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

Evaluation and management (E/M) services involve the assessment, diagnosis, and treatment of the beneficiary and are covered under Medicare Part B when supported by the medical record. Documentation must clearly substantiate the level of E/M service billed. The criteria depicting the appropriate level of E/M service are outlined by the American Medical Association (AMA) in the Current Procedural Terminology (CPT) Professional Edition code books. The level of E/M service may be determined by one of two methods: the documented total time spent on the service, or the three key components of the service, which include the beneficiary’s history, examination of the beneficiary, and the level of medical decision making (MDM).

Medicare covers a broad range of services for beneficiaries residing in a nursing facility, and when facilities cannot meet all care needs, external providers may deliver services such as eye examinations or treatment for ocular conditions. The E/M CPT codes 99309 (Subsequent nursing facility care with moderate level of medical decision making, per day, if using time, at least 30 minutes) and 99310 (Subsequent nursing facility care with high level of medical decision making, per day, if using time, at least 45 minutes) may be reported when the documentation supports the level of service billed, whether based on the documented total time spent or the applicable E/M service components, including MDM. In 2023, the AMA updated the CPT code descriptors for 99309 and 99310 to reflect a moderate level of MDM for CPT 99309 and a high level of MDM for CPT 99310, while allowing code selection to be based alternatively on total time, when supported by the documentation.

In December 2025, the Office of Inspector General (OIG) published a report A-05-24-00009 titled “Optometrists Billing Services for Medicare Enrollees Residing in Nursing Facilities,” in which the OIG identified for dates of service 2021 through 2023, $4.7 million was paid to 200 optometrists that billed CPT 99309 or 99310. The top 15 optometrists accounted for 72% of the total paid by Medicare. The OIG audited a stratified random sample of 15 beneficiaries from each of the identified top 15 providers and found for this entire sub-sample of 225 beneficiaries, that the documentation did not support the level of the code billed. An estimated $3 million was identified as potential overpayments due to noncompliance with Medicare requirements.

Reason for Review

The SMRC is tasked to perform data analysis and conduct medical record reviews on claims billed with CPT Codes 99309 and 99310 billed with dates of service January 1, 2023 through December 31, 2023.

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. Please Note: The provider is responsible for obtaining all documentation from the ordering/referring provider, or requesting facility to ensure medical necessity criteria have been met
2. Documentation to support both the medical necessity and the level of evaluation and management service billed, such as: beneficiary history, examination, provider medical decision making, counseling, coordination of care, nature of presenting problem, or minimum time spent for the duration of visit
3. Documentation to support the code(s) and modifiers billed
4. Providers and/or suppliers are encouraged to review the documentation prior to submission, to ensure that signature information is available. Please include a signature log or signature attestation for any missing or illegible signature within the medical record
5. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician.
6. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
7. Any other supporting/pertinent documentation
8. 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

References

Social Security Act (SSA), Title XI

• Section (§) 1135 Authority to Waive Requirements During National Emergencies

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 Provision
• §1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• §1877(g) Blanket Waivers of Section 1877 (G) of the Social Security Act Due to Declaration of COVID-19 Outbreak in the United States as a National Emergency
• §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)

• §410.20 Physician Services
• §410.3 Scope of benefits
• §411.15 Particular Services Excluded from Coverage
• §414.40 Coding and Ancillary policies
• §§424.5 and 424.5(a)(6) Basic Conditions and Sufficient Information

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

• Chapter (Ch.) 15, §30.4 Optometrist’s Services
• Ch. 16 General Exclusion from Coverage

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

• Ch. 12, §30.6.1 Selection of Level of Evaluation and Management Service
• Ch. 12, §30.6.10 Consultation Services
• Ch. 12, §30.6.13 Nursing Facility Services
• Ch. 23, §20.9 National Correct Coding Initiative (NCCI)
• 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 Action

CMS Coding Policies

• National Correct Coding Initiative Edits (NCCI). NCCI Policy Manual for Medicare Services. §§ 2022 and 2023
• National Correct Coding Initiative Policy Manual Chapter 1, Section D Evaluation & Management (E/M) Services
• National Correct Coding Initiative Policy Manual Chapter 1, Section E Modifiers and Modifier Indicators
• NCCI Policy Manual for Medicare Services, Effective January 1, 2020. Chapter 11, Section U Evaluation & Management Services

Other

• American Academy of Professional Coders (AAPC). Evaluation and Management Coding, E/M Codes. Evaluation and Management Coding, E/M Codes – AAPC
• American Medical Association (AMA), Current Procedural Terminology (CPT) Manual, Professional Edition (2023)
• Centers for Medicare and Medicaid Services (CMS). Coronavirus Disease (COVID-19) Emergency Declaration Blanket Waivers for Health Care Providers. Updated October 13, 2022. COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (cms.gov)
• CMS Medical Learning Network (MLN) MM12982. Medicare Physician Fee Schedule Final Rule Summary: CY 2023. Effective January 1, 2023. Retrieved from MM12982 – Medicare Physician Fee Schedule Final Rule Summary: CY 2023 (cms.gov)
• Office of Inspector General (OIG) Report (A-05-24-00009) “Optometrists Billing Services for Medicare Enrollees Residing in Nursing Facilities”

Last Updated Jul 10, 2026