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 cryosurgery of the prostate billed on dates of service from January 1, 2020, through December 31, 2021. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers and suppliers may wish to consult when submitting claims.

Background

Cryosurgery of the prostate gland, also known as cryosurgical ablation of the prostate (CAP), destroys prostate tissue by applying extremely cold temperature to reduce the size of the prostate. CAP is the primary treatment for localized prostate cancer, stages T1-T3.

Salvage therapy may be used when the patient has recurrent, localized prostate cancer, in addition to failing a trial of radiation therapy as their primary treatment, stage T2B or below, Gleason score less than 9, or Prostate Specific Antigen (PSA) less than 8 ng/ml.

For cryosurgery claims that meet medical necessity and are found to be payable, we note that, the ultrasonic guidance associated with this procedure will not be paid separately. Ultrasonic guidance associated with CAP is bundled into the payment for the surgical procedure.

The SMRC will review claims with Current Procedural Terminology (CPT) code 55873 (Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring) with diagnosis code C61, malignant neoplasm of the prostate.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of cryosurgery of the prostate claims. The SMRC will perform medical record review on supporting documentation to determine if the cryosurgery of the prostate was reasonable and necessary.

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

• Practitioner, nurse, and ancillary progress notes
• Operative/procedure report
• Documentation regarding prior interventions provided and the effectiveness of treatments
• History and Physical reports (include medical history and current list of medications)
• Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
• Documentation supporting the diagnosis code(s) required for the item(s) billed
• Documentation to support National Coverage Determination (NCD)
• Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
• Any other supporting/pertinent documentation
• If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and the 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/Resources

Title XVIII of the Social Security Act (SSA)

• § 1815(a) Payment to Providers of Service
• § 1833(e) Payment of Benefits
• § 1862(a)(1)(A) Exclusions from Coverage and Medicare as Secondary Payer
• § 1869(f)(1)(B) Determinations; Appeals
• § 1879 (a)(1) Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
• § 1893(b) Provider Education and Technical Assistance

Title 42 of the Code of Federal Regulations (CFR)

• § 405.929 Post-Payment Review
• § 405.930 Failure to Respond to Additional Documentation Request
• § 411.15(k)(1) Particular Services Excluded from Coverage
• § 424.5(a)(6) Basic Conditions
• § 482.24 Condition of participation: Medical record services

Medicare National Coverage Determinations (NCD) Manual, Publication 100-03

• Ch. 1, § 230.9 Cryosurgery of Prostate

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

• Ch. 6, § 20 Outpatient Hospital Services

Medicare Claims Processing Manual (MCPM), Publication 100-04

• Ch. 18, § 50 Prostate Cancer Screening Tests and Procedures
• Ch. 23, § 20.9 National Correct Coding Initiative [NCCI]
• Ch. 30, § 50 Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
• Ch. 32, § 180 Cryosurgery of the Prostate Gland

Medicare Program Integrity Manual (MPIM), Publication 100-08

• Ch. 3, § .3.2.3.2 Time Frames for Submission
• Ch. 3 § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Request
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, § 3.6.2.2 Reasonable and Necessary Criteria

Last Updated Jan 27, 2023