Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of Medicare Part B claims billed on dates of service from January 1, 2021, through December 31, 2022. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers or suppliers may wish to consult when submitting claims.

Background

Medicare does not cover an echocardiogram (ECHO) performed for screening purposes, including screening for high-risk patients. Symptoms or an existing condition must be present to meet coverage criteria and support payment for an ECHO.
SMRC completed a medical review project which looked at claims with CPT codes 93306, “Ultrasound of heart with color-depicted blood flow, rate, direction and valve function” and 93307, “Chest ultrasound examination of heart” for dates of service in 2019. The SMRC found a final claim error rate of 37% for those claims that were medically reviewed.

Reason for Review

CMS tasked Noridian, as the SMRC, to perform data analysis and medical record review activities on echocardiography, specifically CPT code 93306. The SMRC will perform medical record review on supporting documentation, to determine if select Part B claims for echocardiography select code 93306 were reasonable and necessary. The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

Access related project details below.

• Documentation Requirements
• References

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.

Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review:

• 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.
• Physician/Non-Physician (NPP) order or evidence of intent to order.
• Transthoracic Echocardiogram (TTE) report, including interpretation of the report of all segments of the service and a summary report at the end of the monitoring episode.
• Complete study that contains: M mode and/or 2D measurements of LV end diastolic diameter, LV end systolic diameter, LV wall thickness, left atrial diameter, aortic valve excursion and a qualitative description of the LV function.
• The progress notes from the referring provider describing and supporting the covered indication along with signs and symptoms for the diagnosis code(s) and modifiers billed.
• History and Physical reports (include relevant medical history and current list of medications).
• Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article.
• A list of all non-standard abbreviations or acronyms used, including definitions.
• The signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services).
• An advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC).
• Any other supporting documentation.
• 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

Social Security Act (SSA), Title XI

• § 1135 Authority to Waive Requirements During National Emergencies

Social Security Act (SSA), Title XVIII

• § 1815(a) Payment to Providers of Services
• § 1833(e) Payment of Benefits
• § 1842(p)(4) Provisions Relating to the Administration of Part B
• § 1861(ddd) (1) Additional Preventive Services; Preventive Services
• § 1861(s)(2)(K) Miscellaneous Provisions (Definitions of Services, Institutions, etc.)
• § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer
• § 1879(a)(1) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• § 1893(f)(7)(A)(B) (i-iv), (h)(4)(B) Medicare Integrity Program

42 Code of Federal Regulations (CFR)

• § 410.32 Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
• § 410.33 Independent Diagnostic Testing Facility
• § 410.64 Additional Preventative Services
• § 411.15(k)(1) Particular Services Excluded From Coverage
• § 424.5 Basic Conditions
• § 482.24(c)(1) Condition of Participation: Medical Record Services

Federal Register

• Final Rule Volume 85, No. 66, Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID–19 Public Health Emergency. Effective March 1, 2020. Retrieved from 2020-06990.pdf (govinfo.gov) .
• Interim Final Rule with Comments (IFC) 85 FR 19230. Revisions in Response to the COVID-19 Public Health Emergency (CMS-1744-IFC). Effective March 1, 2020. Retrieved from CMS-1744-IFC .
• Interim Final Rule with Comments (IFC), 5531. Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program. CMS-5531-IFC. Effective March 1, 2020. Retrieved from CMS-55341-IFC .

Public Law

• Coronavirus Aid, Relief, and Economic Security Act. Title III- Supporting America’s Health Care System in the Fight Against the Coronavirus. Subtitle D-Finance Committee, §§ 3710. Medicare Hospital Inpatient Prospective Payment System add-on Payment for Covid-19 Patients During Emergency Period. § 3711. Increasing Access to Post-Acute Care During Emergency Period. January 3, 2020.Retrieved from BILLS-116hr748enr.pdf (congress.gov) .
• Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 (Pub. L. 116-123, March 6, 2020). § 101. Telehealth Services During Certain Emergency Periods Act of 2020. Retrieved from PUBL123.PS (congress.gov) .
• Public Health Service Act, 2021, § 319(e). Telehealth Enhancements for Emergency Response. Enacted June 25, 2022. Retrieved from COMPS-8773.pdf (govinfo.gov) .
• Robert T. Stafford Disaster Relief and Emergency Assistance Act, Pub. L. No. 100-707, 102 Stat. 4689 (1988), Codified as Amended 42. U.S.C. § 5121. Disaster Relief and Emergency Assistance Amendments. May 2021. Retrieved from Stafford Act, as Amended – FEMA P-592 vol. 1 May 2021 .

Internet Only Manual (IOM), Medicare National Coverage Determination Manual (NCD), Publication (Pub). 100-03

• Chapter (Ch). 1, Part 4, §§220.5. Ultrasound Diagnostic Procedures

IOM, Medicare Benefit Policy Manual (MBPM), Pub. 100-02

• Ch. 6, § 20.4 Outpatient Diagnostic Services
• Ch. 15, § 80 Requirements for Diagnostic X-ray, Diagnostic laboratory, and other Diagnostic tests
• Ch. 16, § 20 General Exclusions from Coverage

IOM, Medicare Claims Processing Manual (MCPM), Publication 100-04

• Ch. 13, § 10.1 Billing Part B Radiology Services and Other Diagnostic Procedures
• Ch. 13, § 20 Payment Conditions for Radiology Services
• Ch. 23, § 20.9 National Correct Coding Initiative (NCCI)
• Ch. 30, § 30.2 Healthcare Provider or Supplier Knowledge and Liability
• Ch. 12, §30.4 Cardiovascular System (Codes 92950-93799)

IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08

• Ch. 3, § 3.2.3.2 Time Frames for Submission
• Ch. 3, § 3.2.3.3 Third-party Additional Documentation Request
• Ch. 3, § 3.2.3.4 Additional Documentation Request Required and Optional Elements
• Ch. 3, § 3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests
• Ch. 3, § 3.3.2.1 Documents on which to Base a Determination
• Ch. 3, § 3.3.2.4 Signature Requirements
• Ch. 3, § 3.6.2 Verifying Errors
• Ch. 5, § 5.9 Documentation in the Patient’s Medical Record
• Ch. 5, § 5.11 Evidence of Medical Necessity
• Ch. 13, §13.5.4 Reasonable and Necessary Provisions in LCDs

CMS Coding Policies

• NCCI Policy Manual for Medicare Services, Effective 2022. Chapter V Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT codes 30000-39999. Section D. Cardiovascular System

Local Coverage Determination (LCD)

• L33577 Transthoracic Echocardiography (TTE)
• L33768 Transthoracic Echocardiography (TTE)
• L34338 Transthoracic Echocardiography (TTE)
• L37379 Echocardiography

Local Coverage Article (LCA)

• A56625 Billing and Coding: Echocardiography
• A56781 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57182 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57306 Billing and Coding: Transthoracic Echocardiography (TTE)
• A57807 Billing and Coding: Independent Diagnostic Testing Facility (IDTF)
• A58559 Billing and Coding: Independent Diagnostic Testing Facilities (IDTF)

Other

• CMS. Non-Emergent, Elective Medical Services, and Treatment Recommendations. April 7, 2020. Non-Emergent, Elective Medical Services, and Treatment Recommendations (cms.gov)
• Medicare Learning Network, MLN Matters 905364. Complying with Medicare Signature Requirements. April 2022
• Medicare Learning Network, MLN Matters MM6563. Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices of Noncoverage (ABNs). Effective April 1, 2010.
• Medicare Learning Network, MLN Matters MLN909060. Independent Diagnostic Testing Facilities (IDTF). October 2022

Last Updated Aug 8, 2023