01-005 Spinal Fusion Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Part A services billed on dates of service from January 1, 2017, through December 31, 2017. 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

Prior CMS directed medical review activities focused on Medicare Severity Diagnosis Related Group (MS-DRG) codes for spinal fusion (MS-DRG 459 spinal fusion, except cervical spine, with major complication or comorbidity [MCC] and MS-DRG 460 spinal fusion, except cervical spine, without MCC). Medical review was performed and further medical review activities were anticipated.

Reason for Review

As a follow-up to the results of that project, the CMS has requested the SMRC to perform medical record review activities on DRGs 459 and 460. The selection of providers for this project was determined through data analysis. Providing additional documentation for each claim is authorized by CMS and is being requested.

Claim Sample Detail

Revenue Code MS-DRG
0001
  • 459: Spinal fusion except cervical w MCC
  • 460: Spinal fusion except cervical w/o MCC

Access related project details below.

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 medical record review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Office notes/hospital record, including history and physical by the attending/treating surgeon
  2. Documentation of the history and duration of unsuccessful conservative therapy (non-surgical medical management as applicable)
  3. Records sufficient to document failed non-surgical medical management to include, but not limited to the following:
    1. Documentation to support activity modifications and exercises or explanation why these could not be completed
    2. Documentation and clinical notes to support supervised skilled physical therapy (PT) and/or occupational therapy (OT) for support of activities of daily living (ADLs) diminished despite completing a plan of care or explanation why these could not be completed
    3. Documentation to support the trial of anti-inflammatory medications, oral or injection therapy as appropriate, and analgesics, or explanation why these could not be used
  4. Interpretation and reports for X-rays, MRI’s, CT’s, etc.
  5. Medical clearance reports (as applicable)
  6. Complete operative report(s)

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare As Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Social Security Act (SSA) Title XVIII, Section 1893(f)(7)(A)(B)(i-iv). Medicare Integrity Program
  • Social Security Act (SSA) Title XVIII, Section 1893(h)(4)(B). Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6). Basic conditions
  • CFR Title 42, 482.24 (c)(1). Condition of participation: Medical record services
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services Not Reasonable and Necessary
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.1. Coverage Determinations
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8 B/C. No Response or Insufficient Response to Additional Documentation Requests
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on Which to Base a Determination
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4. Signature Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3 Section 3.4.1.3. Diagnosis Code Requirements
  • Local Coverage Determination (LCD) L33382: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. Effective 01/01/2017-09/30/2017
  • Local Coverage Determination (LCD) L33382: Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. Effective 10/01/2017-12/31/2017
  • Local Coverage Determination (LCD) L35942: Fusion for Degenerative Joint Disease of the Lumbar Spine. Effective 10/01/2015-02/16/2017
  • Local Coverage Determination (LCD) L35942: Fusion for Degenerative Joint Disease of the Lumbar Spine. Effective 02/17/2017-01/28/2018

Last Updated Jan 17, 2019