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 Evaluation and Management (E&M) dermatology services 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

Evaluation and Management (E&M) is described as a service provided by a physician or other qualified healthcare professional that involves evaluating, diagnosing, and treating patient health and related injuries/illnesses. Modifier 25 is appended to the E&M code to identify a significant and separately identified E&M service for the same patient by the same physician on the same day of a procedure or other service.

The Office of Inspector General (OIG) noted that, in 2019, approximately 56% of dermatologists’ E&M claims were appended with the modifier 25 indicating a significant and separately identifiable E&M service when only a minor surgical procedure (such as lesion removals, destructions, and biopsies) was performed on the same day. Per the OIG, an E&M service could be billed on the same day of a minor surgical procedure only if the surgeon performs a significant and separately identifiable E&M service that is unrelated to the decision to perform a minor surgical procedure. This may indicate a potential vulnerability where the provider used modifier 25 to bill Medicare for a significant and separately identifiable E&M service when only a minor surgical procedure and related preoperative and postoperative services are supported by the beneficiary’s medical record.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and conduct medical record review of E&M dermatology claims that also include a minor surgical procedure. The SMRC will conduct medical record reviews in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References/Resources

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, Practitioner, nurse, and ancillary progress notes
2. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
3. Office visit/E&M documentation if billed on same date of service under medical review
4. 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
5. Documentation to support the code(s) and modifier(s) billed
6. Operative/procedure report as well as any documentation to support cutting or paring procedures on the skin
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 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 Services.
• Social Security Act (SSA) Title XVIII, Section 1833(e). Payment of Benefits.
• 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, Sections 1893(b), (f)(7)(A)(B)(i-iv), and (h)(4)(B). Medicare Integrity Program.
• Code of Federal Regulations (CFR) Title 42, Section 410.3. Scope of Benefits.
• Code of Federal Regulations (CFR) Title 42, Section 410.20. Physician Services.
• Code of Federal Regulations (CFR) Title 42, Section 410.74. Physician Assistants’ Services.
• Code of Federal Regulations (CFR) Title 42, Section 410.75. Nurse Practitioners’ Services.
• Code of Federal Regulations (CFR) Title 42, Section 410.134. Provider Qualifications.
• Code of Federal Regulations (CFR), Title 42, Section 424.5(a)(6). Basic Conditions.
• Code of Federal Regulations (CFR), Title 42, Section 482.24(c). Condition of Participation: Medical Record Services.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 6, Section 6.8. Medical Review of Evaluation and Management (E/M) Documentation.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 5, Section 5.9. Documentation in the Patient’s Medical Record.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3.2. Time Frames for Submission.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3. 4. Additional Documentation Request Required and Optional Elements.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No Response or Insufficient Response to Additional Documentation Requests.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on which to Base a Determination.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
• Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6. Determinations Made During Medical Review.
• Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 1. General Billing Requirements.
• Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 30.6. Evaluation and Management Service Codes – General (Codes 99201 – 99499).
• Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 23. Fee Schedule Administration and Coding Requirements.
• Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 30, Section 50. Advance Beneficiary Notice of Non-coverage (ABN).
• American Academy of Professional Coders (AAPC). Evaluation and Management Coding, E/M Codes. Evaluation and Management Coding, E/M Codes – AAPC
• CMS 1995 Documentation Guidelines for Evaluation and Management Services.
• CMS 1997 Documentation Guidelines for Evaluation and Management Services.
• The Centers for Medicare and Medicaid Services (CMS). Medical Learning Network (MLN) ICN MLN006764 February 2021. Evaluation and Management Services Guide.

Last Updated Mar 15, 2022