01-310 Right Heart Catheterization 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 Endomyocardial Biopsy with Right Heart Catheterization 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 may wish to consult when submitting claims.

Background

Right heart catheterization (RHC) is the introduction of a catheter(s) into the right atrium, right ventricle, and pulmonary artery. It generally includes hemodynamic measurements and cardiac output determination. It may also include, when medically indicated, shunt determinations, and/or blood sampling, and/or hydrogen arrival time.

RHC for the purpose of monitoring hemodynamic status during an electrophysiologic, other interventional cardiac procedure, or angioplasty is included in that procedure; it is not separately reimbursable. RHC performed solely for the purpose of inserting a temporary pacemaker, performing endomyocardial biopsy or performing electrophysiologic studies is not covered by Medicare.

Modifier 59 is used to indicate that a provider performed a distinct procedure or service for a beneficiary on the same day as another procedure or service. Potential misuse of this modifier represents a potential vulnerability and has been featured in work done by the Office of the Inspector General.

Reason for Review

The SMRC is tasked with performing claim review on a sample of RHC 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 Codes Description
33210 Placement of temporary pacemaker leads, single chamber
37248 Transluminal balloon angioplasty 1st vein
75970 Vascular biopsy
76932 Echo guide for heart biopsy
93451 Right heart cath
93505 Endomyocardial biopsy
93530 Rt heart cath congenital
93602 Intra-atrial recording
93603 Right ventricular recording
93610 Intra-atrial pacing
93612 Intraventricular pacing
93620 Electrophysiology evaluation

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. Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations that support medical necessity for the procedure(s) billed
  3. Beneficiary’s medical records (which may include history and physical and practitioner medical records) to support the medical necessity for the procedure(s) billed
  4. Operative/procedure report
  5. Documentation to support the code(s) and modifier(s) billed
  6. Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  7. If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  8. Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  9. Advance Beneficiary Notice of Liability (ABN); if applicable
  10. Any other supporting documentation
  11. 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
  12. 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 XVI, Section 1138. Hospital protocols for organ procurement and standards for organ procurement agencies.
  • SSA, Title XVIII, Section 1833(e). Providers must furnish information.
  • SSA, Title XVIII, Section 1835(2)(A). Procedure for Payment of Claims of Providers of Services.
  • SSA, Title XVIII, Section 1861(d). Definitions of services by a supplier.
  • SSA, Title XVIII, Section 1861(s)(1). Definitions of services by a physician.
  • SSA, Title XVIII, Section 1861(aa)(2)(G). Definitions of services for routine tests and additional tests.
  • SSA, Title XVIII, Section 1862. Exclusion from Coverage and Medicare as a Secondary Payer.
  • SSA, Title XVIII, Section 1879(a)(1). Limitations on Liability of Beneficiary Where Medicare Claims are Disallowed.
  • SSA, Title XVIII, Section 1893(f)(7)(A)(B)(i-iv). Recovery of overpayments by post payment audits.
  • Code of Federal Regulations (CFR) Title 42, Section 121. Organ procurement and transplantation network.
  • CFR, Title 42, Section 410.32. Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  • CFR, Title 42, Section 411.15(k)(1), Particular Services excluded from coverage.
  • CFR, Title 42, Section 65. Covered Surgical Procedures.
  • CFR, Title 42, Section 424. Conditions for Medicare Payment.
  • CFR, Title 42, Section 482.24. Condition of Participation: Medical record services.
  • Medicare Benefit Policy Manual (MBPM), Publication 100-02, Chapter 15, Section 80.1. Clinical Laboratory Services.
  • MBPM, Publication 100-02, Chapter 15, Section 80.6. Requirements for Ordering and Following Orders for Diagnostic Tests.
  • MBPM, Publication 100-02, Chapter 16, Section 20. Services Not Reasonable and Necessary.
  • Medicare Claims Processing Manual (MCPM), Publication 100-04, Chapter 12, Section 20.3. Bundled Services/Supplies.
  • MCPM, Publication 100-04, Chapter 12, Section 30(M). Correct Coding Policy. Mutually Exclusive Procedures.
  • MCPM, Publication 100-04, Chapter 16. Laboratory Services.
  • MCPM, Publication 100-04, Chapter 23, Section 10. Reporting ICD Diagnosis and Procedure Codes.
  • MCPM, Publication 100-04, Chapter 23, Section 20.3-20.4. Use and Acceptance of HCPCS Codes and Modifiers.
  • MCPM, Publication 100-04, Chapter 23, Section 20.9.1.1-20.9.2. Instructions for Codes with Modifiers.
  • 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 1. Overview of Medical Review (MR) and Benefit Integrity (BI) Programs.
  • MPIM, Publication 100-08, Chapter 3. Verifying Potential Errors and Taking Corrective Actions.
  • MPIM, Publication 100-08, Chapter 3, Section 3.2.3.8. No response or Insufficient Response to Additional Documentation Requests.
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.1. Documents on Which to Base a Determination.
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.4. Signature Requirements.
  • MPIM, Publication 100-08, Chapter 3, Section 3.3.2.8. MAC Articles.
  • MPIM, Publication 100-08, Chapter 3, Section 3.6.2. Verifying Errors.
  • Medicare Contractor Beneficiary and Provider Communications Manual, Publication 100-09, Chapter 6, Section 20.4. Provider Education.
  • National Correct Coding Initiative Policy Manual Manual for Medicare Services. (Coding Policy Manual), revised January 1, 2019.
  • Local Coverage Determination (LCD) L33959. Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015.
  • LCD L33557. Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015.
  • Local Coverage Article (LCA) A52850. Billing and Coding: Cardiac Catheterization and Coronary Angiography. Effective October 1, 2015.
  • LCA A56500. Billing and Coding: Cardiac Catheterization and Coronary Angiography. Effective October 1, 2018.

Last Updated Feb 16, 2022