01-069 Treatment of Chronic Venous Insufficiency 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 treatment of chronic venous insufficiency 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

Chronic Venous Insufficiency (CVI) is a cause of abnormalities of the venous system producing edema, skin changes, or venous ulcers and may be associated with varicose veins. Varicose veins of the lower extremities are a manifestation of chronic venous disease (CVD). Varicose veins may be caused by primary venous disease with local or multifocal structural weakness of the vein wall leading to valvular insufficiency or valvular reflux.

Venous valvular insufficiency results in dilated, tortuous, superficial vessels that protrude from the skin of the lower extremities. Venous insufficiency and varicosities may cause painful lesions in the lower extremities due to its effect on the skin and adjacent tissue, resulting in inflammation, ulceration, hemorrhage, skin deterioration, and recurrent phlebitis, affecting disability and deterioration of health-related quality of life.

Vein Ablation services consist of four treatment modalities: Endoluminal Radiofrequency Ablation (ERFA), Mechanochemical Vein Ablation, Laser Vein Ablation, and Transcatheter Chemical Adhesive Ablation.

Medicare covers items and services that are reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member. Medicare does not provide coverage for cosmetic surgery.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of chronic venous insufficiency claims. The SMRC will perform medical record review on supporting documentation to determine if vein ablation was reasonable and necessary.

Claim Sample Detail

POS CPT
24 – Ambulatory Surgical Center 36465, 36466, 36470, 36471, 36473, 36474, 36475. 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780

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. History and Physical reports (include medical history and current list of medications)
  2. Documentation of presurgical conservative measures/treatments
  3. Physician/Non-Physician (NPP) Admission Orders
  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 1833(e). Prohibits Medicare payment for any claim which lacks the necessary information to process the claim.
  • SSA Title XVIII, Section 1862 (a) (7). Excludes routine physical examinations and services.
  • SSA Title XVIII, Section 1862(a)(1)(a). Allows coverage and payment for only those services that are considered to be reasonable and necessary.
  • SSA Title XVIII, Section 1862(a)(10). No payment may be made under part A or part B for any expenses incurred for items or services where such expenses are for cosmetic surgery or are incurred in connection therewith, except as required for the prompt repair of accidental injury or for improvement of the functioning of a malformed body member.
  • SSA Title XVIII, Section 1879 (a)(1). Payments will not be made to the provider if it was determined the service did not meet coverage criteria and liability will remain with the provider.
  • Code of Federal Regulations (CFR) Title 42, Section 411.15(k)(1). Services Excluded from Coverage.
  • CFR Title 42, Section 424.5(a)(6). Sufficient Information.
  • Medicare National Coverage Determinations Manual (MNCDM), Pub. No. 100-03, Chapter 1 Coverage Determinations, Part 4, Section 220.5. Ultrasound Diagnostic Procedures.
  • Medicare Benefit Policy Manual (MBPM), Pub. No. 100-02, Chapter 15, Covered Medical and Other Health Services; Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests.
  • MBPM, Pub. No. 100-02, Chapter 16, General Exclusions from Coverage and Section 20, Services Not Reasonable and Necessary.
  • MBPM, Pub. No. 100-02, Chapter 16, General Exclusions from Coverage and Section 120, Cosmetic Surgery.
  • Medicare Program Integrity Manual (MPIM), Pub. No. 100-08, Chapter 13 Local Coverage Determinations, Section 13.5.4 Reasonable and Necessary Provision in an LCD.
  • MPIM, Pub. No. 100-08, Chapter 3, Section 3.6.2.2. Reasonable and Necessary Criteria.
  • MPIM, Pub. No. 100-08, Chapter 3, Section 3.4.1.3 Diagnosis Code Requirements.
  • MPIM, Pub. No. 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • MPIM, Pub. No. 100-08, Chapter 3, Section 3.2.3.8. The requested records were not received.
  • Local Coverage Determination (LCD) L33454, Varicose Veins of the Lower Extremities.
  • LCD L33575, Treatment of Varicose Veins of the Lower Extremity.
  • LCD L33762, Treatment of Varicose Veins of the Lower Extremity.
  • LCD L34010, Treatment of Varicose Veins of the Lower Extremity.
  • LCD L34082, Varicose Veins of the Lower Extremity, Treatment of
  • LCD L34209, Treatment of Varicose Veins of the Lower Extremity.
  • LCD L34536, Treatment of Varicose Veins of the Lower Extremities.
  • LCD L34924, Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities.
  • LCD L3870, Treatment of Chronic Venous Insufficiency of the Lower Extremities.
  • Local Coverage Article (LCA) A52870, Billing and Coding: Treatment of Varicose Veins of the Lower Extremity.
  • LCA A55229 Treatment of Chronic Venous Insufficiency of the Lower Extremities.
  • LCA A56368, Billing and Coding: Varicose Veins of the Lower Extremities.
  • LCA A56914, Billing and Coding: Treatment of Varicose Veins of the Lower Extremities.
  • LCA A57305, Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of
  • LCA A57706, Billing and Coding: Treatment of Varicose Veins of the Lower Extremity.
  • LCA A57707, Billing and Coding: Treatment of Varicose Veins of the Lower Extremities.
  • LCA A57781, Billing and Coding: Treatment of Varicose Veins of the Lower Extremity.
  • LCA A58250, Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities.

Last Updated Feb 24, 2022