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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Unbundling of Critical Care
_0098
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
06/16/2018

Unbundling of Critical Care

Issue Name: Unbundling of Critical Care
Issue Number: _0098
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/16/2018
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: Region-1
References:     Title XVIII of the Social Security Act: Section 1833€, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.12 (J) effective 7/25/14
Implantable Automatic Defibrillators
_0093
Complex
Outpatient Hospital, ASC, Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
05/15/2018

Implantable Automatic Defibrillators

Issue Name: Implantable Automatic Defibrillators
Issue Number: _0093
Review Type: Complex
Provider Type: Outpatient Hospital, ASC, Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/15/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and after 2/15/2018
Description: The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications as published in the CMS National Coverage Determinations (NCD) Manual, Publication 100-03, Section 20.4 and CMS IOM 100-04, Ch. 32 §§270,270.1,270.2. Affected Codes: 33240, 33241, 33243, 33244, 33249.
References:   CMS 100-03 Chapter 1, Part 1, §20.4, Effective 1/27/2005, CMS IOM 100-04 Chapter 32, §§270 Effective: 8-31-10, 270.1 Effective: Upon implementation of ICD-10, 270.2 Effective: Upon implementation of ICD-10
Group 3 Pressure Reducing Support Surfaces
_0094
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
05/15/2018

Group 3 Pressure Reducing Support Surfaces

Issue Name: Group 3 Pressure Reducing Support Surfaces
Issue Number: _0094
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/15/2018
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 Group 3 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0194 Air Fluidized Bed.
References: Title XVIII, Social Security, §1833€, Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c) and section 405.986, Code of Federal Regulations, 42 CFR; section 410.38(g)(3), Code of Federal Regulations, 42 CFR; section 410.38(g)(4), Code of Federal Regulations, 42 CFR; section 424.57 (12), Medicare Benefit Policy Manual, Chapter 15, Section 110, Durable Medical Equipment – General, Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8, Air-Fluidized Beds, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 30 Section 50.13.4, Supplier’s Right to Recovery Resalable Items for Which Refund Has Been Made, Medicare Program Integrity Manual, (IOM) Publication 100-8, Chapter 4, Section 4.26, Supplier Proof of Delivery Documentation Requirements, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, Nationwide Local Coverage Determination (LCD) L33692, Pressure Reducing Support Surfaces - Group 3 Effective 10/1/2015; Revised 01/01/2017, Policy Article A52468, Pressure Reducing Support Surfaces - Group 3 Effective 10/01/2015 Revised 01/01/2017.
Duplicate Payment - Exact
_0091
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
05/11/2018

Duplicate Payment - Exact

Issue Name: Duplicate Payment - Exact
Issue Number: _0091
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/11/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Duplicate claims are any claims paid across more than one claim number for the same Beneficiary, CPT/HCPCS code and service date by the same provider. Affected Codes: All CPT, HCPCS Codes
References: Title XVIII of the Social Security Act: Section 1833€ , Medicare Financial Management Manual: Publication 100-06; Chapter 3, Section 10.2, Medicare Claims Processing Manual: Publication 100-04; Chapter 1, § 120.2 (B), Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 20.4.2, Medicare Claims Processing Manual: Publication 100-04; Chapter 26, § 10.5.
Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array
_0092
Complex
Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region-1
1 - All Region 1 states
05/08/2018

Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array

Issue Name: Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array
Issue Number: _0092
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/08/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Providers that submit and were paid for code, 64553 and/ or code 64555 must support in the documentation that the code billed was actually the service rendered and that all coverage criteria were met.
References: " Social Security Act: Section 1833€, 42 Code of Federal Regulations §411.15(k)(1), Centers for Medicare & Medicaid Services, Internet Only Manual 100-3, National Coverage
Technical Component of Lab/Pathology for Outpatient Hospitals
_0090
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
04/03/2018

Technical Component of Lab/Pathology for Outpatient Hospitals

Issue Name: Technical Component of Lab/Pathology for Outpatient Hospitals
Issue Number: _0090
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/03/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: The technical component (TC) of lab/pathology services furnished to patients in an outpatient hospital setting are not separately payable. Findings are limited to claim lines billed with modifier TC and claim lines for service codes with TC/PC Indicator “3” for TC component only. Affected Codes See Appendix D.
References:    Title XVIII of the Social Security Act: Section 1833€, Medicare Claims Processing Manual 100-04; Chapter 23; File Layout
Ventilators Subject to ACA Requirements Prior to January 1, 2016
_0082
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
03/14/2018

Ventilators Subject to ACA Requirements Prior to January 1, 2016

Issue Name: Ventilators Subject to ACA Requirements Prior to January 1, 2016
Issue Number: _0082
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/14/2018
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 Ventilators meet coverage criteria and/or are medically reasonable and necessary. Affected Codes: E0450, E0460, E0461, E0463, E0464.
References: Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c) and section 405.986, Code of Federal Regulations, 42 CFR; section 410.38(g)(3), Code of Federal Regulations, 42 CFR; section 410.38(g)(4), Code of Federal Regulations, 42 CFR; section 424.57 (a)(12), Title XVIII, Social Security, §1833(e), Title XVIII, Social Security, §1862(a)(1)(A), CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20, CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1.
Lab Services Rendered During an Inpatient Stay
_0085
Automated
Lab and Outpatient
Region-1
1 - All Region 1 states
03/19/2018

Lab Services Rendered During an Inpatient Stay

Issue Name: Lab Services Rendered During an Inpatient Stay
Issue Number: _0085
Review Type: Automated
Provider Type: Lab and Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Laboratory services are covered under Part A, excluding anatomic pathology services and certain clinical pathology services, therefore if billed separately should be denied as unbundled services, according to 1. CMS IOM 100-04 Chapter 3, section 10.4. See 0085 Appendix D for affected codes.
References:     CMS IOM 100-04 Chapter 3, section 10.4, CPT Coding Book
Cataract Removal Excessive Units - Partial Denial
_0083
Automated
Professional Services, Outpatient, ASC
Region-1
1 - All Region 1 states
03/19/2018

Cataract Removal Excessive Units - Partial Denial

Issue Name: Cataract Removal Excessive Units - Partial Denial
Issue Number: _0083
Review Type: Automated
Provider Type: Professional Services, Outpatient, ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Cataract removal cannot be performed more than once on the same eye on the same date of service. This query identifies overpayments where providers are billing for more than one unit of cataract removal for the same eye, on the same line of the claim. Affected codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
References:      Title XVIII of the Social Security Act: Section 1833€, Title XVIII of the Social Security Act: Section 1862(a)(1)(A), National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D) .