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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)
_0128
Automated
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
01/01/2019

Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)

Issue Name: Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)
Issue Number: _0128
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/01/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review)
Description: Claims for more than one spinal orthosis within the reasonable useful lifetime (Spinal Orthosis within the Reasonable Useful Lifetime [RUL]), will be denied. Affected codes: L0627, L0631, L0637, L0642, L0648, L0650
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; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies; 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; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions; 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and edeterminations Initiated by a Contractor;  and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party; 42 CFR §405.986- Good Cause for Reopening; 42 CFR §414.210- General Payment Rules; 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; 42 CFR §424.57(c)- Application Certification Standards; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General; 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; Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements ; Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis; Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity; 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
Transforaminal Epidural Injections Billed with Guidance
_0127
Automated
Professional Services (Physician/non-physician practitioner)
Region-1
1 - All Region 1 states
11/19/2018

Transforaminal Epidural Injections Billed with Guidance

Issue Name: Transforaminal Epidural Injections Billed with Guidance
Issue Number: _0127
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/19/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review)
Description: Based on the American Medical Association (AMA), Current Procedural Terminology (CPT), CPT Codes 77002-77003 and 77012 are not to be reported with CPT Codes 64479-64480 and 64483-64484. Codes 64479 – 64484 already include imaging guidance (fluoroscopy or CT) and guidance codes are not be billed in addition to these procedures. Affected codes: 77002, 77003, 77012, 64479, 64480, 64483, 64484
References: Title XVIII of the Social Security Act: Section 1833(e); American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current (see description included in CPT manual under Radiologic Guidance/Fluoroscopic Guidance)
Part B Therapies in a Hospital Setting (Inpatient)
_0124
Automated
Physical Therapist, Occupational Therapist, Speech language Therapist
Region-1
All A/B MACs
11/29/2018

Part B Therapies in a Hospital Setting (Inpatient)

Issue Name: Part B Therapies in a Hospital Setting (Inpatient)
Issue Number: _0124
Review Type: Automated
Provider Type: Physical Therapist, Occupational Therapist, Speech language Therapist
Region: Region-1
State: All A/B MACs
Date Approved: 11/29/2018
Dates Service: Claims having a "claim paid date" which is less than 3 years prior to the informational letter date (automated review).
Description: "HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist or speech language therapist in private practice. Affected Codes: HCPCS/CPT Codes with a PC/TC Indicator of ""7"" in the MPFSDB (See Appendix D for complete list of HCPCS/CPT code and descriptions)"
References: Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] (e); Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23, Addendum-MPFSDB File, Layouts, 2001-2018 File Layout
Excessive Units of Destruction of Premalignant Lesions
_0121
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
12/03/2018

Excessive Units of Destruction of Premalignant Lesions

Issue Name: Excessive Units of Destruction of Premalignant Lesions
Issue Number: _0121
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/03/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Based on CPT Code descriptions, CPT Code 17000 may only be billed once per date of service; CPT Code 17003 may only be billed thirteen times per date of service and CPT Code 17004 may only be billed once per date of service. Affected codes: 17000, 17003 and/or 17004
References: Title XVIII of the Social Security Act: Section 1833(e); American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current (Destruction, Benign or Premalignant Lesions)
Technical Component (TC) of Diagnostic Procedures during an Inpatient Stay
_0123
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
12/10/2018

Technical Component (TC) of Diagnostic Procedures during an Inpatient Stay

Issue Name: Technical Component (TC) of Diagnostic Procedures during an Inpatient Stay
Issue Number: _0123
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/10/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date (automated reivew)
Description: When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay. Affected codes: CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Layouts, 2011-2018 File Layout; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, § 30 Services Paid Under the Medicare Physician’s Fee Schedule; Medicare Benefit Policy Manual: CMS Publication 100-02; Chapter 15 Covered Medical and Other Health Services, § 30.1 Provider-Based Physician Services
Endoscopy Procedures: Diagnostic and Surgical Same Day
_0126
Automated
Outpatient Facility; ASC; Professional Services
Region-1
1 - All Region 1 states
11/27/2018

Endoscopy Procedures: Diagnostic and Surgical Same Day

Issue Name: Endoscopy Procedures: Diagnostic and Surgical Same Day
Issue Number: _0126
Review Type: Automated
Provider Type: Outpatient Facility; ASC; Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/27/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported. Affected codes: 45331-45335, 45337-45338, 45341-45342, 45346-45347, 45350, 45380-45382, 45384-45386, 45388-45393, 45398, 45378, 45330
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 §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 42 CFR §405.986- Good Cause for Reopening Medicare Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §30- Correct Coding Policy, (E)- Separate Procedures, (G)- Family of Codes, and (H)- Most Extensive Procedures AMA CPT Manual Endoscopy Section; 2015 to current National Correct Coding Initiative Policy Manual for Medicare Services, Chapter VI, §C"
Outpatient Hospice-Related Services
_0122
Automated
Part A Outpatient
Region-1
1 - All Region 1 states
11/28/2018

Outpatient Hospice-Related Services

Issue Name: Outpatient Hospice-Related Services
Issue Number: _0122
Review Type: Automated
Provider Type: Part A Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/28/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately.
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 §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 42 CFR §405.986- Good Cause for Reopening CMS Claims Processing Manual, Chapter 11- Processing Hospice Claims, §10- Overview, §40.2- Processing Professional Claims for Hospice Beneficiaries, §50- Billing and Payment for Services Unrelated to Terminal Illness CMS Benefit Policy Manual 100-02, Chapter 9- Coverage of Hospice Services under Hospital Insurance, §10- Requirements, General"
MCP (Monthly Capitation Payment) for ESRD (End-Stage Renal Disease) Receiving 4 or more Visits per Month
_0112
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
11/12/2018

MCP (Monthly Capitation Payment) for ESRD (End-Stage Renal Disease) Receiving 4 or more Visits per Month

Issue Name: MCP (Monthly Capitation Payment) for ESRD (End-Stage Renal Disease) Receiving 4 or more Visits per Month
Issue Number: _0112
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/12/2018
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review).
Description: A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. If a home dialysis patient receives dialysis in a dialysis center or other outpatient facility during the month, the MCP physician or practitioner is paid the management fee for the home dialysis patient and cannot bill the ESRD-related service codes for managing center based patients. Affected codes: 90951 - 90962
References: Title XVIII of the Social Security Act: Section 1833(e); Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 8, § 140; §140.1 and §140.4; American Medical Association (AMA), Current Procedural Terminology 2015 to current
Modifier 57 for Procedure with a 0 and 10 day Global Indicator
_0120
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
11/02/2018

Modifier 57 for Procedure with a 0 and 10 day Global Indicator

Issue Name: Modifier 57 for Procedure with a 0 and 10 day Global Indicator
Issue Number: _0120
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/02/2018
Dates Service: Less than 3 years
Description: Carriers may not pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period. E&M Codes Included in the Global Package billed with Modifier 57 will be recovered as overpayments as they are not allowed for surgical procedures with a 0 or 10 global surgical period. E&M codes listed in Appendix D
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12- Physician/ Non Physician Practitioner, § 30.6.6 (Payment for Evaluation and Management Services Provided During Global Period of Surgery) Section C: “CPT modifier ‘57’ – Decision for Surgery Made Within Global Surgical Period, effective 06/01/06