Noridian conducting numerous prepayment reviews

November 09, 2015

Noridian, California's Medicare Administrative Contractor, recently announced that it is conducting a targeted audit of code 45378 (colonoscopy). On October 21, 2015, Noridian announced it is adding several more audits to the list, including G0439 (annual wellness visit), 78452 (SPECT), 70553 (MRI of the brain ) and 76700 (abdominal ultrasound). 

Noridian Part B Medical Review conducts these targeted reviews based on national and local data in conjunction with the findings from Comprehensive Error Rate Testing to identify atypical billing.

All of the reviews are being 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 of the request, or a claim denial will result. Noridian also accepts records via Medicare's Electronic Submission of Medical Documentation (esMD) transactions.

For detailed information regarding these reviews and required documentation, click here. For more assistance on signature and documentation requirements, refer to the Documentation Guidelines for Medicare Services on Noridian’s website.

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

  • Any other documentation to support the CPT code that was billed

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.


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