Polysomnography - Jurisdiction F (JF) Service Specific Post-Payment Final Findings - JF Part A
Polysomnography - JF 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 95810-95811 for the JF region.
Summary of Findings
Since the initiation of the review, 188 claims were reviewed from January 11, 2021 through July 15, 2021 with an overall claim error rate of 38% and payment error rate of 36.3%. The breakdown of those findings are as follows:
- 116 claims were accepted
- 6 claims received correction for the following reasons:
- Documentation did not support modifier billed
- 66 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.
|Paragraph Name||Paragraph Details|
|Diagnostic Testing Criteria||Per the Local Coverage Determination (LCD) L34040 (JF) 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:
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 a 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) L34040 (JF) for a full description.
Additional information can be found in the National Coverage Determination (NCD) 240.4.1.
|Modifier 52||Per the Current Procedural Terminology (CPT®) Manual, for sleep services 95800, 95801, 95806, 95807, 95810, and 95811 that have less than 6 hours of recording, modifier 52 should be appended to the code billed. Documentation should be reviewed carefully to ensure modifier 52 is appended correctly and that documentation supports the use of the modifier. If there are more than 6 hours of recording supported in the medical records, modifier 52 should not be appended.|
|Credentialing||Per the Local Coverage Determination (LCD) L34040 (JF), 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 L34040 (JF). 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) L34040 (JF), 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) A55479 (JF) direction. A confirmed diagnosis of OSA requires the following:
|Correct Coding||The Current Procedural Terminology (CPT®) Manual is a listing of descriptive terms and identifying codes for reporting medical services and procedures. The purpose of the terminology is to provide a uniform language that accurately describes medical, surgical, and diagnostic services, and thereby provides an effective means for reliable nationwide communication among physicians, patients, and third parties. The name of the procedure or service that most accurately identifies the service performed and documented in the medical record should be selected. Inclusion of a descriptor and its associated five digit identifying code number in the CPT® manual is generally based upon the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations.
It is the responsibility of providers to be familiar with the descriptive terms and identify the most appropriate and comprehensive CPT® codes for reporting medical procedures and services. The complete, descriptive documentation of all services rendered is absolutely necessary in order for a claim to be properly evaluated. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect.
|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.
|Physician Orders for a Diagnostic Test||An order from the treating practitioner may be delivered via the following forms of communication:
While an order is not required to be signed, the treating physician/practitioner must clearly document in the medical record his or her intent that the test be performed.
For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 80.6.
|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 18.104.22.168, 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 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 98510-98511.
This service specific post-payment file is now closed for JF 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 JF Provider Contact Center at 1-877-908-8431.
Last Updated Tue, 27 Jul 2021 17:54:57 +0000