The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 93306 - Echocardiography. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons:

• Failure to Return Records
• Documentation does not Support Medical Necessity as Listed in the Coverage Requirement
• Documentation does not support the service billed.

Educational Resources

• How to Respond to ADR
• Signature Requirement Questions and Answers
• Required Documentation

Education

Echo

National Coverage Determination (NCD) 220.5 Ultrasound Diagnostic Procedures lists echocardiography as a category I procedure and it is not considered experimental. Per the Social Security Act 1862 (a)(1)(A) a service must be "reasonable and necessary for the diagnosis and treatment of an illness or injury or to improve the functioning of a malformed body member."

In determining if a transthoracic echocardiograph provided was reasonable and necessary, review of guidelines from national specialty societies assist to establish an accepted standard of medical practice. For example, the American College of Cardiology (ACC) and the American Heart Association (AHA) provide practice guidelines for echocardiography in the ACC/AHA Guidelines for the Clinical Application of Echocardiography. The guidelines assist physicians in clinical decision making and attempt to establish practice guidelines for most patients in most circumstances.

Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT®/HCPCS 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).

Failure to Return Records

When the MAC requests documentation for prepayment review, it is the provider's responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services must be determined to be reasonable and necessary for the prevention or treatment of illness. Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).

Medical Necessity

As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.

Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. In order to be considered medically necessary, items and services must be proven as safe and effective.

Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary in order for a claim to be properly evaluated. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.