01-062 EDX Diabetes Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for CMS, is conducting post-payment review of claims for Medicare electrodiagnostic diabetes tests 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.

In 2018, Noridian Healthcare Solutions, LLC (Noridian) as the current Supplemental Medical Review Contractor (SMRC), performed medical record review on supporting documentation to determine if the EDX testing was reasonable and necessary. An overpayment rate of 58% was found for the project. It also determined that 75% of the EDX claims billed with a diabetes diagnosis code were denied.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record reviews on EDX test claims billed with a diabetes diagnosis. This is to determine if the EDX test was reasonable and medically necessary, and to determine if submitted documentation supports the claim as billed. Noridian will complete medical record review on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

ICD-10 CPT
Diabetes: E08.00 – E13.9 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

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/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. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  13. Advance Beneficiary Notice of Liability (ABN); if applicable
  14. Any other supporting documentation
  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
  16. PLEASE NOTE: It is the responsibility of the supplier/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 1815(a). Payment to Providers of Service
  • Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section 1835(2)(B). Procedure for Payment of Claims of Providers of Services
  • Social Security Act (SSA) Title XVIII, Section 1861(s)(2)(C). Medical and Other Health Services
  • Social Security Act (SSA) Title XVIII, Section 1861(aa)(2)(G). Rural Health Clinic Services and Federally Qualified Health Center Services
  • Social Security Act (SSA) Title XVIII, Section 1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Section 1879(a)(1). Limitation on Liability of Beneficiary Where Medicare Claims are Disallowed
  • Social Security Act (SSA) Title XVIII, Section 1893(b). Medicare Integrity Program
  • Code of Federal Regulations (CFR) Title 42, Sections 410.32(a) and (b). Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
  • Code of Federal Regulations (CFR) Title 42, Section 411.15(k)(1). Particular Services Excluded from Coverage
  • Code of Federal Regulations (CFR) Title 42, Section 424.5(a)(6). Basic Conditions
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 6, Section 20.4. Outpatient Diagnostic Services
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 80. Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 4, Section 10. Hospital Outpatient Prospective Payment System (OPPS)
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 23, Sections 20-20.4. Description of Healthcare Common Procedure Coding System (HCPCS)
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, Section 50. Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.2. Time Frames for Submission
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.3.2. Medical Review Guidance
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.2 Reasonable and Necessary Criteria
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.4 Coding Determinations
  • Medicare Program Integrity Manual (MPIM), Publication 100-08, Chapter 3, Section 3.6.2.5 Denial Types
  • Local Coverage Determination L34594. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L34859. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L35048. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L35081. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L35098. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L35897. Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Determination L36524. Nerve Conduction Studies and Electromyography. Effective June 1, 2016
  • Local Coverage Determination L36526. Nerve Conduction Studies and Electromyography. Effective June 1, 2016
  • Local Coverage Article A54095. Billing and Coding: Nerve Conduction Studies and Electromyography. Effective October 1, 2015
  • Local Coverage Article A54969. Billing and Coding: Nerve Conduction Studies and Electromyography. Effective June 1, 2016
  • Local Coverage Article A54992. Billing and Coding: Nerve Conduction Studies and Electromyography. Effective June 1, 2016
  • Local Coverage Article A56035. Nerve Conduction Studies and Electromyography Revision to the Part A and Part B LCD. Effective May 31, 2018
  • Local Coverage Article A56619. Nerve Conduction Studies and Electromyography. Effective June 13, 2019
  • Local Coverage Article A57123. Nerve Conduction Studies and Electromyography. Effective October 3, 2018
  • Local Coverage Article A57307. Nerve Conduction Studies and Electromyography. Effective
  • September 26, 2019
  • Local Coverage Article A57478. Nerve Conduction Studies and Electromyography. Effective
  • October 31, 2019
  • Local Coverage Article A57668. Nerve Conduction Studies and Electromyography. Effective
  • November 13, 2019
  • Local Coverage Article A58319. Nerve Conduction Studies and Electromyography Revision to the Part A and Part B LCD. Effective October 3, 2018

Last Updated Feb 16, 2022