01-067 Echocardiography Notification of Medical Review

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

An echocardiogram (ECHO) is an ultrasound of the heart. It is a type of medical imaging using ultrasound (high-frequency sound waves) to generate images of the heart’s valves and chambers and helps evaluate the pumping action of the heart.

Medicare does not cover ECHOs performed with equipment that provides limited evaluations. Such evaluations typically do not provide a permanent image and complete interpretation is not performed. These tests have demonstrated value in screening-type evaluations, although they are then considered part of the physician’s exam, similar to a BP measurement and are not separately payable under Medicare.

Symptoms or an existing condition must be present to meet coverage criteria and support payment for an ECHO. ECHO performed for screening purposes is not covered. Screening includes testing performed on patients who present with risk factors (including the risk factor such as having a positive family history, e.g., familial history of Marfan’s disease).We note that screening for high-risk patients is not covered by Medicare.

Reason for Review

The SMRC is tasked with performing claim review on a sample of echocardiography claims 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

CPT Description
93306 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography
93307 Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, without spectral or color Doppler echocardiography

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. Echocardiogram report
  3. Interpretation of the report of all segments of the service
  4. Necessity of the test frequency, when applicable
  5. Physician, Practitioner, nurse, and ancillary progress notes
  6. Trans Thoracic Echocardiogram (TTE) report
  7. Summary report at the end of the monitoring episode
  8. Documentation to support the diagnosis code(s) and modifier(s) billed
  9. Medical record documentation to support the dates of service billed on the claim
  10. Documentation to support the specific reason for the study
  11. History and Physical reports (include medical history and current list of medications)
  12. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  13. List of all non-standard abbreviations or acronyms used, including definitions
  14. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services
  15. Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)
  16. Any other supporting documentation
  17. 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
  18. PLEASE NOTE: It is the responsibility of the 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, § 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, § 1879(a)(1). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • Code of Federal Regulations (CFR) Title 42, § 410.32. Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
  • CFR Title 42, § 410.64. Additional Preventative Services
  • CFR Title 42, § 411.15(k)(1). Particular services excluded from coverage
  • CFR Title 42, § 424.5. Basic Conditions
  • CFR Title 42, § 482.24(c)(1). Conditions of Participation: Medical Record Service
  • Medicare National Coverage Determinaiton Manual (NCD), Publication 100-03, Chapter 1, Part 4, §220.5. Ultrasound Diagnostic Procedures
  • Medicare Benefit Policy Manual (MBPM) Publication 100-02, Chapter 6, § 20.4. Outpatient Diagnostic Services
  • MBPM, Chapter 15, § 80. Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests
  • MBPM, Chapter 16, § 20. Services Not Reasonable and Necessary
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 13, §10.1. Billing Part B Radiology Services and Other Diagnostic Procedures
  • MCPM, Chapter 13, §20. Payment Conditions for Radiology Services
  • MCPM, Chapter 23, § 20.9. National Correct Coding Initiative (NCCI)
  • MCPM, Chapter 30, § 30.2. Healthcare Provider or Supplier Knowledge and Liability
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, § 3.2.3.2. Time Frames for Submission
  • PIM, Chapter 3, § 3.2.3.3. Third-party Additional Documentation Request
  • PIM, Chapter 3, § 3.2.3.8(A). Additional Documentation Requests
  • PIM, Chapter 3, § 3.3.2.4. Signature Requirements
  • PIM, Chapter 3, § 3.6.2.1. Coverage Determinations
  • PIM, Chapter 3, § 3.6.2.2. Reasonable and Necessary Criteria
  • PIM, Chapter 13, § 13.5.4. Reasonable and Necessary Provisions in LCDs
  • Local Coverage Determination (LCD) L37379, Echocardiography
  • LCD L34338, Transthoracic Echocardiography (TTE)
  • LCD L33768, Transthoracic Echocardiography (TTE)
  • LCD L33577, Transthoracic Echocardiography (TTE)
  • Local Coverage Article(LCA) A56625, Billing and Coding: Echocardiography
  • LCA A57306, Billing and Coding: Transthoracic Echocardiography (TTE)
  • LCA A57182, Billing and Coding: Transthoracic Echocardiography (TTE)
  • LCA A56781, Billing and Coding: Transthoracic Echocardiography (TTE)

Last Updated Apr 4, 2022