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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Automated Arthroscopic Limited Debridement
_0117
Automated
Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered  prior to 10/1/2017 due to change from T (multiple surg payment)  to J1 (APC payment).
Region-1
1 - All Region 1 states
10/19/2018

Automated Arthroscopic Limited Debridement

Issue Name: Automated Arthroscopic Limited Debridement
Issue Number: _0117
Review Type: Automated
Provider Type: Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered  prior to 10/1/2017 due to change from T (multiple surg payment)  to J1 (APC payment).
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822). Code 29822, is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same beneficiary at the same encounter. Affected codes: When CPT code 29822 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828 for the same date of service, for the same beneficiary, for the same shoulder, at the same encounter, if the provider was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, and/or 29828, then 29822 will be denied.
References: Title XVIII of the Social Security Act (SSA), Section 1833(e) and 1862(a)(1)(A); 42 Code of Federal Regulations §§411.15(k)(1), 424.5(a)(6); Internet Only Manual, CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16 §20.; National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014- current
Home Visits Physician Services Overlapping Inpatient Stay
_0115
Automated
Physician Claims
Region-1
1 - All Region 1 states
10/16/2018

Home Visits Physician Services Overlapping Inpatient Stay

Issue Name: Home Visits Physician Services Overlapping Inpatient Stay
Issue Number: _0115
Review Type: Automated
Provider Type: Physician Claims
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/16/2018
Dates Service: Claims having a “claim paid date” which is on or after October 1, 2015 (ICD-10 codes only)
Description: Home Visits for physician services should not overlap an active Inpatient Stay. Providers cannot billed for services that are rendered. Affected codes: See Appendix D in downloadable Excel file
References: Title XVIII of the Social Security Act: Section 1833(e); Medicare Claims Processing Manual: Publication 100-04; Chapter 1, § 120.2 (B)
Improperly Paid Modifiers TC and 26
_0116
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
10/12/2018

Improperly Paid Modifiers TC and 26

Issue Name: Improperly Paid Modifiers TC and 26
Issue Number: _0116
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review)
Description: HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed. Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied.
References: 1. Title XVIII of the Social Security Act: Section 1833€; 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23; Addendum - MPFSDB Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf
Transthoracic Echocardiography: Medical Necessity
_0111
Complex
Inpatient Hospital, Outpatient Hospital, SNF
Region-1
CGS, NGS, Palmetto
10/12/2018

Transthoracic Echocardiography: Medical Necessity

Issue Name: Transthoracic Echocardiography: Medical Necessity
Issue Number: _0111
Review Type: Complex
Provider Type: Inpatient Hospital, Outpatient Hospital, SNF
Region: Region-1
State: CGS, NGS, Palmetto
Date Approved: 10/12/2018
Dates Service: Claims billed on or after 10/1/2015. For Palmetto- Claims billed on or after 9/18/2017
Description: Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary. Affected codes: 0111 Appendix D in downloadable Excel file
References: Social Security Act (Section 1833(e); Social Security Act (Section 1862(a)(1)(A); Social Security Act (Section 1862(a)(7); 42 CFR §410.32(a) ; 42 CFR §411.15(k)(1); Medicare Benefit Policy Manual, Pub 100-02, Chapter 15, §§80.6-80.6.4; Medicare Claims Processing Manual, Pub 100-04, Chapter 9, §100; Medicare Claims Processing Manual, Pub 100-04, Chapter 12, §30.4; CGS LCD L34338; Effective date 10/1/2015; Revised 10/1/2017; First Coast LCD L33768; Effective date 10/1/2015; Revised 10/1/2017; NGS LCD L33577; Effective date 10/1/2015; Revised 10/1/18; Palmetto LCD L37379; Effective date 9/18/2017; Revised 2/26/2018; Annual American Medical Association CPT Manual, Coding Guidelines
Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary
_0073
Complex
Inpatient Rehabilitation Facility
Region-1
1 - All Region 1 states
10/12/2018

Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary

Issue Name: Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary
Issue Number: _0073
Review Type: Complex
Provider Type: Inpatient Rehabilitation Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: Inpatient hospital services furnished to a patient in an inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary
References: 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; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system; 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, and (5)- Interdisciplinary Team Approach to Care; Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.3- Documentation Requirements for Therapy Services; Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS; Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements
DME While in Hospice
_0114
Automated
DME Supplier/DME by Physician
Region-5
5 - Nationwide
09/20/2018

DME While in Hospice

Issue Name: DME While in Hospice
Issue Number: _0114
Review Type: Automated
Provider Type: DME Supplier/DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/20/2018
Dates Service: Less than 3 years prior to the Initial Finding Letter date
Description: All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D of the downloadable Excel file.
References: 1. Code of Federal Regulations 42, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals; 2. CMS Pub. 100-2, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance, Section 10; 3. CMS Pub. 100-4, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims, Section 10, Section 30.3, Section 40.2; 4. CMS Pub 100-4, Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Section 10.2
Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial
_0110
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/20/2018

Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial
Issue Number: _0110
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Exclude Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And prior to January 1, 2016.
Description: Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Admin. Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Affected codes: CPT/HCPCS codes listed on the Appendix D of the downloadable Excel file - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier. (https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation.html)
References: 1. Title XVIII of the Social Security Act: Section 1833(d), 2. Medicare Claims Processing Manual: Publication 100-04; Chapter 6, § 20.1.1; 3. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation - https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html
Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full
_0109
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/20/2018

Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full
Issue Number: _0109
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Exclude Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And prior to January 1, 2016.
Description: Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Admin. Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Affected Codes: All CPT/HCPCS codes Excluding those service codes listed in 109 Appendix D of the downloadable Excel file.
References: 1. Title XVIII of the Social Security Act: Section 1833(d), 2. Medicare Claims Processing Manual: Publication 100-04; Chapter 6, § 20.1.1; 3. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation - https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html
Facility vs Non-Facility Reimbursement
_0108
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/14/2018

Facility vs Non-Facility Reimbursement

Issue Name: Facility vs Non-Facility Reimbursement
Issue Number: _0108
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/14/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the date of the informational Letter
Description: Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The rate, facility or nonfacility, which a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. Download Excel file for affected POS code list in _0108 Appendix D
References: 1. Title XVIII of the Social Security Act: Section 1833€, 2. Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 20.4.2