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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Ambulance SNF to SNF Transfer
_0049
Automated
Ambulance Providers
1
1 - All Region 1 States
08/09/2017

Ambulance SNF to SNF Transfer

Issue Name: Ambulance SNF to SNF Transfer
Issue Number: _0049
Review Type: Automated
Provider Type: Ambulance Providers
Region: 1
State: 1 - All Region 1 States
Date Approved: 08/09/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the “Initial Finding” Letter date will be excluded.
Description: Ambulance claims for SNF to SNF transfers (modifier NN) are not separately payable under Part B. The SNF discharging the Beneficiary to another SNF is financially responsible for the transportation fees. Ambulance providers should seek payment from the transferring SNF. Affected codes: A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0392, A0394, A0396, A0398, A0420, A0422, A0425, A0426, A0427, A0427, A0429, A0432, A0433, A0434, A0888, A0999.
References: Title XVIII of the Social Security Act: Section 1833(e), Title XVIII of the Social Security Act: Section 1862(a) (1) (A), Medicare Claims Processing Manual: Publication 100-04; Chapter 6, §20.3.1, and Chapter 15, § 30.2.2, American Medical Association (AMA), Professional HCPCS Level II Manual 2014 to current, Medicare Benefit Policy Manual: Publication 100-02; Chapter 10, §10.3.3nt,
Hospital Discharge Day Management Service
_0040
Automated
Physician; Professional Services
1
1 - All Region 1 States
03/09/2017

Hospital Discharge Day Management Service

Issue Name: Hospital Discharge Day Management Service
Issue Number: _0040
Review Type: Automated
Provider Type: Physician; Professional Services
Region: 1
State: 1 - All Region 1 States
Date Approved: 03/09/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the “Initial Finding” Letter date will be excluded.
Description: Only one hospital discharge day management service is payable per patient per hosptial stay. Only the attending physician of record reports the discharge day management service. Affected Codes: 99238-99239
References: 1. Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.9.2 .
Inpatient Hospital Validation of Condition Code 42
_0005
Complex
Inpatient Hospital
1
1 - All Region 1 states
08/02/2017

Inpatient Hospital Validation of Condition Code 42

Issue Name: Inpatient Hospital Validation of Condition Code 42
Issue Number: _0005
Review Type: Complex
Provider Type: Inpatient Hospital
Region: 1
State: 1 - All Region 1 states
Date Approved: 08/02/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Initial Finding Letter date will be excluded.
Description: IPPS hospitals are incorrectly billing condition code 42 on claims with discharge status code 06
References: Pub 100-04, Chapter 3, §§20.1.2.4C; 40.2.4C
Evaluation and Management (E/M) Coding in Skilled Nursing Facilities
_0056
Automated
Physician/Non-physician Practitioner (NPP)
1
1 - All Region 1 states
08/02/2017

Evaluation and Management (E/M) Coding in Skilled Nursing Facilities

Issue Name: Evaluation and Management (E/M) Coding in Skilled Nursing Facilities
Issue Number: _0056
Review Type: Automated
Provider Type: Physician/Non-physician Practitioner (NPP)
Region: 1
State: 1 - All Region 1 states
Date Approved: 08/02/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the “Initial Finding” Letter date will be excluded.
Description: When evaluation and management (E/M) services are provided to patients in a Skilled Nursing Facility (SNF), CPT codes (99306,99309, 99310) should be reported. It is inappropriate to report hospital inpatient care codes (99223, 99232,99233) for SNF E/M services. Affected Codes: 99223, 99232, 99233, 99306, 99309, 99310.
References: Title XVIII of the Social Security Act (SSA), §1833(e), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12, §30.6.13, AMA CPT Manual, Evaluation and Management section, Nursing Facility Services Guidelines
Complex Spinal Orthoses
_0024
Complex
DME by supplier; DME by physician
5
5 - Nationwide
08/02/2017

Complex Spinal Orthoses

Issue Name: Complex Spinal Orthoses
Issue Number: _0024
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5 - Nationwide
Date Approved: 08/02/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Documentation will be reviewed to determine if Spinal Orthoses meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.
References: Social Security Act, Section 1833 (e); Section 1834 (a) [42 U.S.C. 1395m], PAYMENT FOR DURABLE MEDICAL EQUIPMENTCMS PUBLICATION 100-08, MEDICARE PROGRAM INTEGRITY MANUAL, CHAPTER 4, SECTIONS 4.26, 4.26.1; CHAPTER 5, SECTIONS 5.2, 5.7, AND 5.8.., 42 Code of Federal Regulations (C.F.R.) §§405.980 (b) and (c), 42 C.F.R. §405.986, CGS Administrators, LCD L11448, Effective 10/1/1993, Revision 5/1/2015, Retired 9/30/2015, CGS A24086 Local Coverage Article: Spinal Orthoses: TLSO and LSO, Effective 1/1/2005, Revision 10/31/2014, Retired 9/30/2015, Nationwide LCD L33790, Effective date 10/01/2015, Nationwide A52500 Local Coverage Article: Spinal Orthoses: TLSO and LSO, Effective date 10/01/2015, National Government Services (NGS) LCD L27017, Effective 10/1/1993, Retired 9/30/2015, NGS Local Coverage Article, A47059, Effective 1/1/2005, Retired 9/30/2015,NHIC LCD L11470, Effective 10/1/1993, Retired 9/30/2015, NHIC Local Coverage Article, A23663, Effective 1/1/2005, Retired 9/30/2015, Noridian LCD L11459, Effective 10/1/1993, Retired 9/30/2015, Noridian Local Coverage Article, A23846, Effective 1/1/2005, Retired 9/30/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Complex Medical Necessity Patient Lifts
_0020
Complex
DME by Supplier, DME by Physician
5
5 - Nationwide
06/01/2017

Complex Medical Necessity Patient Lifts

Issue Name: Complex Medical Necessity Patient Lifts
Issue Number: _0020
Review Type: Complex
Provider Type: DME by Supplier, DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 06/01/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Patient lifts must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined Local Coverage Determinations (LCDs) for Patient Lifts (L33799 and retired LCDs L11577, L27218, L11562, and L5064). Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected Codes: E0630, E0635, E0639, E0640.
References: CGS and Noridian Healthcare Solutions LCD L33799: Effective 10/01/2015, CGS and Noridian Healthcare Solutions Article A52516: Effective 10/01/2015, CGS LCD L11562: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, NHIC LCD L5064: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, NGS LCD L27218: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, Noridian LCD L11577: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, CGS Article A23976: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, NHIC Article A23657: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, NGS Article A47230: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, Noridian Article A23901: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015 
Complex Review Vagus Nerve Stimulation
_0055
Complex
Outpatient Hospital
1
1 - All Region 1 states
07/21/2017

Complex Review Vagus Nerve Stimulation

Issue Name: Complex Review Vagus Nerve Stimulation
Issue Number: _0055
Review Type: Complex
Provider Type: Outpatient Hospital
Region: 1
State: 1 - All Region 1 states
Date Approved: 07/21/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: "Vagus Nerve Stimulation (VNS) is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for resistant depression. Medical documentation will be reviewed to determine that services were medically reasonable and necessary." Affected Codes: 64568 and 64569.
References: Title XVIII of the Social Security Act: Section 1833(e), Title XVIII of the Social Security Act: Section 1862(a)(1)(A),CMS Publication 100-3 Medicare National Coverage Determinations Manual, Chapter 1, Part 2; Section 160.18, CMS Publication 100-4 Medicare Claims Processing Manual, Chapter 32, Section 200.
Complex Medical Necessity AFO & KAFO Orthoses
_0013
Complex
DME by Supplier and DME by Physician
5
5 - Nationwide
07/05/2017

Complex Medical Necessity AFO & KAFO Orthoses

Issue Name: Complex Medical Necessity AFO & KAFO Orthoses
Issue Number: _0013
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 07/05/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded
Description: Ankle-Foot Orthosis and Knee-Ankle-Foot Orthosis must meet basic coverage criteria and subsequent, whether at initial purchase or at any point during a rental period as outlined in CMS Publications and Local Coverage Determination (LCDs) for AFO/KAFO Orthoses. Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.
References: 42 CFR 414.402, Social Security Act, Section 1833 (e), Social Security Act, Section 1842 (p) (4),Social Security Act, Section 1847 (a) (2), Social Security Act, Section 1834 (h) (1) (F) (i) (ii), Social Security Act, Section 1861 (s) (9), Social Security Act, Sec.1834. [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (1) (E) (i) (ii) (v), Social Security Act, Section.1834 [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (7) (C) (i), (ii) and (iii), Social Security Act, Section.1834 [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (4), Supplier Standards 42 CFR, 424.57(12), CMS Publication 100-02 Medicare Benefit Policy Manual Chapter 15, Section 110.2 (C), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 100.2, CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, part C and Chapter 4, Section 4.26, 4.26.1 and Chapter 5, Section 5.2, 5.2.1, 5.2.3, 5.2.4, 5.2.7, 5.7, 5.8 and 5.9, CMS Local Coverage Determinations (LCDs) for AFO, KAFO LCD L142, L11517, L27229, L11527 (superseded/retired issues prior to 10/1/15), CMS Local Coverage Determination (LCD) for AFO, KAFO L33686 for DOS on/after 10/1/15, CMS Policy Article for AFO, KAFO (A19800, A19806, A47227, A19885)(superseded/retired issues prior to 10/1/15), CMS Policy Article for AFO, KAFO (A52457) for DOS on/after 10/1/1, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Complex Comprehensive Negative Pressure Wound Therapy Pumps
_0017
Complex
DME by Supplier
5
5 - Nationwide
04/28/2017

Complex Comprehensive Negative Pressure Wound Therapy Pumps

Issue Name: Complex Comprehensive Negative Pressure Wound Therapy Pumps
Issue Number: _0017
Review Type: Complex
Provider Type: DME by Supplier
Region: 5
State: 5 - Nationwide
Date Approved: 04/28/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Medical Necessity Review Negative Pressure Wound Therapy Pumps - Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in NHIC's Local Coverage. Affected Codes; E2402, A6550, A7000
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833(e), Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, §110, Durable Medical Equipment - General, Revised 10/01/2003, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 34, §10.6.1, Timeframes for Contractor Initiated Reopenings and 10.6.2, Timeframes for Party Requested Reopenings Revision for both sections Rev 1069 11/29/2006, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, §§5.7, Documentation in the Patient's Medical Record (Rev. 242, Effective 3/1/2008), 5.8, Supplier Documentation (Rev. 612, Effective 9/29/2015), and 5.9, Evidence of Medical Necessity, Chapter Revision 623 11/03/2015, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, §§ 3.3.2 (Rev. 377, Effective 6/28/2011), Medical Review Guidance, §3.3.2.4 (Rev. 604, Effective 8/25/2015), Signature Requirements, and §3.4.1.1 (Rev. 377, Effective 6/28/2011), Linking LCD and NCD ID numbers to Edits, Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 7/1/2016, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 7/1/2016, Local Coverage Determinations (LCDs) L11500, L5008, L27025, and L11489 – Negative Pressure Wound Therapy Pumps, Effective 10/1/2000; Retired 9/30/2015, MAC Policy Articles A35347, A35363, A47111, and A35425, Effective 10/1/2005; Retired 9/30/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)