Diagnostic Cardiac Imaging Targeted Probe and Educate Review Results - JE Part A
Diagnostic Cardiac Imaging Targeted Probe and Educate Review Results
The Jurisdiction E, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review on a variety of diagnostic cardiac imaging service codes. The findings of the claims reviewed from October 1, 2024 through December 31, 2024 are as follows:
Review Results
- 219 claims were reviewed with 20.0% error rate
Top Trending Errors
- Medical necessity for specific diagnostic cardiac imaging on review
- Documentation to support services rendered
Educational Resources
- Documentation Requirements
- IOM, Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3
Education
Medical Necessity
As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.
Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. To be considered medically necessary, items and services must be proven as safe and effective.
Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary for a claim to be properly evaluated.
National Coverage Determinations
The Internet Only Manual (IOM), Publication 100-03, Medicare National Coverage Determinations (NCD) Manual describes circumstances for Medicare coverage nationwide. It is a useful tool for determining whether specific medical items, services, treatment procedures, or technologies can be paid for under Medicare. Medicare providers are responsible for being familiar with these references when submitting Medicare claims and to ensure requirements are being met prior to billing of claims.
Documentation Supporting Services Rendered
Under section 1833(e), Title XVIII of the Social Security Act (SSA) states, "no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period."
No Medicare payment can be made for claims that lack the necessary information for processing. Medicare claims will be allowed to process, when there is sufficient documentation in the patient’s records to verify the services were performed and were medically necessary and reasonable for the medical condition. Justification for the service may be documented in the physician’s clinic or hospital progress notes and/or laboratory results. If there is no documentation, or insufficient documentation to support the service, then Medicare considers the service not rendered and services will be denied.
