Medical Review Frequently Asked Questions (FAQs)

Q1.  When documentation is requested for a lab or other test (such as an x-ray, CT scan or endoscopy) does documentation from the ordering/referring provider need to be submitted as well?  The ordering/referring provider may not be with/or located at the same facility.
A1. Yes.  In addition to the lab/test report and order/requisition/intent to order, clinical notes from the ordering/referring provider is needed to support the reasonable medical necessity of the service provided.  The clinical records must substantiate the diagnoses utilized on the claim/orders. The Social Security Act, the law governing Medicare, Section 1842(p)(4) mandates that: In case of an item or service…ordered by a physician or a practitioner…but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.

A letter is available to assist in obtaining documentation from the ordering/referring provider. View the Dear Ordering/Referring Physician Letter [PDF].

Q2. When billing a nail debridement procedure code 11720 or 11721, does documentation to support the class findings need to be included in each note?
A2. The documentation for each date of service should support the information for the class findings of Q7, Q8 or Q9 findings. Each note must show a current up to date evaluation of the feet/toes. See the Modifiers Q7, Q8, and Q9.

Q3. If letters requesting documentation sent by Noridian are being sent to an old address for a provider, how can the address be changed?
A3. To change the address, you can contact the Provider Contact Center.

Q4. When submitting documentation to Noridian for endoscopy procedures, do the progress notes prior to the procedure need to be submitted? Will the previous procedure notes be sufficient instead of progress notes?
A4. The progress notes prior to the procedure should be submitted; however, if not available the previous procedure notes may be sufficient if there is a notation that an endoscopy will be done in the future. CMS issues national coverage determinations (NCDs) that specify whether certain items, services, procedures or technologies are reasonable and necessary under §1862(a) (1) (A) of the Act. In the absence of an NCD, Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors, and ZPICs shall consider an item or service to be reasonable and necessary if the item or service meets the following criteria:

  • It is appropriate, including the duration and frequency in terms of whether the service or item is:
  • It is not experimental or investigational; and
  • It is safe and effective;
    • Furnished in a setting appropriate to the beneficiary's medical needs and condition;
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the beneficiary's condition or to improve the function of a malformed body member;
    • One that meets, but does not exceed, the beneficiary's medical need.
    • Ordered and furnished by qualified personnel; and,

The Endoscopy NCD is 100.2.

There are several exceptions to the requirement that a service be reasonable and necessary for diagnosis or treatment of illness or injury to be considered for payment. The exceptions appear in the full text of §1862(a) (l) (A) of the Act. See also CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Sections 5.1 and 7.1.


Last Updated Jan 03, 2019