01-047 Electrodiagnostic Testing Axial Muscles and Spinal Levels Notification of Medical Review

Noridian Healthcare Solutions, LLC, 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 Electrodiagnostic (EDX) Testing Axial Muscles and Spinal Levels billed on dates of service from January 1, 2019 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

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.

Noridian Healthcare Solutions, LLC (Noridian) as the current Supplemental Medical Review Contractor (SMRC), was previously directed in 2018 to perform data analysis and medical record review activities for claims billed during 2017. The SMRC performed medical record review and found an overpayment rate of 58% for the project. Based on medical review findings, additional medical record reviews were recommended for EDX claims where CPT codes 95887 and 95886 were billed together during calendar year 2019.

Reason for Review

Based on SMRC findings, CMS directed medical review of EDX claims where CPT codes 95887 and 95886 were billed together during calendar year 2019. Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory, and sub-regulatory 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/> 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. Physician/Non Physician (NPP) order or evidence of intent to order
  2. History and physical
  3. Diagnostic tests and results
  4. Medical record documentation that describes in detail the underlying medical condition, treatment interventions, and effectiveness of the treatment
  5. Documentation to support severe peripheral involvement
  6. Reason and result for the Nerve Conduction Study
  7. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  8. All relevant documentation to 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
  9. Documentation to detail the number of and specific limbs or areas tested
  10. Documentation providing the latency, amplitude, configuration and conduction velocity diagnostic testing results
  11. Interpretive statement, which specifically explains the test results and how it will be used in the beneficiary’s care
  12. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  13. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  14. 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
  15. Signature attestation and credentials of all personnel providing services

References/Resources

  • Social Security Act (SSA), Title XVIII, §§1833(e). Payment of Benefits.
  • SSA, Title XVIII, §§1835(2)(B). Procedure for Payment of Claims of Providers of Services.
  • SSA, Title XVIII, §§1861(aa)(2)(G). Definitions of Services, Institutions, Etc.
  • SSA, Title XVIII, §§1862(a)(1)(a). Exclusions from Coverage and Medicare As Secondary Payer.
  • SSA, Title XVIII, §§1879 (a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • SSA, Title XVIII, §§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.
  • 42 C.R. §410.32(2)(i). Order by physician or non-practicitioner must maintain documentation of medical necessity
  • 42 C.R. §424.5(a)(6). Basic Conditions
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80. Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80.6-80.6.4. Requirements for Ordering and Following Orders for Diagnostic Tests.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.3. Use and Acceptance of HCPCS Codes and Modifiers.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23, Section 20.4. Deleted HCPCS Codes/Modifiers.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 50. Routine Notice Prohibition (ABN).
  • CMS IOM, Publication 100-04, 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 3.3.2.4. Signature Requirements.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8. No Response of Insufficient Response to Additional Documentation. Requests.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2. Medical Review Guidance.
  • 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.
  • Local Coverage Determination (LCD) L34594: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L34859: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L35048: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L35081: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L35098: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L35897: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCD L36524: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present.
  • LCD L36526: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present.
  • Local Coverage Article (LCA) A54095: Nerve Conduction Studies and Electromyography. Effective 10/01/2015-present.
  • LCA A54969: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present.
  • LCA A54992: Nerve Conduction Studies and Electromyography. Effective 06/01/2016-present.
  • LCA A56035: Nerve Conduction Studies and Electromyography revision to Part A and Part B LCD. Effective 05/31/2018-present.
  • LCA A56619: Nerve Conduction Studies and Electromyography. Effective 06/13/2019-present.
  • LCA A57037: Nerve Conduction Studies and Electromyography. Effective 09/26/2019-present.
  • LCA A57123: Nerve Conduction Studies and Electromyography. Effective 10/03/2018-present.
  • LCA A57478: Nerve Conduction Studies and Electromyography. Effective 10/31/2019-present.
  • LCA A57668: Nerve Conduction Studies and Electromyography. Effective 11/21/2019-present.
  • LCA A58319: Nerve Conduction Studies and Electromyography – revision to the Part A and Part B billing and coding article. Effective 10/03/2018-present.

Last Updated Jun 10, 2021