End-Stage Renal Disease (ESRD) - Related Monthly Service - Service Specific Targeted Review Final Findings

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 and closure of the case for CPT® 90960, 90961, and 90962.

Summary of Findings

Since the initiation of the review, 120 claims were reviewed from July, 27, 2021 through October 4, 2021. The breakdown of those findings are as follows:

  • 31 claims were allowed
  • 1 claim was corrected for the following reasons:
    • The service billed was paid at a higher level, as the documentation supported four ESRD visit were performed and requirements were met
  • 87 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 services were rendered as billed.

The overall error rate since the initiation of this service specific targeted review is 69.82%. 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).

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).

Rendered as Billed

The documentation requested must support that the services were rendered as billed. A claim will be denied when the documentation does not support the services billed were performed. Refer to IOM-Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.5(A).

Correct Coding

If documentation indicates it supports a higher or lower level code, the claim will be up or down coded as indicated. Proper coding is necessary on Medicare claims because codes are generally used in determining coverage and payment amounts. CMS accepts only HIPAA approved ICD-10-CM/ICD-10-PCS codes.

The Current Procedural Terminology (CPT®) Manual and Healthcare Common Procedure Coding System (HCPCS) Manual are listings 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® and HCPCS 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® or HCPCS 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.

Services provided by your facility are expected to be billed in compliance with CMS claims processing guidelines. Medical Review will continue to correct claims based on the submitted documentation if billing is found to be incorrect. Noted continued billing errors may be referred to the Provider Outreach and Education (POE) representatives for education on proper billing in accordance with CMS requirements. If a provider is consistently billing incorrectly, this may be highlighted for review and possible referral to the Unified Program Integrity Contractor (UPIC) for potential compliance or abuse issue Please refer to Section 1833(e), Title XVIII of the Social Security Act, Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4, and IOM, Pub 100-04, Medicare Claims Processing Manual, Chapters 12 and 23.

End Stage Renal Disease (90960-90962)

Physicians and practitioners managing patients on dialysis (center based) are paid a monthly capitation payment (MCP) for most outpatient dialysis-related physician services furnished to a Medicare end stage renal disease (ESRD) beneficiary. The MCP is reported once per month for services performed in an outpatient setting that are related to the patients’ ESRD.

The payment amount varies based on the number of visits provided within each month and the age of the ESRD beneficiary. The physician or practitioner who provides the complete assessment, establishes the patient’s plan of care, and provides the ongoing management is the physician or practitioner who submits the bill for the monthly service. Visits must be furnished face-to-face by a physician, clinical nurse specialist, nurse practitioner, or physician’s assistant. The MCP physician or practitioner may use other physicians or qualified nonphysician practitioners to provide some of the visits during the month. The MCP physician or practitioner does not have to be present when these other physicians or practitioners provide visits.

  • Only one monthly payment is made for any renal disease patient per month
  • The MCP payment is made after the month has passed; i.e., do not pay the MCP in advance of the services actually furnished
  • The payment amount is based on the age of the beneficiary and the number of visits furnished during a calendar month (center based patients)
  • Duplicate charges billed as a duplicate MCP or as separate charges for services covered by the monthly payment are denied
  • Where several physicians or practitioners form a team to provide the monthly continuity of services to a group of patients, make only one monthly payment for each patient

Concurrent services by another physician or practitioner who is part of the MCP practice team are covered and reimbursed separately only for services not included in the MCP (e.g. a visit not related to managing the patients ESRD)

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 ESRD.
  • 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

Based on the error rate for this service specific probe this case is now closed 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 in the future, data indicates variances or high utilization, providers may be subject to a pre-payment or post-payment review.

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® code 90960-90962 widespread 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, 25 Oct 2021 15:17:29 +0000