Comprehensive Metabolic Panel - CA Service Specific Post-Payment Final Findings

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Noridian’s priority is to minimize potential future losses to the Medicare Trust Fund by preventing inappropriate Medicare payments.  This is accomplished through provider education, training, and the medical review of claims. A post-payment review has been initiated based on data analysis.

This is to update providers of the claim review findings and closure of the file of Current Procedural Terminology (CPT®) code 80053 for California.

Summary of Findings

Since the initiation of the review, 300 claims were reviewed from December 28, 2020 through October 8, 2021 with an overall claim error rate of 37.6% and payment error rate of 37.4%. The breakdown of those findings are as follows:

  • 187 claims were accepted
  • 113 claims were denied in full for the following reasons:
    • Documentation did not support medical necessity of services billed.
    • No medical records were received in response to Additional Documentation Request (ADR).

If you are a provider that had claims involved in the review sample and disagree with a claim determination, the normal appeal process may be followed as directed on the Noridian website under Appeals or as directed in your claim remittance advice.

Education

Paragraph Name Paragraph Details
Comprehensive Metabolic Panel Medical Necessity

Per the Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, Section 3.6.2 for services with no National Coverage Determination (NCD) or Local Coverage Determination (LCD), Medicare contractors must determine whether services are reasonable and necessary. To determine if a service is reasonable and necessary contractors consider the following information:

  • Is it safe and effective;
  • It is not experimental or investigational; and
  • Appropriate for patient:
    • Provided within the accepted standards of medical practice for that patient’s diagnosis or treatment;
    • Provided in the appropriate setting;
    • Ordered and provided by the qualified personnel; and
    • Meets the patient’s needs

In determining if a comprehensive metabolic panel (CMP) ordered is reasonable and necessary, the documentation should support:

  • Authenticated order or documentation which supports intent to order
  • Documentation that supports the indication for testing which may include (this is not an all-inclusive list):
    • Beneficiary comorbid conditions
    • Medications the patient is taking, for example diuretics, statins, anti-hypertensives or chemotherapy drugs
  • If testing is being completed for annual exam and/or pre-operative testing the documentation should justify the overall reasonableness of testing

The Current Procedural Terminology (CPT®) Manual guidelines should be reviewed to ensure the appropriate coding is reported on the claim. Per CPT® Manual guidelines, "if a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes. E.g. Do not report 80047 and 80053 in conjunction."
Timely Submission of Documentation and 569PPs It is the responsibility of Medicare providers to submit all documentation requested on the additional documentation requests (ADR) within the allotted time frame. Noridian allows 45 calendar days for the medical records to be received per the ADR request for post-payment reviews. On day 46, if the medical records have not been received, the claim will be denied provider liable with reason code 569PP. If there is no documentation to complete the medical review (MR), services billed on the claim cannot be supported.

A redetermination request should be submitted to Noridian within 120 days from the date of the 569PP denial. Contractors shall reopen the claim for review as long as all conditions are met. The determination made on the reopening claim has the potential to reverse non-covered dollars.

For additional information, refer to Internet-only Manual Pub 100-08, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), and Social Security Act sections 1815(a), 1833(e) and 1862(a)(1)(A).

 

References

View references used in review. Further educational opportunities may be found under Education and Outreach. If you are in need of an individualized education training event, contact the POE Department at mac@noridian.com. If you need coding assistance, please check your CPT®, HCPCS, ICD-10 books and your specific association.

Provider Action Required

File results and trending errors are being shared with all providers to assess compliance and billing practices if the service is provided within your facility. If your facility had claim documentation requested for this review, please refer to the individual result letter you received. You can also access individual determinations for claims that were requested from your facility by reviewing comments in either DDE or on the Noridian Medicare Portal (NMP).

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of Current Procedural Terminology (CPT®) code 80053.

Summary

This service specific post-payment file is now closed for HI and Noridian will no longer request documentation for this review. Noridian will continue to monitor data analysis and perform medical review for medical necessity and appropriate coding practices.

If you have any other questions, contact the JE Provider Contact Center at 1-855-609-9960.

 

Last Updated Dec 09 , 2023