DEXA - Current Procedural Terminology (CPT) 77080 - JF Service Specific Targeted Review Interim Findings

Current Review Results

In order to fulfill its contractual obligation with CMS, Noridian Healthcare Solutions (Noridian), your Medicare Contractor, performs post-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 77080, Dual-energy X-ray absorptiometry (DEXA), bone density study, 1 or more sites; axial skeleton (eg, hips, pelvis, spine). 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.

Summary of Findings

Since the initiation of the review, 39 claims were reviewed from October 1, 2020 through December 31, 2020. The breakdown of those findings are as follows:

  • 16 claims were allowed.
  • 23 claims were denied in full for the following reasons:
    • The requested records were not received.
    • The documentation submitted was incomplete and/or insufficient.
    • The documentation submitted does not support medical necessity.

The overall error rate since the initiation of this service specific targeted review is 56.78%. The error rate is calculated by dividing the dollar amount of charges billed in error (minus any confirmed under-billed charges) by the total amount of charges for services medically reviewed. If you 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, although this will not affect the error rate of the post-payment review.

Education

Failure to Return Records

When the MAC requests documentation for 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).

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).

Supporting Documentation

Documentation submitted to support radiology services must clearly state the provider’s order or intent that the test be performed. There also must be documentation submitted that supports the reasonable necessity of the service. Submitting only the report and interpretation is not sufficient enough to support the service was reasonable and necessary.

Documentation Does Not Support The Ordered Service

If additional documentation was requested because compliance with a benefit category requirement is questioned and the documentation received fails to support compliance with the benefit category the claim will be denied by medical review.

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 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. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5A.

DEXA Scan

A Dual-energy X-ray absorptiometry (DXA), bone density study of one or more sites of the axial skeleton and billed with CPT ® 77080. Coverage requirements can be found in the National Coverage Determination (NCD) 150.3, “Bone (Mineral) Density Studies and the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 80.5.

A bone mass measurement (BBM) is defined as a radiologic, radioisotopic, or other procedure performed to identify bone mass, detect bone loss, or determine bone quality. This is performed with either a bone densitometer (other than single-photon or dual-photon absorptiometry) or a bone sonometer system and includes a physician’s interpretation of the results.

Coverage guidelines include an order by the physician or qualified nonphysician practitioner who is treating the beneficiary following an evaluation of the need for a BMM and determine the appropriate BMM to be used. This would be performed under the appropriate level of physician supervision as defined in 42 CFR 410.32(b) for diagnosing and treating the beneficiary.

To be covered the beneficiary must meet specific conditions such as women who are estrogen deficient and at clinical risk for osteoporosis. Other conditions would include a beneficiary with vertebral abnormalities, receiving or expecting to receive glucocorticoid therapy for more than three months, beneficiaries with primary hyperparathyroidism or are being monitored to assess the response to or efficacy of an FDA-approved osteoporosis drug therapy.

A BMM is allowed once every two years with at least 23 months since the month the last covered BMM was performed. More frequent BMM’s may be covered if the beneficiary is being monitored due to long-term glucocorticoid therapy (more than 3 months) or to confirm a baseline BMM to permit monitoring of beneficiates in the future.

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.

Resources

For additional educational resources, please visit our Education and Outreach department.

Provider Action Required

Providers should review individual claim determinations.

To review individual claim comments via the Noridian Medicare Portal, complete the following steps:

  1. Log into Noridian Medicare Portal at https://www.noridianmedicareportal.com/
  2. Choose Claim Status from the menu bar.
  3. On the Claim Status Inquiry page:
    1. Fill in all Provider/Supplier Details.
    2. Select MEDB under Program drop down box
    3. Fill in all Beneficiary Details
    4. Fill in Claim Details.
  4. Click the Submit Inquiry button at the bottom of the form.
  5. On the Claim Status Results page
    1. Choose View Claim.
    2. On the right side of the page will the heading: Related Inquiries
    3. Choose Noridian Comments.
  6. Scroll down the page and under the Claim Status Line Details the comment will display.

Note: If documentation was sent late (>45 days from the date of the ADR), the claim may have been reopened by the examiner. These reviews are not currently available on the portal.

Initial documentation must be sent by fax, mail or esMD. Additional documentation requested can be submitted fax, mail or Noridian Medicare Portal.

Further provider action recommended includes:

  • Provide education regarding errors noted to applicable staff members.
  • Verify documentation supports medical necessity of the Dual-energy X-ray absorptiometry (DEXA), bone density study.
  • Ensure ADR submissions are timely, complete, and include all documentation to support medical necessity and a valid physician order.
  • If records supporting the services on the claim are located at another facility, as the billing provider, your facility is responsible for obtaining those records for review.

Summary

This service specific targeted review will continue until medical review results demonstrate provider compliance with Medicare guidelines and education provided. This file is reviewed at least quarterly; providers with low/no errors after a reasonable sample will no longer be reviewed for this file. Remaining providers will continue to be reviewed.

If you would like to receive information regarding findings specific to your facility prior to the completion of the review, send an email to medicalreviewb@noridian.com. In order to facilitate the response, follow these instructions:

  • Complete the Subject line with the following information: Results request for CPT 77080 targeted review
  • In the body of the email, include the following elements:
    • Your name, title, and telephone number
    • The facility name
    • NPI Number
    • Short description of information you would like to receive
  • Indicate if you would like to receive results via phone call, fax or US Mail and include a fax number or mailing address as applicable.

Upon request receipt, Noridian Medical Review will respond as timely as possible. Requests may take up to two weeks to be completed.

If you have any questions, contact the Provider Contact Center

 

Last Updated Mon, 08 Feb 2021 16:15:36 +0000