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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Ambulance Services Billed During Hospice: Unbundling
_0163
Automated
Ambulance Services
Region-1
1 - All Region 1 states
07/22/2019

Ambulance Services Billed During Hospice: Unbundling

Issue Name: Ambulance Services Billed During Hospice: Unbundling
Issue Number: _0163
Review Type: Automated
Provider Type: Ambulance Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/22/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the Informational Letter date.
Description: Ambulance transports of a hospice patient, which are related to the terminal illness and occur after the effective date of election, are the responsibility of the hospice provider. Payment for the ambulance claim will be recouped if the above condition occurs and separate payment was paid to the provider.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. Title XVIII, §1861(dd)(1) of the Social Security Act- Hospice Care; Hospice Program 4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 Code of Federal Regulations (CFR) §418.54(a)- Standard: Initial Assessment 7. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 9. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services Under Hospital Insurance, §40.1.9- Other Items and Services 10. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, §50- Billing and Payment for Services Unrelated to Terminal Illness"
Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements
_0162
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
07/16/2019

Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements

Issue Name: Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements
Issue Number: _0162
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/16/2019
Dates Service: Claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request (complex review).
Description: All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage. Affected codes: CPT 75574 (computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
References: "1. SSA, §1862(a)(1)(A), §1862(a)(7) – Exclusions from coverage 2. SSA, §1833(e) – Payment of benefits 3. 42 CFR §411.15(a)(1) – Particular services excluded from coverage; Routine physical checkups. 4. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations 5. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 6. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 7. 42 CFR §405.986- Good Cause for Reopening 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions. 9. Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations 220- Radiology; 220.1- Computed Tomography (CT) §A- General, and §F- Computed Tomographic Angiography (CTA) 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8 - No Response or Insufficient Response to Additional Documentation Requests 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.4.1.3- Diagnoses Code Requirement 12. CPT Manual"
Outpatient Therapy Services During Home Health: Unbundling
_0158
Automated
Hospital Outpatient, SNF Outpatient, Outpatient Rehabilitation Facility
Region-1
1 - All Region 1 states
07/11/2019

Outpatient Therapy Services During Home Health: Unbundling

Issue Name: Outpatient Therapy Services During Home Health: Unbundling
Issue Number: _0158
Review Type: Automated
Provider Type: Hospital Outpatient, SNF Outpatient, Outpatient Rehabilitation Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/11/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 6. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20- Home Health Prospective Payment System (HH PPS) Consolidated Billing 7. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2.2 - Therapy Editing"
Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements
_0157
Complex
Place of Service 24 with Type of Service “F”
Region-1
1 - All Region 1 states
06/26/2019

Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements

Issue Name: Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements
Issue Number: _0157
Review Type: Complex
Provider Type: Place of Service 24 with Type of Service “F”
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/26/2019
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date
Description: Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifier 73.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 42 CFR §414.40 Coding and Ancillary Policies 3. 42 CFR §419.44 Payment Reductions for Procedures 4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 5. 42 CFR §405.986- Good Cause for Reopening 6. Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 7. Medicare Claims Processing Manual, Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS), § 10.5 Discounting; §20.6 Use of Modifiers, §20.6.1 Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4 Use of Modifiers for Discontinued Services 8. Medicare Claims Processing Manual, Chapter 14 Ambulatory Surgical Centers, §40.4 Payment for Terminated Procedures 9. Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements, §20.3 Use and Acceptance of HCPCS Codes and Modifiers 10. American Medical Association (AMA), Current Procedural Terminology, Appendix A Modifiers 11. AHA Coding Clinic for HCPCS 2007, Volume 7, Number 1, Page 1 Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS 12. AHA Coding Clinic for HCPCS 2008, Volume 8, Number 2, Pages 1-4 Special Issue: Modifiers 52, 73, and 74 13. AHA Coding Clinic for HCPCS 2016, Volume 16, Number 1, Page 12 Appropriate Use of Modifiers for Discontinued Services under the OPPS 14. AMA CPT Assistant, September 2003, Page 3 Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’"
HCPCS A4253: Blood Glucose Test or Reagent Strips
_0152
Complex
DME by Supplier/DME Physician
Region-5
5 - Nationwide
06/14/2019

HCPCS A4253: Blood Glucose Test or Reagent Strips

Issue Name: HCPCS A4253: Blood Glucose Test or Reagent Strips
Issue Number: _0152
Review Type: Complex
Provider Type: DME by Supplier/DME Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 06/14/2019
Dates Service: Claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request.
Description: "The quantity of glucose test strips (A4353) that are covered depends upon the usual medical needs of the diabetic patient. Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips (A4253) were met. "
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 10. 42 CFR §424.57(c)- Application Certification Standards 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 12. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 13. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 14. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 15. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 19. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 20. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 21. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 22. CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1 Coverage Determinations, Section 40.2 Home Blood Glucose Monitors 23. CMS Pub. 100-03, (Medicare National Coverage Determinations Manual), Chapter 1 Coverage Determinations, Section 190.20- Blood Glucose Testing 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822-Glucose Monitors, Effective Date: 10/1/2015; Revised 01/12/2017 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464 Glucose Monitor - Policy Article, Effective Date: 10/01/2015; Revised: 06/07/2018 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018"
Ophthalmic Diagnostic CPT Codes: Excessive Units
_0159
Automated
Professional Services (Physician/non-physician practitioner)
Region-1
1 - All Region 1 states
06/17/2019

Ophthalmic Diagnostic CPT Codes: Excessive Units

Issue Name: Ophthalmic Diagnostic CPT Codes: Excessive Units
Issue Number: _0159
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/17/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: CPT codes 92133 and/or 92134 will be considered in this edit, if billed together during the same patient encounter, on the same date of service. Only one is allowed per day, therefore the lower allowed amount CPT Code will be recovered as an overpayment. Based on CPT Code descriptions, CPT Code 92133 and/or 92134 cannot be reported at the same patient encounter.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 6. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 – current (Special Ophthalmological Services)"
Ambulatory Surgical Center Coding Validation
_0153
Complex
ASC
Region-1
1 - All Region 1 states
05/26/2019

Ambulatory Surgical Center Coding Validation

Issue Name: Ambulatory Surgical Center Coding Validation
Issue Number: _0153
Review Type: Complex
Provider Type: ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/26/2019
Dates Service: 3 Years
Description: Ambulatory Surgical Center coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the CPT/HCPCS coding and associated modifiers by reviewing the procedures affecting or potentially affecting payment. Affected codes: Claims with payment indicator A2; G2; J8
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4. 42 CFR §405.986- Good Cause for Reopening 5. 42 CFR § 414.B Payment for Part B Medical and Other Health Services- Coding and Ancillary Policies 6. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions §3.6.2.4- Coding Determinations 8. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package 9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; 40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; 40.5- Payment for Multiple Procedures 10. American Medical Association (AMA), Current Procedure Terminology 11. ASC Payment System; Addendum AA; Payment indicators A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight), G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate. ASC Payment rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html 12. National Correct Coding Initiative Policy Manual 13. American Medical Association CPT Assistant 14. American Hospital Association Coding Clinic for HCPCS"
Upper Limb Orthoses within the Reasonable Useful Lifetime (RUL)
_0155
Automated
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
05/17/2019

Upper Limb Orthoses within the Reasonable Useful Lifetime (RUL)

Issue Name: Upper Limb Orthoses within the Reasonable Useful Lifetime (RUL)
Issue Number: _0155
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/17/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Claims for upper limb orthoses with dates of service within 5 years of the date of service of a previously paid upper limb orthoses for the same beneficiary, for HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met. Affected codes: L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984 and L3995
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 2. Social Security Act, Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment. 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment 4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §414.210- General Payment Rules 7. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.C 8. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018"
Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services
_0154
Complex
Ambulance
Region-1
1 - All Region 1 states
05/20/2019

Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services

Issue Name: Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services
Issue Number: _0154
Review Type: Complex
Provider Type: Ambulance
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/20/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: "Medicare pays for nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation are contraindicated (i.e. would endanger the beneficiary). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment. Origin or Destination Descriptions D Diagnostic or therapeutic site other than P (physician’s office) or H (hospital) when these are used as origin codes E Residential, domiciliary, or custodial facility (other than a SNF) G Hospital-based ESRD facility H Hospital I Site of transfer (e.g., an airport or a helicopter pad) between modes of ambulance transport J Freestanding ESRD facility N SNF P Physician’s office R Residence S Scene of accident or acute event X Intermediate stop at physician’s office on way to hospital (destination code only)"
References: "1. Social Security Act (SSA) § 1833 (e) Payment of Benefits. 2. SSA 1862(a)(1) states that no payment may be made under part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 3. SSA 1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in the regulations. 4. SSA 1834(l) (10)-(16) Fee Schedule for Ambulance Services. 5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 6. 42 CFR §405.986 Good Cause for Reopening 7. 42 CFR §424.5 (a)(6) Basic Conditions; Sufficient Information 8. 42 CFR 410.40 (b) Coverage of ambulance services; Levels of service. 9. 42 CFR 410.40 (d)(1) Coverage of ambulance services; Medical necessity requirements. 10. 42 CFR 410.40 (d)(2) Special rule for nonemergency, scheduled, repetitive ambulance services. 11. 42 CFR 410.40 (d)(3) Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis 12. 42 CFR 410.41 (c) Requirements for ambulance suppliers; Billing and reporting requirements. 13. 42 CFR 414.605 Definitions 14. 42 CFR 414.610 Basis of Payment 15. 42 CFR 411.15 (k)(1) Particular Services Excluded from Coverage, Any Services not Reasonable and Necessary. 16. 42 CFR 424.36 Signature Requirements and 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary. 17. IOM, 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 10, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services, Emergency Response, Definition. 18. IOM, 100-04, Medicare Claims Processing Manual, Chapter 15, §30 (A) & (B), Modifiers Specific to Ambulance Service Claims and HCPCS Codes. 19. Novitas LCD L35162, Ambulance Services (Ground Ambulance). Effective Date 10/01/2015. 20. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015."