Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for CMS, is conducting post-payment review of claims for Medicare Part B billed on dates of service from January 1, 2022, through December 31, 2023. 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

Nerve blocks are one-time injections delivered to temporarily interrupt the conduction of impulses in the peripheral nerves or nerve trunks and are used to alleviate pain. A local anesthetic solution is injected into the nerve structures acting on the sodium channels at the cellular level which prevents impulse propagation and excitation of the nerve, resulting in pain relief. According to Chapter 2 within the Medicare National Correct Coding Initiative (NCCI) policy, the nerve block may be administered during the preoperative phase, intraoperative phase, or post operatively.

Reason for Review

The SMRC was issued a Task Order 1 and Task Order 6 on May 20, 2024, to perform data analysis and medical review activities on nerve block injections, specific to diagnosis code G89.18. The SMRC will perform medical record review on supporting documentation to determine if the nerve block injection was medically necessary and met coverage criteria by Medicare.

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.

1. History and Physical reports (include medical history and current list of medications).
2. Preoperative evaluations including anesthesia evaluation.
3. Physician/Non-Physician (NPP) order or evidence of intent to order.
4. Operative/procedure report.
5. Anesthesia records (including pre- and post-anesthesia).
6. Documentation to support the code(s) and modifier(s) billed.
7. Documentation that supports the nerve block analgesia.
8. Documentation to support referral of care to anesthesia/CRNA, if applicable.
9. Any other supporting or pertinent documentation.
10. All medical record documentation must have at least two identifiers to include, at a minimum, the beneficiary’s name and date of service.
11. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
12. Providers/suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available when authenticity is not conclusively documented. Please include a signature log or signature attestation for any missing or illegible signature within the medical record.
13. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) or Policy Article.
14. If Medical record documentation 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: The supplier or provider is responsible for obtaining 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

• §1815(a). Payment to Providers of Services.
• §1833(e). Payment of Benefits.
• §1861(s)(2)(A) or (B). Medical and Other Health Services.
• §1861(t). Drugs and Biologicals.
• §1862 (a)(1) (A) and (a)(7). Exclusions from Coverage and Medicare as Secondary Payer.
• §1877(g). Limitation on Certain Physician Referrals.
• §1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.

Code of Federal Regulations (CFR) Title 42

• §411.15. Exclusions from Medicare and Limitations on Medicare Payment.
• §413.1. Subpart A, Introduction and General Rules.
• §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

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

• Ch. 15, §30. Physician Services.
• Ch. 15, §50. Drugs and Biologicals.
• Ch. 15, §60. Services and Supplies Furnished Incident to a Physician’s/NPP’s Professional Service.
• Ch. 16. General Exclusion from Coverage.

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

• Ch. 1. General Billing Requirements.
• Ch. 12, §40. Surgeons and Global Surgery.
• Ch. 12, §50. Payment for Anesthesiology Services.
• Ch. 30, §50. Advance Beneficiary Notice of Non-coverage (ABN).

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

• Ch. 3. Verifying Potential Errors and Taking Corrective Actions.
• Ch 13, §13.5.1. Reasonable and Necessary Provisions in LCDs.

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. §§2021, 2022, and 2023.

Local Coverage Determination (LCDs)

• L36850. Peripheral Nerve Blocks.
• L33933. Peripheral Nerve Blocks.

Local Coverage Articles (LCAs)

• A57452. Billing and Coding: Peripheral Nerve Blocks.
• A57788. Billing and Coding: Peripheral Nerve Blocks.

Other

• ASRA Pain Medicine, Regional Anesthesia Billing: Survival Anesthesia Versus Postoperative Analgesia. February 7, 2020. Regional Anesthesia Billing: Surgical Anesthesia Versus Postoperative Analgesia (asra.com)
• MLN907166. Global Surgery. cms.gov

Last Updated Jul 19, 2024