Medical Review - JF Part B

Q1: I have submitted my claim multiple times, and it keeps getting denied. Why?
A1: If a provider submits a new claim for a service that was previously submitted, developed, reviewed by Medical Review/Policy, and denied, it will be denied in the claims system automatically as a duplicate. Rebilling a claim that has been denied is an inappropriate billing practice. If the claim submitted is denied as a duplicate the provider will need to submit an appeal and provide additional documentation or justification. However, If the claim submitted is denied due to not submitting the requested documentation, submit that documentation to medical review. Also, re-billing inappropriate can be considered abuse. Refer to: Noridian Duplicate Denials, Fraud and Abuse

Q2: I am doing billing and coding for Evaluation and Management (E&M) codes. What are some resources I can use for this?
A2: The Internet Only Manuals (IOM) provide excellent guidance for E&M services. Refer to: Medicare Claims Processing Manual chapter 12, section 30.6. The Centers for Medicare and Medicaid provides an excellent resource on the Evaluation & Management Visits page. Refer to: Evaluation & Management Visits | CMS. Check the Education and Outreach page on the Noridian Webpage for a schedule of events related to E&M services. Refer to: Schedule of Events

Q3: Other than a medical doctor, who can bill for an Evaluation and Management service?
A3: Providers who can bill include non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)) whose Medicare benefit permits them to bill these services. A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. Services must be medically necessary and within the scope of practice of the provider. Refer to: CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6

Q4: I am really concerned that the primary exam code 90791 is not getting paid even though the timed code(s) were denied?
A4: If the denial is related to medical necessity, all of the codes on the claim will be denied. Also, if the denial time not being met, or time not being listed. For procedure code 90971, as a timed code there needs to be a start and end time for that service.

Q5: What are the signature requirements for regular medical review processes related to the recent revision of the Internet Only Manuals (I00-08, Program Integrity Manual (PIM), Chapter 3, Sections 303.2.4, and 3.3.2.5? When do these changes take effect? In addition to signature requirements covered in section 3.3.2.4, what are the updates related to section 3.3.2.5?
A5: Per CMS for reviews starting on and after June 10th, 2024, with an effective date of 06/10/2024; and Implementation date as well of 06/10/2024.

For medical review purposes, Medicare requires that the person(s) responsible for the care of the beneficiary, including providing/ordering/certifying items/services for the beneficiary, be identifiable as such in accordance with Medicare billing and coverage policies, such as the Social Security Act §1815(a) and §1833(e). Medicare contractors shall consider the totality of the medical record when reviewing for compliance with the above.

Signatures are required upon medical review for two distinct purposes:

1. To satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and
2. To resolve authenticity concerns related to legitimacy or falsity of the documentation.

If a signature is required per statute, regulation, National Coverage Determination (NCD) or Local coverage Determination (LCD): Contractors shall use the totality of the record to determine if the signature requirement, as outlined in statute, regulation, NCD, LCD is met.

If the signature requirement is not met, and it is not an instance in which the statute, regulation or NCD/LCD policy indicate that a signature must be in place prior to a given event or a given date, the attestation process may be used to try and resolve the issue.

If the attestation process does not resolve the issue, the contractor may pursue a denial and/or any other appropriate corrective actions. If the signature requirement is not met because the signature is illegible, the signature log process may be used to try and resolve the issue. If signature is not required per statute, regulation, NCD, or LCD: Contractors shall determine if the signature is necessary to identify the author of the record for the purposes of authenticity. If not, the contractor shall disregard the missing or illegible signature and continue their review of all medical documentation to determine if the claim meets coverage, coding, and billing requirements. If there is not an explicit signature requirement, but in the Contractor's review of the totality of the record they have authenticity concerns related to the legitimacy or falsity of the documentation, they shall pursue the attestation, signature log, denial, and/or fraud referral process, as appropriate. Note: If review contractors find reasons for denial unrelated to signature requirements, the reviewer need not proceed to signature authentication

The updates related to the next section 3.3.2.5 titled Amendments, Corrections and Delayed Entries in Medical Documentation with the same effective and implementation date as above.

Amendments

• All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided may not be properly documented. In this scenario, the documentation may need to be amended, corrected, or entered after rendering the service. The date and author of any amendment, correction or delayed entry should be identifiable, and the change/addenda should be clearly and permanently denoted.

Note: The following provides a best practice: "The date and author of any amendment, correction or delayed entry should be identifiable, and the change/addenda should be clearly and permanently denoted"; however, we note that such recordkeeping principles should not be the source of a denial. Rather, signatures in the amendment, correction, and delayed entry are subject to the same signature analysis as provided in revised Pub. 100-08 (PIM), Chapter 3, Section 3.3.2.4, as noted above.

Refer to: CMS Internet Only Manual (IOM), Publication 100-03, Medicare Program Integrity Manual, Chapter 3, Social Security Act §1815 , and Social Security Act §1833.