01-054 Carotid Artery Screening/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 carotid artery screening/testing 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 Centers for Medicare and Medicaid Services (CMS) issued a Project Authorization Form (PAF) on June 8, 2021 to Noridian Healthcare Solutions, LLC (Noridian) as the current Supplemental Medical Review Contractor (SMRC), to conduct data analysis and related medical review activities on carotid artery testing/screening. Medicare Part B covers carotid artery testing in certain circumstances for select indications. Non-invasive vascular studies done for screening purposes (i.e., without signs or symptoms of disease) are considered not reasonable and necessary and are therefore non-covered by Medicare.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical review on carotid artery screening/testing claims. Noridian will complete medical review on a sample of claims related to carotid artery screening/testing services. The SMRC will conduct reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

CPT
  • 93880: Duplex scan of extracranial arteries; complete bilateral study
  • 93882: Duplex scan of extracranial arteries; unilateral or limited 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. PLEASE NOTE: It is the responsibility of the billing provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met
  2. Physician/Non-Physician (NPP) order or evidence of intent to order
  3. Documentation that supports the clinical significance of the test performed
  4. Cardiac Risk Factors Assessment
  5. Diagnostic/Vascular studies
  6. Documentation supporting the diagnosis code(s) required for the item(s) billed
  7. Medical record documentation to support the dates of service billed on the claim
  8. History and Physical reports (include medical history and current list of medications)
  9. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  10. Any other supporting documentation
  11. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  12. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  13. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  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. 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/Resources

  • Social Security Act (SSA) Title XVIII, §1815(a). Payment to Providers of Services.
  • SSA, Title XVIII, §1833(e). Payment of Benefits.
  • SSA, Title XVIII, §1842(p)(4). Provisions Relating to the Administration of Part B.
  • SSA, Title XVIII, §1861(ddd). Preventive Services.
  • SSA, Title XVIII, §1862(a)(1)(A). Exclusion from Coverage and Medicare as a 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.
  • 42 Code of Federal Regulations (C.F.R.) 410.32. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions.
  • 42 C.F.R. 410.64. Additional Preventative Services.
  • 42 C.F.R. 411.15(k)(1). Particular services excluded from coverage.
  • 42 C.F.R. 424.5. Basic Conditions.
  • 42 C.F.R. 424.535. Revocation of enrollment in the Medicare Program.
  • 42 C.F.R. 482.24(c)(1). Conditions of Participation: Medical Record Service.
  • CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 20.4. Outpatient Diagnostic Services.
  • CMS 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 16, Section 20. General Exclusions from Coverage.
  • CMS IOM, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Section 20.17. Noninvasive Tests of Carotid Function.
  • CMS IOM, Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 220.5. Ultrasound Diagnostic Procedures.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 13, Section 1. Billing Part B Radiology Services and Other Diagnostic Procedures.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 2. Healthcare Provider or Supplier Knowledge and Liability.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2. Time Frames for Submission.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.3. Third-party Additional Documentation Request.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(A). Additional Documentation Requests.
  • 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.
  • 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 13, Section 13.5.4. Reasonable and Necessary Provisions in LCDs.
  • Local Coverage Determination (LCD) L34045. Non-Invasive Vascular Studies. Effective October 1, 2015-present
  • LCD L33695. Non-Invasive Extracranial Arterial Studies. Effective October 1, 2015-present
  • LCD L33627. Non-Invasive Vascular Studies. Effective October 1, 2015-present
  • LCD L34221. Noninvasive Cerebrovascular Studies. Effective October 1, 2015-May 11, 2020.
  • LCD L35397. Non-Invasive Cerebrovascular Arterial Studies. Effective October 1, 2015-present
  • LCD L35753. Non-Invasive Cerebrovascular Studies. Effective October 1, 2015-present
  • Local Coverage Article (LCA) A56697. Billing and Coding: Non-Invasive Vascular Studies. Effective July 11, 2019-present
  • LCA A57670. Billing and Coding: Non-Invasive Extracranial Arterial Studies. Effective October 3, 2018-present
  • LCA A56758. Billing and Coding: Non-Invasive Vascular Studies. Effective August 1, 2019-present
  • LCA A57199. Billing and Coding: Noninvasive Cerebrovascular Studies. Effective October 1, 2015- May 11, 2020.
  • LCA A52992. Billing and Coding: Non-Invasive Cerebrovascular Arterial Studies. Effective October 1, 2015-present
  • LCA A57592. Billing and Coding: Non-Invasive Cerebrovascular Studies. Effective November 1, 2019-present
  • Medicare Learning Network, MLN Matters SE1419. Medicare Signature Requirements – Educational Resources for Health Care Professionals.
  • Medicare Learning Network, MLN Matters MM6563. Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs).

Last Updated Jul 26, 2021