Comprehensive Metabolic Panel - HI Service Specific Post-Payment Final Findings - JE Part A
Comprehensive Metabolic Panel - HI 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 Hawaii.
Summary of Findings
Since the initiation of the review, 75 claims were reviewed from December 28, 2020 through June 10, 2021 with an overall claim error rate of 12.3% and payment error rate of 21.3%. The breakdown of those findings are as follows:
- 59 claims were accepted
- 16 claims were denied in full for the following reasons:
- Documentation did not support medical necessity of services billed
- Documentation was illegible
- Missing documentation to support medical necessity
- Documentation did not meet signature requirements
- Missing laboratory results to support service rendered
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.
|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 paid 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 was not rendered. Services will be denied without the necessary documentation to support services were rendered as billed.
|Documentation to Support Medical Necessity
The practitioner that orders a service must maintain documentation to support medical necessity for that service in the beneficiary's medical record. It is the responsibility of the provider submitting the claim to maintain documentation that is received and that it reflects the information received from the ordering practitioner. The submitting provider may request additional information from the ordering practitioner to support the service billed is reasonable and necessary as laid out in the Social Security Act 1862.
Upon receipt of the Additional Development Request (ADR), the billing provider must submit documentation of an order for the service, which includes information to identify and contact the ordering practitioner, to verify appropriate completion of the order and services billed.
For additional information on record keeping supporting medical necessity of billed claims, refer to 42 Code of Federal Registry (CFR) section 410.32.
|Handwritten documentation may be difficult to read. Please keep in mind that the primary purpose of medical documentation is to ensure that the patient's treatment is recorded for quality of care and continuity of appropriate patient treatment. Medical record documentation may need to be read by several practitioners caring for the patient.
|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:
Documentation utilized in the medical review process must be signed by the person responsible for the care of the patient and must comply with Medicare's policies. Documentation that has not been signed would not be considered when reviewing submitted records.
A valid signature must meet the following criteria:
If a scribe has been utilized to document care provided in the medical record, the scribe is not required to sign/date the documentation. The treating physician/non-physician practitioner is required to sign/date the documentation.
For additional information, reference the Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual (MPIM), Chapter 3, Section 188.8.131.52.
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 email@example.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.
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.