Medical Review - JF Part B
Medical Review Frequently Asked Questions (FAQs)
Q1: Why am I unable to charge re-evaluation CPT 97164 for every visit or every 10th visit as required by Medicare?
A1: 97164: A re-evaluation is only allowed if there is a significant change in the beneficiary and/or the plan of care. To meet Medicare’s medical necessity standard the medical record must support that the patient had an unanticipated significant change in their status or condition that required additional evaluation and/or assessment services. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Medicare’s medical necessity standard is not met in instances when the documentation supports that time was spent simply gathering data to show that the patient was i.e., making progress as anticipated in accordance with the plan of care. If the patient doesn’t specifically need the additional assessment/evaluative services, then the service minutes are not covered and are not separately reimbursable.
A re-evaluation should be very rare, and the re-certifications required by Medicare, every 10th visit progress reports, or when a physician signature is needed to continue therapy are not separately billable to Medicare and are not considered a re-evaluation. Note that a re-evaluation (CPT 97164) is an untimed code, and these minutes must not be counted as time-based treatment minutes - they don’t meet the code descriptor requirements.
10th visit progress reports are often routine re-assessments of the patient’s progress in accordance with the plan of care and minutes spent providing this service typically do not meet Medicare’s medical necessity standard and are not separately reimbursable.
Q2. How do I know what the signature requirements are for medical documentation?
A2. For a note to be valid, it must be authenticated by the author. The signature shall be handwritten or an electronical signature and must be legible. More information can be found at Medical Documentation Signature Requirements.
Q3: How can I share my thoughts on my experience with Noridian? This is related to an email I received with a survey link.
A3: Noridian is devoted to providing solutions that put people first. We want to hear from you about your experiences with us. Please let us know how we’re doing by completing one of our Customer Experience surveys, which are specialized by topic.
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Q4: What are the covered indication for a stress echocardiogram and where can I find them?
A4: The covered indications are as follows and can be found on LCD L36889 LCD - Cardiovascular Stress Testing. A stress echocardiogram is reasonable and necessary in addition to an electrical stress test in the following instances:
- An electrical stress test alone is not useful or effective, and a stress echocardiogram is needed. Such circumstances may include:
- An abnormal resting ECG due to digitalis, left ventricular hypertrophy, bundle branch block, preexcitation syndrome (Wolff-Parkinson-White), electronically paced ventricular rhythm, or greater than 1 mm of resting ST depression;
- A prior equivocal stress ECG; or
- A history of posterior wall MI.
- The patient has significant valvular heart disease, and measuring the physiologic changes with exercise is necessary to determine the need for a valve intervention,
- When needed to determine the significance or the extent of myocardial ischemia (or scar), or to assess myocardial viability (e.g., risk stratification following acute myocardial infarction),
- When information from the clinical assessment and an electrical stress test does not adequately assess functional capacity, and such information is needed to manage the patient (e.g., for a patient with angina and left bundle branch block to assess the level of exercise tolerance for treatment planning),
- When needed to aid in diagnosis of hypertrophic or dilated cardiomyopathy,
- When needed to differentiate ischemic from non-ischemic cardiomyopathy,
- As part of a preoperative evaluation of a patient who is at intermediate or high risk for CAD when the surgery is likely to induce significant cardiac stress.