August 05, 2015
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement Public Payors
Noridian, California's Medicare administrative contractor, has announced it will be conducting service-specific targeted audits of procedure codes 99205 and 99233 when rendered by providers with specific specialties:
- 99205 performed by cardiology (Centers for Medicare and Medicaid Services specialty designation 06) and pulmonary (29)
- 99233 performed by internal medicine (11) and hematology/oncology (83)
Noridian conducts these targeted reviews based on data analysis. An analysis of these procedure codes, when performed by physicians in these specialties, indicated a higher utilization by California providers when compared to national claim payment ratios for the same services by the same specialties.
These reviews are conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional documentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt, or a claim denial will result.
More information on the ADR process can be found here. Documentation that may support the services billed includes:
- Legible copy of the patient's medical record for listed date(s) of service
- Legible physician signature
- Consultation reports
- Physician progress notes
- Diagnostic test results/reports, including imaging reports if applicable
- Any other documentation to support the CPT Code that was billed
For more assistance on signature and documentation requirements, refer to the Documentation Guidelines for Medicare Services on Noridian’s website.
Noridian will review the documentation submitted within 30 days of receipt. No letters will be sent on the outcome of each individual claim. The claim decisions will be reflected in the remittance advice and may be appealed through the normal appeal process, if unfavorable.
When the audit is complete, Noridian will analyze the results and determine if any subsequent actions are necessary. The results will be posted to Noridian’s JE Part B website.