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 of claims for Medicare Unspecified Outpatient Dental Services Current Procedural Terminology (CPT) 41899 (Unlisted procedure, dentoalveolar structures), billed on dates of service January 1, 2019, through May 31, 2022. 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

The Office of Inspector General (OIG) published a report (A-06-16-05003) in March 2017 titled “Medicare Contractors’ Payments to Providers for Hospital Outpatient Dental Services Generally Did Not Comply with Medicare Requirements.” It was noted from January 2011 through December 2014, Medicare contractors paid providers for hospital outpatient dental services that may be ineligible for Medicare payment. The OIG conducted audits of six Medicare contractors and found that 542 of the 600 dental services audited did not comply with Medicare requirements.

In September 2019, Noridian, as the SMRC, completed medical review and data analysis on outpatient dental services with an overall error rate of 91%. The SMRC found that the CPT code 41899 (Unlisted procedure, dentoalveolar structures) had a claim error rate of 92% with an overpayment error rate of 95%.

Reason for Review

The SMRC was directed to perform data analysis and medical record review activities. The SMRC will perform medical record review on Part B and Part B of A claims billed with CPT code 41899 with dates of service (DOS) January 1, 2019, through May 31, 2022.

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 specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

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

1. Physician/Non-Physician Practitioner (NPP) order or evidence of intent to order
2. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Policy Article
3. Medical record documentation to support the medical condition for the dental service billed with a medical CPT code
4. Medical record documentation to support the history of phosphonate or bisphosphonate usage; if applicable
5. History and Physical reports (include medical history and current list of medications)
6. Operative/procedure report(s)
7. Imaging studies and accompanying radiology interpretation including, but not limited to, CT, MRI, PET, nuclear medicine (e.g., bone scan) or ultrasound
8. Diagnostic tests, lab results, pathology reports and other pertinent test results and interpretations
9. Signed Consent Form(s)
10. Surgical recommendation
11. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
12. Advance Beneficiary Notice of Liability (ABN); if applicable
13. Any other supporting documentation
14. 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
15. 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 of the Code of Federal Regulations (CFR)

• § 410.32(a) & (a)(2) Diagnostic x-ray test, diagnostic laboratory tests, and other diagnostic tests: Conditions.
• § 411.15(i) & (k) Particular Services Excluded from Coverage.
• § 424.5 Basic Conditions.
• § 440.100 Dental Services.

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

• Ch. 5, § 70.2 Dentists.

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

• Ch. 1, § 70 Inpatient Services in Connection with Dental Services.
• Ch. 6, § 20.4 Outpatient Diagnostic Services.
• Ch. 15, § 150 Dental Services.
• Ch. 16, § 140 Dental Service Exclusion.

IOM, Medicare Program Integrity Manual (PIM), 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.
• Ch. 13 § 13.5.4 Reasonable and Necessary Provisions in LCDs.

Local Coverage Determination (LCD)

• L34574 Dental Services. Effective October 1, 2015

Local Coverage Article (LCA)

• A56663 Billing and Coding: Dental Services. Effective July 4, 2019
• A52977 Billing and Coding: Routine Dental Services. Effective October 1, 2015
• A52978 Billing and Coding: Routine Dental Services. Effective October 1, 2015

Last Updated Aug 9, 2022