitted to support reasonable and necessary criteria for Carotid Artery Screening.
• Insufficient Documentation
  • The documentation submitted was incomplete and/or insufficient. Refer to Internet-Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C; 42 CFR 424.5(a)(6), Social Security Act 1833(e), and Social Security Act 1862(a)(1)(A). The documentation submitted did not contain supporting documentation, diagnostic imaging, interpretation, or order/intent to order needed for the Carotid Artery Screening.
• Medical Necessity of the service performed
  • The documentation submitted does not support medical necessity as listed in coverage requirements in the National Coverage Determination or Local Coverage Determination. Refer to Social Security Act 1862, Internet Only Manual, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2. The documentation submitted did not support a covered diagnosis or did not include signs and/or symptoms to support the diagnosis billed for the Carotid Artery Screening.

Resources

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services.
• § 1833(e) Payment of Benefits.
• § 1842(p)(4) Provisions Relating to the Administration of Part B.
• § 1861(ddd) Preventive 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.
• § 410.64 Additional Preventative Services.
• § 411.15(k)(1) Particular services excluded from coverage.
• § 424.5 Basic Conditions.
• § 424.535 Revocation of enrollment in the Medicare Program.
• § 482.24(c)(1) Conditions of Participation: Medical Record Service.

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

• Ch. 6, § 20.4 Outpatient Diagnostic Services.
• Ch. 15, § 80 Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests.
• Ch, 16, § 20 General Exclusions from Coverage.

Medicare National Coverage Determinations Manual, Publication 100-03

• Ch 1, Part 1, § 20.17 Noninvasive Tests of Carotid Function.
• Ch 1, Part 4, § 220.5 Ultrasound Diagnostic Procedures.

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

• Ch 13, § 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures.
• Ch 30, § 30.2 Healthcare Provider or Supplier Knowledge and Liability.

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

• Ch 3, § 3.2.3.2 Time Frames for Submission.
• Ch 3, § 3.2.3.3 Third-party Additional Documentation Request.
• Ch 3, § 3.2.3.8(A) 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 Coverage Determinations.
• Ch 3, § 3.6.2.2 Reasonable and Necessary Criteria.
• Ch 13, § 13.5.4 Reasonable and Necessary Provisions in LCDs.

Related Local Coverage Determination (LCD)

• L33627 Non-Invasive Vascular Studies.
• L33695 Non-Invasive Extracranial Arterial Studies.
• L34045 Non-Invasive Vascular Studies.
• L34221 Noninvasive Cerebrovascular Studies.
• L35397 Non-Invasive Cerebrovascular Arterial Studies.
• L35753 Non-Invasive Cerebrovascular Studies.

Related Local Coverage Article (LCA)

• A52992 Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies.
• A56697 Billing and Coding: Non-Invasive Vascular Studies.
• A56758 Billing and Coding: Non-Invasive Vascular Studies.
• A57199 Billing and Coding: Noninvasive Cerebrovascular Studies.
• A57592 Billing and Coding: Non-Invasive Cerebrovascular Studies.
• A57670 Billing and Coding: Non-Invasive Extracranial Arterial Studies.

Other:

• Medicare Learning Network, MLN Matters SE1419 Medicare Signature Requirements – Educational Resources for Health Care Professionals.
• Medicare Learning Network, MLN Matters MM6563 Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs).

Last Updated Jan 26, 2024