Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review for Medicare dental bone grafting claims billed on dates of service January 1, 2020, through December 31, 2021. This notification includes the reasons for the review, the documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

Dental services are generally excluded from Medicare coverage by statute and regulation when related to the care, treatment, filling, removal, or replacement of teeth or structures directly supporting the teeth. When an excluded service is the primary procedure involved, it is not covered regardless of its complexity or difficulty. Coverage is not determined by the value or the necessity of the dental care but by the type of service provided and the anatomical structure on which the procedure is performed. For dental services to be covered, they must be performed as incident to and as an integral part of a procedure or service covered by Medicare.

Data analysis has been conducted by CMS and Noridian, and dental bone grafting was identified as a potential area of vulnerability.

Reason for Review

The SMRC is tasked with performing medical record reviews on dental bone grafting claims billed dates of service (DOS) January 1, 2020, through December 31, 2021.

The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References/Resources

Documentation Requirements

Below is a list of the specific documentation requirements that will be included in each ADR letter to obtain the necessary documentation to perform the medical record review.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

1. Medical record documentation to support the medical condition for the dental service billed with a medical CPT code
2. Medical record documentation to support the history of phosphonate or bisphosphonate usage; if applicable
3. History and Physical reports (include medical history and current list of medications)
4. Operative/procedure report(s)
5. Imaging studies and accompanying radiology interpretation including, but not limited to, CT, MRI, PET, nuclear medicine (e.g., bone scan) or ultrasound
6. Diagnostic tests, lab results, pathology reports and other pertinent test results and interpretations
7. Signed Consent Form(s)
8. Physician and/or Dentist progress notes
9. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
10. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
11. Any other supporting/pertinent documentation
12. If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
13. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/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 Part E – Miscellaneous Provisions.
• § 1862(a)(1)(a) & (12) Exclusion from Coverage and Medicare as a Secondary Payer.
• § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
• § 1893(f) (7) (A) (B) (i-iv) Medicare Integrity Program.

Title 42 Code of Federal Regulations (CFR)

• § 411.15 (i) & (k)(1) Particular services excluded from coverage.
• § 424.5(a)(6) Basic Conditions.
• § 440.100 Dental Services.

Internet Only Manual (IOM), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01

• Chapter (Ch.) 5, § 70.2 Dentists.

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

• Ch. 15, § 150 Dental Services.
• Ch. 16, § 140 Dental Service Exclusion.

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

• Ch. 30 § 50 Advance Beneficiary Notice of Non-coverage (ABN).

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

• Ch. 3 § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests.
• Ch. 3 § 3.3.2.4 Signature Requirements.
• Ch. 3 § 3.6.2.1 Coverage Determinations.
• Ch. 3 § 3.6.2.2 Reasonable and Necessary Criteria.

Last Updated Feb 17, 2023