Noridian Healthcare Solutions, LLC, (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid (CMS), has conducted post-payment review of claims for Medicare Part B claims billed on dates of service from January 1, 2021, through December 31, 2022. Below are the review results:

Background

Medicare does not cover an echocardiogram (ECHO) performed for screening purposes, including screening for high-risk patients. Symptoms or an existing condition must be present to meet coverage criteria and support payment for an ECHO.

SMRC completed a medical review project which looked at claims with CPT codes 93306, “Ultrasound of heart with color-depicted blood flow, rate, direction and valve function” and 93307, “Chest ultrasound examination of heart” for dates of service in 2019. The SMRC found a final claim error rate of 37% for those claims that were medically reviewed.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and medical record review activities on echocardiography, specifically CPT code 93306. The SMRC performed medical record review on supporting documentation, to determine if select Part B claims for echocardiography select code 93306 were reasonable and necessary. The SMRC conducted medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Non-Response to the ADR
  • According to the 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), Social Security Act 1833(e), and Medicare Program Integrity Manual (PIM) Pub. 100-08, Chapter 3, Section 3.2.3.8, providers are to respond to requests for documentation within 45 calendar days of the additional documentation request (ADR) for the dates of service under review. In instances the documentation was not submitted from the provider to support the claim as requested by the ADR the claims resulted in denial.
• Incomplete or Insufficient Documentation Received
  • Insufficient documentation resulted in denial to align with 42 CFR 424.5(a)(6), Social Security Act 1862(a)(1)(A), and Social Security Act 1833(e). Most commonly, the submitted documentation did not contain medical records such as an office visit to support medical necessity for the study and/or findings for the echocardiography completed.
• No order or documentation to support intent to order
  • The documentation submitted did not include a signed physician order or documentation to support intent to order. Refer to 42 CFR 410.32, Social Security Act 1842(p)(4), Internet Only Manual (IOM), Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4, IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6. The documentation submitted did not include an order or intent to order for the echocardiography.

References

Social Security Act (SSA), Title XI

• §1135 Authority to Waive Requirements During National Emergencies

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) (1) Additional Preventive Services; Preventive Services
• §1861(s)(2)(K) Miscellaneous Provisions (Definitions of Services, Institutions, etc.)
• §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(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• §410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions§ 410.33 Independent diagnostic testing facility
• §410.64 Additional Preventative Services
• §411.15(k)(1) Particular services excluded from coverage
• §424.5 Basic Conditions

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.
• 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

Public Law

• Coronavirus Aid, Relief, and Economic Security Act. Title III- Supporting America’s Health Care System in the Fight Against the Coronavirus. Subtitle D-Finance Committee, §§ 3710. Medicare Hospital Inpatient Prospective Payment System add-on Payment for Covid-19 Patients During Emergency Period. § 3711. Increasing Access to Post-Acute Care During Emergency Period. January 3, 2020. Retrieved from BILLS-116hr748enr.pdf (congress.gov)
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). § 101. Telehealth Services During Certain Emergency Periods Act of 2020. Retrieved from PUBL123.PS (congress.gov)
• Public Health Service Act, 2021, § 319(e). Telehealth Enhancements for Emergency Response. Enacted June 25, 2022. Retrieved from COMPS-8773.pdf (govinfo.gov)
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. May 2021. Retrieved from Stafford Act, as Amended – FEMA P-592 vol. 1 May 2021

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

• Chapter (Ch). 1, Part 4, §§220.5 Ultrasound Diagnostic Procedures

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

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

• Ch.13, §10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch. 13, §20 Payment Conditions for Radiology Services
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, §30.2 Healthcare Provider or Supplier Knowledge and Liability
• Ch. 12, §30.4 Cardiovascular System (Codes 92950-93799)

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, §3.2.3.4 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, §3.6.2 Verifying Errors
• Ch. 5, §5.9 Documentation in the Patient’s Medical Record
• Ch. 5, §5.11 Evidence of Medical Necessity
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• NCCI Policy Manual for Medicare Services, Effective 2022. Chapter V Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT codes 30000-39999. Section D. Cardiovascular System

Local Coverage Determination (LCD)

• L33577 Transthoracic Echocardiography (TTE)
• L33768 Transthoracic Echocardiography (TTE)
• L34338 Transthoracic Echocardiography (TTE)
• L37379 Echocardiography

Local Coverage Article (LCA)

• A56625 Billing and Coding: Echocardiography.
• A56781 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57182 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57306 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57807 Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
• A58559 Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)

Other

• CMS. Non-Emergent, Elective Medical Services, and Treatment Recommendations. April 7, 2020. Non-Emergent, Elective Medical Services, and Treatment Recommendations (cms.gov)
• Medicare Learning Network, MLN Matters 905364. Complying with Medicare Signature Requirements. April 2022
• Medicare Learning Network, MLN Matters MM6563. Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs). Effective April 1, 2010
• Medicare Learning Network, MLN Matters MLN909060. Independent Diagnostic Testing Facilities (IDTF). October 2022

Last Updated Jul 18, 2024