Noridian Announces Widespread Service-Specific Probe Review for 66984

Date: November 10, 2015

On October 20, 2015, Noridian (the Medicare Administrative Contractor for a large number of states in the Western US) announced that they are initiating a review of documentation related to CPT code 66984 in all states within their Jurisdiction E (JE).  The states in JE are California, Hawaii, Nevada, American Samoa, Guam, and the Northern Marianas Islands.  Noridian’s announcement for this review can be viewed here.

Each Medicare contractor is tasked by CMS with “ensuring payment is made only for those medical services that are reasonable and necessary”.  In this case, Noridian’s Part B Medical Review process will verify “if billing problems exist through claims reviews to validate provider compliance with Medicare coverage as well as coding and billing guidelines.”

In the announcement, Noridian noted the following:

  • This particular “Widespread Probe Review” of 66984 was prompted by findings from a CERT (Comprehensive Error Rate Testing) review of randomly selected claims from a number of different Part B providers.
  • Those claims selected for review by Noridian Part B will be notified one time via the Automated Development System (ADS) process.  Practices should provide all applicable documentation to support the claim.  In this case, we believe this means the actual operative notes for 66984 for the date of service in question as well as the exam and testing that supported the decision for that eye’s planned surgery.
  • The ADS request for each service reviewed should be provided to Noridian along with the documentation noted above within 45 days of receipt.  Failure to respond will result in a claims denial.  Noridian will respond within 30 days of receipt.
  • Denials may result in future specific complex reviews.
  • Noridian will post overall results of the reviews at the conclusion of each quarter and at the end of the review.

Based on our own experience, we believe that the biggest areas of risk relate to 2nd eye cataract surgery.  Documentation of the second procedure is often weak, especially when the surgeries are close together in time.  Remember that the medical necessity for each surgery must be robust and the documentation for each surgery must stand alone.  Practices should “revisit” the second eye’s symptoms and Activities of Daily Living (ADL) after the first eye stabilizes.  We feel it is not enough to have symptoms for both eyes in your documentation before the first surgery but then not re-visit it “between eyes” to support that a problem still exists or has worsened in the second eye.

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