Medical Review

Polysomnography - 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®) codes 95810-95811 for JE.

Summary of Findings

Since the initiation of the review, 194 claims were reviewed from January 18, 2021 through October 25, 2021 with an overall claim error rate of 37% and payment error rate of 37.2%. The breakdown of those findings are as follows:

  • 122 claims were accepted
  • 1 claim received correction for the following reason:
    • Documentation supported a different CPT code
  • 71 claims were denied in full for the following reasons:
    • Documentation did not support medical necessity per LCD
    • Documentation did not include physician/technician credentials
    • Documentation did not include practitioner signed report
    • Documentation was not received in response to 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
Diagnostic Testing Criteria

Per the Local Coverage Determination (LCD) L36861 (JE) and Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 70A, sleep studies or polysomnography for the purposes of diagnostic testing must:

  • Be completed for an approved condition listed in the LCD
  • Be completed in a sleep clinic affiliated with a hospital or under physician guidance
  • Have an authenticated order and/or support of an authenticated referral by an attending physician
  • Have documentation supporting the reason for diagnostic testing, including but not limited to physician examination and previous testing.

Subsequent testing would not be deemed reasonable and necessary in the absence of a clear indication for further testing. Such indications would include: evaluation of treatment response or insufficient response, substantial weight loss or weight gain for patients utilizing Positive Airway Pressure (PAP) devices. If previous testing was completed and the results are available to the attending physician, further testing would not be deemed medically reasonable and necessary for equipment changes or upgrades. Further instruction related to Durable Medical Equipment (DME) may be found in Local Coverage Determination (LCD) L33718 and the Clinician Letter - PAP Devices.

The Clinician Letter - PAP Devices can be found at: https://med.noridianmedicare.com

Durable medical Equipment, Prosthetics, Orthotics and Supplies à Browse by DMEPOS Category à Positive Airway Pressure (PAP) Devices à Clinician Letter - PAP Device Replacement

Additional information can be found in the National Coverage Determination (NCD) 240.4.1.
Medical Necessity

Under Section 1860(a)(1) of the Social Security Act, documentation must support the medical necessity of services billed. Sleep studies or polysomnography diagnostic testing may be considered reasonable and necessary if documentation supports the beneficiary has clinical signs or symptoms of one of the following medical conditions: obstructive sleep apnea; narcolepsy; or parasomnia. In the absence of clinical signs or symptoms, no payment can be made. Refer to Local Coverage Determination (LCD) L36861 (JE) for a full description.

Additional information can be found in the National Coverage Determination (NCD) 240.4.1.
Credentialing

Per the Local Coverage Determination (LCD) L36861 (JE), support of the appropriate credentials/certification for the physician, facility and technician(s) performing sleep studies or polysomnography testing is essential. When submitting documentation to support sleep studies or polysomnography testing, ensure that support of appropriate and current credentialing/certification is also submitted as required by L36861 (JE). No payment will be made for claims submitted lacking support of required credentials/certification.

Examples of documentation to support appropriate credentialing include copies of certificates with issuing date to support certification/credentialing was current at the time of the study or copy of appropriate website validation of certification/credentials that demonstrate certification/credentials were valid at time of the study.
Technician Credentialing

Per the Local Coverage Determination (LCD) L36861 (JE), technicians performing the service must be appropriately credentialed. It is common practice in caring for patient’s undergoing sleep studies or polysomnography testing that there is a technician performing the actual study and another technician performing the scoring of the study. It is important to submit credentials for both technicians when this occurs in order to meet the credentialing requirements of the LCD.

When submitting proof of technician credentials for review, ensure documentation supports the technicians were involved in the patient’s care. For example, if the documentation only supports the initials of the technicians caring for the patient and not their full names, medical review is unable to validate the technician credentials submitted for review are the appropriate credentials.
Split-Night Studies

Split-night studies are useful in the diagnosing and treatment of obstructive sleep apnea (OSA). A split-night study allows for the completion of the initial diagnostic testing with continuous positive airway pressure (CPAP) titration on the same night. This is considered one service and is billed with Current Procedural Terminology (CPT®) code 95811 per Local Coverage Article: Abbreviated Daytime Sleep Study (e.g. PAP-NAP) A55478 (JE) direction. A confirmed diagnosis of OSA requires the following:

  • Apnea-Hypoxia Index (AHI) or Respiratory Disturbance Index (RHI) of at least 15 events an hour and at least 30 events
  • CPAP titration must be completed for a minimum of 3 hours
  • Documentation must support the CPAP effectively prevents respiratory events

Per the Local Coverage Determination (LCD) L36861 (JE) payment cannot be made if these requirements are not supported.
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).

 

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®) codes 95810-95811.

Summary

This service specific post-payment file is now closed for JE 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 Wed, 10 Nov 2021 14:53:05 +0000