01-008 Electrodiagnostic Testing 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 Medicare Part B electrodiagnostic testing 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

The Office of Inspector General (OIG), under report OEI-04-12-00420 titled: “Questionable Billing for Medicare Electrodiagnostic Tests” dated April, 2014, found that in 2011, Medicare paid approximately $486 million to 21,700 physicians who billed for electrodiagnostic tests for 877,000 beneficiaries. Per the OIG, 4,901 physicians had questionable billing for Medicare electrodiagnostic (EDX) tests totaling $139 million.

Further, per the OIG, in 2011, identified 334 physicians billed for an unusually high average number of electrodiagnostic tests for the same beneficiary on the same day. Those claims accounted for $20 million of the 2011 payments for EDX tests. In addition, it was noted that 907 physicians billed for an unusually high percentage of electrodiagnostic tests that did not include both Nerve Conduction Testing (NCT) and a needle electromyography (EMG) test. These claims accounted for $19 million of the 2011 payments for electrodiagnostic tests. Upon analysis of their data, the OIG also noted that physicians in the New York, Los Angeles, and Houston metropolitan areas had the highest total questionable billing for Medicare EDX tests in 2011.

Reason for Review

In response to the OIG report, CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review.  Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory and subregulatory guidance.

Claim Sample Detail

CPT
  • 95907: Nerve conduction test 1-2 studies
  • 95908: Nerve conduction test 3-4 studies
  • 95909: Nerve conduction test 5-6 studies
  • 95910: Nerve conduction test 7-8 studies
  • 95911: Nerve conduction test 9-10 studies
  • 95912: Nerve conduction test 11-12 studies
  • 95913: Nerve conduction test 13 or more studies
  • 95885: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited
  • 95886: Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels
  • 95887: Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction, amplitude and latency/velocity study

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

  1. Documentation to support medical necessity for the services billed. This should include History and Physical, office notes, operative report (if applicable), interpretation of test results, any additional documentation to support procedures ordered and/or performed
  2. Documentation to support the need to evaluate the beneficiary for peripheral neuropathy
  3. Documentation to support a nerve conduction study without EMG, if applicable
  4. All relevant documentation that may support having exceeded the parameters of number of tests and frequency, as established by your LCD and/or by the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines, if applicable
  5. Documentation to detail the number of limbs or areas tested
  6. Documentation providing the latency, amplitude, configuration and conduction velocity diagnostic testing results
  7. Treating physician order or documentation to support the intent to order
  8. Medical documentation to support the treating physician used the results in the management of the beneficiary’s specific medical condition
  9. Advance Beneficiary Notice (ABN), if applicable
  10. Valid clinician signatures
  11. Signature Attestation and Signature Log should be submitted when Physician or Clinician signatures are illegible

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act, Title XVIII, Section §1835(2)(B). Procedure for Payment of Claims of Providers of Services
  • Social Security Act, Title XVIII, Section §1861(aa)(2)(G). Definitions of Services, Institutions, Etc.
  • 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 (b). Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 42, Section 410.32(a). Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 80. Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 15, Section 80.6-80.6.4. Requirements for Ordering and Following Orders for Diagnostic Tests
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 23, Section 20.3. Use and Acceptance of HCPCS Codes and Modifiers
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 23, Section 20.4. Deleted HCPCS Codes/Modifiers
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.8. No Response of Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2. Medical Review Guidance
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.4. Coding Determinations
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 30, Section 40.3.6. Routine Notice Prohibition
  • Local Coverage Determination (LCD) L35897: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L34859: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L35098: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L36524: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present
  • Local Coverage Determination (LCD) L36526: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present
  • Local Coverage Determination (LCD) L35081: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L34265: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-01/29/2018
  • Local Coverage Determination (LCD) L35048: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Determination (LCD) L34594: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Article A54095: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Article A54969: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
  • Local Coverage Article A54992: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
  • Local Coverage Article A54159: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present
  • Local Coverage Article A54990: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present
  • Local Coverage Article A54991: Nerve Conduction Studies and Electromyography. Effective 10/01/2016-present

 

Last Updated Feb 20, 2019