01-060 E&M No Response Providers DME Part II Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid Services (CMS), is conducting post-payment review of claims for Medicare Part B 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

In 2020, the SMRC completed medical review project 01-021 No Response Providers for DME/DTS Part I, which reviewed the ordering and dispensing of diabetic test strips (DTS) and lancets. The results of this review identified numerous referring providers that did not respond to supplier requests for additional documentation. Failure to respond to a supplier’s request for additional documentation may represent a potential vulnerability.

For purposes of this project, the SMRC shall perform review of traditional Evaluation and Management (E&M) services for those referring provider National Provider Identifiers (NPIs) that did not respond to supplier requests for additional documentation.

Reason for Review

The SMRC is tasked with performing claim review on a sample of Evaluation and Management Services from January 1, 2019 through December 31, 2019. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

POS CPT
11,19,22,49 99202-99205 (E/M office visit for new patient)
99211-99215 (E/M office visit for established patient)

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 collection 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. Physician, Practitioner, nurse, and ancillary progress notes
  2. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  3. Documentation to support time in/out or actual time spent
  4. Office visit/E&M documentation if billed on same date of service under medical review
  5. Documentation to support the level of evaluation and management service billed to include beneficiary history, examination, provider medical decision making, counseling, coordination of care, nature of presenting problem and time spent when the code is based on duration of visit
  6. All records that justify and support the level of care received
  7. Outcomes assessment, treatment plan, medical plan of care, vital sign records, and weight sheets
  8. Review of beneficiary prior and current medical and functional conditions and comorbidities
  9. Documented pharmacologic management to include prescription and dosage adjustment/changes
  10. Medical record documentation to support the dates of service billed on the claim
  11. Documentation to support the code(s) and modifier(s) billed
  12. Beneficiary’s medical records (which may include; practitioner medical records, hospital records, nursing home records, home care nursing notes, prior course of treatment, physical/occupational therapy notes, including all interventions and/or evaluations) that support the item(s) provided is/are reasonable and necessary
  13. Any other supporting documentation
  14. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  15. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  16. Signature attestation and credentials of all personnel providing services
  17. 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
  18. 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, Section 1833(e). Payment of Benefits
  • SSA Title XVIII, Section 1861 (s)(2)(w) and 1861(ww). Medical and other Health Services
  • SSA Title XVIII, Section 1861 (s)(2)(FF) and 1861 (hhh). Medical and other Health Services
  • SSA Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • SSA Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • SSA Title XVIII, Section 1893(b). Medicare Integrity Program.
  • SSA Title XVIII, Section 1815(a). Payment to Providers of Services.
  • Code of Federal Regulations (CFR) Title 42, Section 482.24(c)(1). Condition of Participation: Medical Record Services.
  • 42 C.F.R., Section 424.5(a)(6). Basic Conditions
  • 42 C.F.R., Section 411. Exclusions from Medicare and Limitations on Medicare Payment
  • 42 C.F.R., Sections 411.15 (a)(1) and 411.15(k)(l). Particular Services Excluded from Coverage.
  • 42 C.F.R.,Section 424.535. Revocation of enrollment in the Medicare Program.
  • 42 C.F.R, Section 410.32. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions.
  • 42 C.F.R, Section 410.16. Initial Preventive Physical Examination: Conditions for and limitations on coverage.
  • 42 C.F.R, Section 410.15. Annual Wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage.
  • 42 C.F.R, Section 410.20. Physician Services
  • 42 C.F.R, Section 410.74. Physician Assistants’ Services
  • 42 C.F.R, Section 410.75. Nurse Practitioners’ Services
  • 42 C.F.R, Section 410.134. Provider Qualifications
  • CMS Internet Only Manual (IOM), Medicare Program Integrity Manual 100-08, Chapter 6, Section 6.8 Medical Review of Evaluation and Management (E/M) Documentation
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.9. Documentation in the Patient’s Medical Record
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.11. Evidence of Medical Necessity
  • 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 3.2.3.8(A). Additional Documentation Requests.
  • CMS IOM, Publication 100-08, Chapter 3, Medicare Program Integrity Manual, 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 3.3.2.4. Signature Requirements.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination.
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Sections 3.6.2.4 and 3.6.2.5. Denial Types
  • 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 3, Section 3.6.2.1. Coverage Determinations
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual,Chapter 1, General Billing Requirements.
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, section 30.6. Evaluation and Management Service Codes – General (Codes 99201 – 99499)
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 23-Fee Schedule Administration and Coding Requirements
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 10. General Exclusions form Coverage.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 50.4.3 Examples of Not Reasonable and Necessary.
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60. Services and Supplies
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60.1-60.3. Incident to Physician’s Professional Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services
  • CMS 1995 Documentation Guidelines for E&M services
  • CMS 1997 Documentation Guidelines for E&M services
  • Evaluation and Management Coding, E/M Codes-AAPC
  • Evaluation and Management Services Guide Booklet
  • Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List effective January 1, 2019

Last Updated Feb 16, 2022