Medical Review

Thyroid Stimulating Hormone (TSH) Assay 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 84443 for JE.

Summary of Findings

Since the initiation of the review, 295 claims were reviewed from January 25, 2021 through November 1, 2021 with an overall claim error rate of 46% and payment error rate of 46%. The breakdown of those findings are as follows:

  • 158 claims were accepted
  • 1 claim was partially denied for the following reason:
    • Documentation did not support medical necessity for number of services billed.
  • 136 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
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.
Practitioner Signature

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:

  • Signatures shall be handwritten or an electronic signature.
  • Signatures are legible
  • Stamped signatures are not acceptable unless used in accordance with the Rehabilitation Act of 1973

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 3.3.2.4.
Thyroid Testing Medical Necessity

Per the National Coverage Determination (NCD) 190.22, thyroid lab tests may be reasonable to detect the presence or absence of hormonal abnormalities of the thyroid gland. Thyroid testing may be appropriate to:

  • Confirm or rule out hypothyroidism/hyperthyroidism
  • Monitor thyroid levels in patients with thyroid disease (thyroid cancer, goiter or nodules)
  • To monitor therapy in patients with hypothyroidism/hyperthyroidism

Thyroid function testing may be medically necessary in a variety of situations. Medical documentation from the ordering provider should reflect the medical rational for thyroid testing.
Additional medical necessity rationales for thyroid function testing can be found in NCD 190.22.
Thyroid Testing Limitations Per the limitations in the National Coverage Determination (NCD) for thyroid testing (190.22), testing may be covered up to two times a year. Additional testing may be reasonable and necessary in patients with an alteration in thyroid therapy or if signs and symptoms of hypothyroidism/hyperthyroidism are noted. Medical documentation from the treating provider should reflect the reason for additional testing.
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®) code 84443.

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 Tue, 16 Nov 2021 16:34:46 +0000