01-057 Potentially Unnecessary Surgeries 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 of A laparoscopic total hysterectomy claims billed on dates of service from January 1, 2020 through December 31, 2020. 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 coverage for hysterectomies, sterilizations and related surgeries is limited to those performed as a necessary part of the treatment of an illness or injury, such as the removal of diseased ovaries, uterus, or testes due to malignancy. However, when the primary indication for these procedures is sterilization, they are not medically necessary and are non-covered under Medicare.

The SMRC identified a potential vulnerability for claims billed with Current Procedural Terminology (CPT) code 58571, laparoscopic total hysterectomy for uterus 250g or less.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of laparoscopy total hysterectomy for uterus 250g or less claims. The SMRC will perform medical record review on supporting documentation to determine if the hysterectomy was reasonable and necessary.

Claim Sample Detail

TOB CPT
13x 58571 – Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s)

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. The documentation requested has been made specific, to assist the provider in collecting and submitting pertinent information to decrease provider burden. Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.

  1. Practitioner, nurse, and ancillary progress notes
  2. History and Physical reports (include medical history and current list of medications)
  3. Preoperative evaluations including anesthesia evaluation
  4. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  5. Operative/procedure report
  6. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  7. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  8. Advance Beneficiary Notice of Liability (ABN); if applicable
  9. Any other supporting documentation
  10. 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
  11. PLEASE NOTE: It is the responsibility of the supplier or provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met

References/Resources

  • Social Security Act (SSA) Title XVIII, Section 1812. Scope of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1815(a). Payment to Providers of Services.
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
  • Social Security Act (SSA) Title XVIII, Section 1833(t). Prospective Payment System for Hospital Outpatient Department Services.
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer.
  • Code of Federal Regulations Title 42, Section 410.28 Hospital or CAH Diagnostic Services Furnished to Outpatient’s: Conditions.
  • Code of Federal Regulations Title 42, Section 32 (d)(2) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  • Code of Federal Regulations Title 42, Section 64 Additional preventive services.
  • Code of Federal Regulations Title 42, Section 411.15(k)(1). Particular services excluded from coverage.
  • Code of Federal Regulations Title 42, Section 416. Ambulatory surgical services.
  • Code of Federal Regulations Title 42, Section 424.5(a)(6). Basic conditions.
  • Medicare National Coverage Determinations (NCD) Manual, Publication 100-03, Chapter 1, Part 4, Section 230.3.
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 6, Section 20. Hospital Services Covered Under Part B.
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary.
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 23, Section 10. Reporting ICD Diagnosis and Procedure Codes.
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2. Time Frames for Submission.
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on Which to Base a Determination.
  • 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 3.6.2.1. Coverage Determinations.
  • 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 3.6.2.3. Limitation of Liability Determinations.
  • Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.6.2.5. Denial Types.

Last Updated Apr 7, 2022