Coronary Artery Calcium Scoring, CPT® 75571 - Targeted Probe and Educate Review Results - JE Part B
Coronary Artery Calcium Scoring, CPT® 75571 - Targeted Probe and Educate Review Results
In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs pre-payment reviews in accordance with CMS direction. CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. Medical review assesses submitted documentation to validate provider compliance with Medicare payment rules and regulations, including coverage, coding and billing guidelines.
This is to update providers of the claim review findings for CPT 75571, Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium. The results of this focused review are not a reflection on providers’ competence as a health care professional or the quality of care provided to patients. Specifically, the results are based on the documentation requested by Medicare and/or your facility’s compliance with the required documentation.
The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 75571 - Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium. The quarterly edit effectiveness results from October 1, 2023, through December 31, 2023, are as follows:
Top Denial Reasons
- Failure to return records.
- The documentation submitted does not support medical necessity.
- The documentation submitted was incomplete and/or insufficient.
Educational Resources
Education
Failure To Return Records
The Internet-Only Manual (IOM) addresses timeframes for submission of records for pre-payment reviews in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.2.3.2.
"When requesting documentation for prepayment review, the MAC and ZPIC shall notify providers that the requested documentation is to be submitted within 45 calendar days of the request. The reviewer should not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46."
Incomplete And/Or Insufficient Documentation
When additional documentation has been requested to verify compliance with the CPT® code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).
Coronary Artery Calcium Scoring, CPT® 75571
Computed tomography directs multiple narrow beams of x-rays around the body structure being studied and uses computer imaging to produce thin, cross-sectional views of various layers (or slices) of the body. It is useful for the evaluation of calcium deposits on the coronary tree. Patients are required to remain motionless during the study. This code reports the CT of the heart and quantitative evaluation of calcium deposits in the coronary tree. High levels of calcium deposits in the heart triple a person's likelihood of suffering an adverse coronary event (e.g., myocardial infarct, cardiac arrest, etc.)
