01-031 DRG Thyroid, Parathyroid and Thyroglossal Procedures Notification of Medical Review

Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare and Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part A claims that include thyroid, parathyroid and/or thyroglossal procedures, billed on dates of service from July 1, 2018 through December 31, 2019. 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

Medicare severity diagnosis related group (MS-DRG) is a system used to classify various diagnoses and procedures for inpatient hospital stays so that Medicare can accurately reimburse the hospital under the inpatient prospective payment system (IPPS). In 2018, the Comprehensive Error Rate Testing (CERT) Medicare Fee-for-Service Improper Payment Report noted an improper payment rate of 49.1% for thyroid, parathyroid and thyroglossal procedure MS-DRGs.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and DRG validation review. Noridian will complete a coding review for DRG validation on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

TOB MS-DRG
11X: Hospital Inpatient Part A
  • 625: Thyroid, Parathyroid & Thyroglossal Procedures with MCC
  • 626: Thyroid, Parathyroid & Thyroglossal Procedures with CC
  • 627: Thyroid, Parathyroid & Thyroglossal Procedures without  CC/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 review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Medical notes to support the beneficiary’s medical condition and procedure for the billed service, including, but not limited to:
    1. Admission notes
    2. History and Physical
    3. Progress notes
    4. Discharge summary
    5. Procedure notes
    6. Consultations
  2. Full detailed itemization of services, including diagnosis codes
  3. Physician Orders to support procedure being billed
  4. Lab / Diagnostic reports
  5. Legible handwritten Physician and/or Clinician signatures
    1. Signature Attestation and Signature Log should be submitted when Physician or Clinician signatures are illegible
  6. Valid electronic physician and/or clinician signatures
  7. Advance Beneficiary Notice of Noncoverage (ABN), if applicable
  8. Any and all other documentation to support the service(s) billed

References/Resources

  • Social Security Act (SSA) Title XVIII, §1812. Scope of Benefits
  • SSA, Title XVIII, §1815(a). Providers must furnish information
  • SSA, Title XVIII, §1833(e). Payment of Benefits
  • SSA, Title XVIII, §1862(a)(1)(a). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §1886. Payment to Hospitals for Inpatient Hospital Services
  • SSA, Title XVIII, §1879. Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Code of Federal Regulations (CRF) Title 42, 412.1(a)(1). Scope of Part
  • CFR, Title 42, 412.2. Basis of payment
  • CFR, Title 42, 424.5(a)(6). Basic conditions
  • CFR, Title 42, 424.24(c)(1). Condition of participation: Medical record services
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual Chapter 23, Section 10.2. Inpatient Claim Diagnosis Reporting
  • CMS IOM, , Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.4.1.3. Diagnosis Code Requirements
  • 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 3.6.2.4. Coding Determinations
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 3, Section 3.6.2.5. Denial Types
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 6, Section 6.5.3. DRG Validation Review
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual Chapter 6, Section 6.5.4. Review of Procedures Affecting the DRG

Last Updated Oct 23, 2020