Noridian Posts Notice Regarding Reviews of MRI Brain Procedures
 


Magnetic Resonance Imaging, Brain, 70553 - Widespread Service Specific Probe Review Notification

Noridian Healthcare Solutions (Noridian) is initiating a service specific probe review for CPT ® 70553 - Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences. This will affect all states/territories with the following CPT ® 70553. Noridian Part B Medical Review has analyzed national and local data in conjunction with the findings from Comprehensive Error Rate Testing (CERT) to identify atypical billing.
Last Updated Oct 21, 2015.

CMS is required by the Social Security Act to ensure that payment is made only for those medical services that are reasonable and necessary. To meet this requirement, Noridian's Part B Medical Review (MR) analyzes national and local data in conjunction with the findings from the OIG and other CMS contractors such as Comprehensive Error Rate Testing (CERT) and Recovery Auditor (RA) to identify atypical billing. After data analysis, MR must verify if billing problems exist through claim reviews to validate provider compliance with Medicare coverage as well as coding and billing guidelines. If issues are identified, MR then determines the severity of problems and develops interventions to correct the problem.
This is to notify providers of the initiation of a Service Specific Probe Review for Magnetic resonance (eg, proton) imaging on:
  • CPT ® 70553 - Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
Noridian MR will review documentation submitted to support claims suspended during this review and post findings on the website. This article further provides instruction on the use of the Noridian MR webpage to facilitate proper submission of appropriate records and MR contact information.
Review Criteria
A JE service specific probe review for all states/territories will be initiated for claims with the following criteria:
  • CPT ® 70553 - Magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material, followed by contrast material(s) and further sequences
This service specific review is initiated based on the following:
  • Magnetic resonance (e.g., proton) imaging, brain services have been identified as a known CERT error and CPT ® 70553 has been identified as a potential vulnerability through data analysis.
One-Time Notification to Providers
Your facility will be notified of the selected claims per the normal Automated Development System (ADS) process. The provider agreement to participate in the Medicare program requires the submission of all documentation necessary to support the services billed on the claim.
Submit all applicable documentation requested for each claim with a copy of the ADS as a coversheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt or a claim denial will occur. Denials may result in future provider specific complex reviews and may be appealed through the normal appeal process. View references and required documentation on the Review Notifications and Findings webpage and detailed instructions on ADS submissions on the Automated Development System (ADS) Requests for Medical Record Submissions webpage.

Review Notifications and Findings - Noridian
When Noridian conducts complex medical reveiws, the following information is made available; Review Topic / Title, Review File Number, Start Date, End Date, and the Review Findings (Interim and/or Final).

Noridian MR Determination
MR will review the claim documentation within 30 days of its receipt and will determine whether or not the services billed are reasonable and necessary per Medicare coverage requirements. Along with the claim determination, MR will make a determination of liability for services and whether you are without fault for overpayments. Overall results of the service specific review will be posted to the Noridian website at the end of each quarter and at the end of the review. Noridian will not post provider specific results on the website. Noridian is only required to give a high-level notice of determination of the claims reviewed. You will not receive an individual notice detailing why your claim(s) was denied and/or paid at a different level of service. Individual claim determinations can be found on your Remittance Advice (RA). If you have any questions, contact the Provider Contact Center.
For questions related to Service Specific Reviews, the Noridian provider community is able to contact Part B Medical Review staff directly via email at medicalreviewpartb@noridian.com.
 


Notice Regarding Medical Board License Renewals/Possible Delays 
 

Attention Renewing Licensees:
Avoid Unnecessary Delays in Your License Renewal

The Department of Consumer Affairs (DCA) is scheduled to transition additional Boards and Bureaus to the new BreEZe online licensing and enforcement system in January 2016.

The transition to the new system will require a temporary shutdown of all licensing processes for several business days, and could result in delays in processing initial license applications, license renewals, and changes such as name changes or changes of address.

Individuals holding a professional license with December 2015 or January 2016 expiration dates who wish to renew their licenses are strongly encouraged to renew as early as possible, preferably before the end of November 2015.

NOTE: You may receive this alert more than once if you are subscribed to multiple Medical Board of California Subscribers' lists.



Delay in Requirement for CURES Enrollment with DEA Prescribers License
 

We previously notified you of the requirement detailed below for CURES registration. As a result of a bill signed by the Governor in October the registration deadline has been extended from 1/1/16 to July 1, 2016. We also expect that the on-line registration process will be enhanced to be more user friendly. We suggest that you wait to complete the process until next year unless you have already done so.

All radiologists and radiation oncologists need to be aware of the new requirement that all physicians authorized to prescribe, order or furnish Schedule II, II , or IV controlled substances are required to register with the DOJ Controlled Substance Utilization Review and Evaluation System (CURES) by 1/1/16. Though most radiologists and radiation oncologists may not prescribe controlled substances you are likely to have a DEA license to do so. This is part of the effort to control appropriate use of opiates and allow prescribing physicians to check patient prescription activity.

There is an on-line application but the application must then also be notarized prior to submission. Click here to get information.