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 Part B billed on dates of service from September 1, 2020, through April 24, 2021. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

In December 2021, the Office of Inspector General (OIG) published a report (A-09-21-03002), titled “Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions.” Medicare Part B provides coverage for the cost of facet joint denervation sessions when they are medically reasonable and necessary. The report looked at two coverage limitations developed by the Medicare Administrative Contractors (MACs), namely, annual limitations on the number of sessions and limitations on the number of joints per denervation session. The OIG noted that these coverage limitations do not apply to facet joint denervation sessions related to the sacral spine. The OIG findings noted that Medicare improperly paid physicians $9.5 million for facet joint denervation services.

Reason for Review

As a result of the OIG report, CMS tasked Noridian, as the SMRC with reviewing a sample of select spinal denervation claims with DOS after the audit period that exceeded MAC coverage session limitations. The SMRC will perform data analysis and conduct medical record review for facet joint denervation session limitations. The SMRC will perform medical record review on supporting documentation, to determine if services were medically necessary. The SMRC will perform medical record review on Part B claims with dates of service (DOS) September 1, 2020, through April 24, 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

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.

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

• Physician or Non-Physician Practitioner (NPP) order for date of service or intent to order for date of service
• Initial pre-procedural evaluation including Qualifying Diagnosis, Treatment plan, and Initial complaint supporting the reason for evaluation
• History and Physical (with musculoskeletal and neurological assessment) including: Onset of pertinent symptoms, complete pain history, treatments, interventions, and medication regimens with outcomes for each that support at least 3 months of moderate to severe pain, functional impairment, and failed response to conservative treatment of at least 6-week duration; including pre and post facet joint intervention pain levels. There must be an evaluation of pain during performance of pain provoking maneuvers
• Repeat/ongoing, and prior imaging studies including a summary of pertinent diagnostic tests or procedures tried, spinal imaging and injections, justifying the possible presence of facet joint pain, include those performed at other treatment centers
• Procedure Report to support each service billed, including procedural details of electrode position, cannula size, lesion, and electrical stimulation parameters, any administered injectate other than local anesthetic, total volume of injectate, medication administration record (MAR), evidence of radiographic guidance (fluoroscopy or computed tomography), and pre and post procedure evaluation
• Documentation to support dual Medial Branch Block (MBB) procedures are submitted with documented results of each block, justification of the steroid or other medication used in the injection, in addition to local anesthetic. If a diagnostic Medial Branch Block (MBB) cannot be performed, the specific restrictions must be clearly documented in the medical record
• For procedures that require use of conscious sedation or Monitored Anesthesia Care (MAC), the medical record documentation must support the medical necessity of sedation
• Documentation of practitioner visits related to the need for the facet joint denervation procedure
• Documentation to support any medical services that were deferred as non-emergent, elective treatment, or preventative during the Public Health Emergency (PHE)
• Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
• List of all non-standard abbreviations or acronyms used, including definitions
• Any other supporting/pertinent documentation
• Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
• Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
• 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
• 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

Social Security Act (SSA), Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• §§ 1812(a)(1), (b)(3) Scope of Benefits
• § 1814(a) Conditions of and Limitations on Payment of Services
• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1833(2)(E)(i) Payment of Benefits (Outpatient Hospital Radiological Services)
• § 1833(t)(B)(i) Payment of Benefits (Prospect Payment Service for Outpatient Part B Department Services)
• § 1834(m)(4)(F) Special Payment Rules for Particular Items and Services
• § 1835(a)(2) Procedure for Payment of Claims of Providers of Services
• § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
• § 1862(a)(7) Excludes Routine Physicals
• § 1869(f)(1)(B) Determinations; Appeals
• § 1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• § 1893(b) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• § 400.200 General Definitions
• § 405.904 Determinations, Redeterminations, Reconsiderations, and Appeals under Original Medicare (Part A and Part B)
• § 410.134 Provider Qualifications
• § 411.15 Exclusions from Medicare and Limitations on Medicare Payment
• § 411.15(k)(l) Particular Services Excluded from Coverage
• § 414.40 Coding and Ancillary Polices – AMA HCPCS Professional Coding Guidelines
• § 419.22 Hospital Services Excluded from Payment
• § 424.5 (a)(6) Basic Conditions of the Medicare Payment; Sufficient Information

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency.  Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov)
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). Telehealth Services During Certain Emergency Periods PUBL123.PS (congress.gov)
• Interim Final Rule with Comments (IFC), 5531. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Effective March 1, 2020. Retrieved from CMS-55341-IFC

Internet Only Manual (IOM), Medicare National Coverage Determinations Manual (NCD), Publication (Pub). 100-03

• Chapter (Ch.) 1, Part 4, § 220.1 Computed Tomography (CT)

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

• Ch. 15, § 30 Physician Services
• Ch. 15, § 50 Drugs and Biologicals
• Ch. 16, § 20 Services Not Reasonable and Necessary

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

• Ch. 1 General Billing Requirements
• Ch. 4, § 20.4 Reporting of Service Units
• Ch. 4, § 20.6 Use of Modifiers
• Ch. 7, § 50Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch. 12, § 20.3 Bundled Services/ Supplies
• Ch. 12, § 30 Correct Coding Policy
• Ch. 12, § 40.7 Claims for Bilateral Surgeries
• Ch. 12, § 70 Payment conditions for Radiology Services
• Ch.12, § 190 Medicare Payment for Telehealth Services
• Ch. 13, § 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch. 13, § 20 Payment Conditions for Radiology Services
• Ch. 13, § 30 Computerized Axial Tomography (CT) Procedures
• Ch. 23 Fee Schedule Administration and Coding Requirements
• Ch. 23, § 20 Description of Healthcare Common Procedure Coding System (HCPCS)
• Ch. 30, § 50 Advance Beneficiary Notice of Non-coverage (ABN)

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

• Ch. 3 Verifying Potential Errors and Taking Corrective Actions
• Ch. 3, § 3.2.3.2 Time Frames for Submission
• Ch. 3, § 3.2.3.4 Additional Documentation Request Required and Optional Elements

• 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, § 3.4.1.3 Diagnosis Code Requirements
• Ch. 3, § 3.6.2.1 Coverage Determination
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria
• Ch. 3, § 3.6.2.3 Limitation of Liability Determinations
• Ch. 3, § 3.6.2.4 Coding Determinations
• Ch. 3, § 3.6.2.5 Denial Types
• Ch. 5, § 5.11 Evidence of Medical Necessity
• Ch. 13, § 13.5.1 General Requirements
• Ch. 13, § 13.5.4 Reasonable and Necessary Provision in an LCD

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. Effective January 1, 2020, and January 1, 2021

Local Coverage Determinations (LCDs)

• L33930 Facet Joint Interventions for Pain Management
• L34832 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
• L34892 Facet Joint Interventions for Pain Management
• L35936 Facet Joint Interventions for Pain Management
• L35996 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
• L36471 Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy

Local Coverage Articles (LCAs)

• A55906 Paravertebral Facet Joint Blocks – Revision to the Part B LCD
• A56463 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
• A56670 Billing and Coding: Facet Joint Interventions for Pain Management
• A56687 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
• A57553 Billing and Coding: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy
• A57787 Billing and Coding: Facet Joint Interventions for Pain Management
• A57826 Billing and Coding: Facet Joint Interventions for Pain Management
• A58105 Paravertebral Facet Joint Blocks – Revision to the Part B LCD

Other

• CMS. Non-Emergent, Elective Medical Services, and Treatment Recommendations. April 7, 2020. Non-Emergent, Elective Medical Services, and Treatment Recommendations (cms.gov)
• Office of Inspector General (OIG). Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation. December 3, 2021. Retrieved from Medicare Improperly Paid Physicians for Spinal Facet-Joint Denervation Sessions A-09-21-03002 12-03-2021 (hhs.gov)

Last Updated Jul 18, 2023