Skip to main content

CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

Filter By:
Issue Name Sort by Descending or Ascending
Issue Number Sort by Descending or Ascending
Review Type Sort by Descending or Ascending
Provider Type Sort by Descending or Ascending
Region Sort by Descending or Ascending
State Sort by Descending or Ascending
Date Posted Sort by Descending or Ascending
Details
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
Custom Fabricated Knee Orthosis: Medical Necessity
_0107
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Custom Fabricated Knee Orthosis: Medical Necessity

Issue Name: Custom Fabricated Knee Orthosis: Medical Necessity
Issue Number: _0107
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Claims for Custom Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied. Affected codes L1844, L1846
References: 1. Social Security Act, Section 1833 (e); Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment., 2. 42 Code of Federal Regulations (C.F.R.) §§405.980 (b) and ©, 3. 42 C.F.R. §405.986, 4.  42 CFR 424.57, 5.  CMS 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. , 6. Nationwide LCD L33318, Effective Date 10/01/2015; Revision Effective Date 10/16/2017, 7.  Nationwide A52465 Local Coverage Article: Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 01/01/2017, 8. CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) Effective 01/01/2017, Revised 12/21/2017
Medical Necessity: Parenteral Nutrition
_0106
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Medical Necessity: Parenteral Nutrition

Issue Name: Medical Necessity: Parenteral Nutrition
Issue Number: _0106
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Dates Service: Excludes claims with DOS prior to 10/1/15 and not more than 3 years prior to the ADR date
Description: This review will determine if Parenteral Nutrition is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. B4164,B4168,B4172,B4176,B4178,B4181,B4185,B4189,B4193,B4197,B4199, B4216,B4220,B4222,B4224,B5000,B5100,B5200
References: 1. Title VIII of the Social Security Act, Section 1862(a)(1)(A), 2. Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit, 3. CFR 42: Section 424.57(12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges, 4. CMS NCD Manual, Chapter 1, Part 3, Section 180.2 (Rev. 173, Issued: 09-04-14, Effective: Upon Implementation of ICD-10, 5. Benefit Policy Manual, Chapter 15, Section 120, 6. Program Integrity Manual 3.3.2.4-Signature Requirements Issued: 10-20-17; Effective: 11-20-17; Implementation 11-20-17, 7. Program Integrity Manual 5.2.2-Verbal and Preliminary Written Order Issued 10-09-15; Effective: 11-10-15; Implementation: 11-10-15, 8. Program Integrity Manual 5.2.6 - Date and Timing Requirements Issued: 05-26-17; Effective: 06-27-17; Implementation: 06-27-17), 9. Program Integrity Manual 5.2.8-Refills of DMEPOS Items Provided on a Recurring Basis Issued: 02-19-16; Effective: 03-19-16; Implementation: 03-19-16, 10. Program Integrity Manual 5.3-Certificates of Medical Necessity (CMNs) and DME Information Forms 9DIFs) Issued 10-27-17; Effective: 11-28-17; Implementation: 11-28-17, 11. Program Integrity Manual 5.5.8-Supplier Documentation Issued 10-20-17; Effective: 11-20-17; Implementation 11-20-17, 12. CMS Pub 100-04, Claims Manual, Chapter 20, Rev 3824, 08-02-17, 13. LCD 33798 Effective date 10/01/2015, Revision 01/01/2017, 14. Article 52515: Effective date 10/01/2015, Revision 01/01/2017, 15. Article 55426: Effective date 01/01/2017, Revision 12/21/2017
Physician Services during Hospice Period
_0105
Automated
Physician/Non-Physician Practitioner
Region-1
Region 1 - All States
08/16/2018

Physician Services during Hospice Period

Issue Name: Physician Services during Hospice Period
Issue Number: _0105
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: Region 1 - All States
Date Approved: 08/16/2018
Dates Service: Less than 3 years
Description: Physician services billed during an active hospice period should be paid by the Hospice provider if services are related to the hospice beneficiary's terminal condition or if a physician is employed or paid under arrangement by the beneficiary's hospice provider. Medicare should not be billed for either of the aforementioned scenarios. Affected codes: Any codes except codes 90732, 90471, Q2034, G0008, G0009, G0010, 90460, 90461, 90472, 90655, 90656, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, Q2035, Q2036, Q2037, Q2038, Q2039, 90740, 90743, 90744, 90746, 90747, 90748
References: CMS 100-02 Medicare Benefit Policy Manual, Chapter 9. Coverage of Hospice Services, Section 10 - Requirements; CMS 100-02 Medicare Benefit Policy Manual, Chapter 9, Section 40.1.3 - Physician Services; CMS 100-04 Medicare Processing Manual, Chapter 11, Section 10, Overview; CMS 100-04 Medicare Processing Manual, Chapter 11, Section 40.2, Medicare Claims Processing Manual, Processing Professional Claims for Hospice Beneficiaries; CMS 100-04 Medicare Processing Manual, Chapter 11, Section 50, Billing and Payment for Services Unrelated to Terminal Illness; Code of Federal Regulations Title 42 PART 418.402-HOSPICE CARE-Individual Liability for Services that are not considered hospice care; CMS Pub. 100-04, Chapter 11, Section 20.1 & 30.3
Outpatient Hospital Comprehensive APC Coding Validation
_0101
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
07/26/2018

Outpatient Hospital Comprehensive APC Coding Validation

Issue Name: Outpatient Hospital Comprehensive APC Coding Validation
Issue Number: _0101
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: 01/01/2015
Description: Comprehensive APC 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 APC by reviewing the procedures affecting or potentially affecting the APC assignment. Affected codes: Claims with only status indicator (SI) = J1
References: 1. 42 Code of Federal Regulations §§414, 419 2. Medicare Claims Processing Manual CMS Publication 100-04 Chapter 4 3. Medicare Program Integrity Manual CMS Publication 100-08 Chapter 3 §3.6.2.4 4. American Medical Association (AMA), Current Procedure Terminology, Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1) and APCs for Hospital Part B services paid through a comprehensive APC (SI = J1) 5. AMA CPT Assistant 6. Integrated OCE (IOCE) CMS Specifications Appendix L: Comprehensive APC Assignment Logic (OPPS Only, V16.0, Effective 01/01/2015 through V19.0 Effective 01/01/2018)
Add-on codes paid without Primary Code and/or denied Primary Code – by ASC
_0104
Automated
Ambulatory Surgery Center (ASC)
Region-1
1 - All Region 1 states
07/26/2018

Add-on codes paid without Primary Code and/or denied Primary Code – by ASC

Issue Name: Add-on codes paid without Primary Code and/or denied Primary Code – by ASC
Issue Number: _0104
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: Less than 3 years
Description: CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. ASC providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Affected codes: Add-on Codes (Code list avail in the downloadable excel file, 0104 Appendix D tab)
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 D. 3. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70 4. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8 5. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 (revised 7/23/2013) 6. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html 7. AMA CPT Code book
Urological Supplies Effective 8/1/2018
_0103
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/19/2018

Urological Supplies Effective 8/1/2018

Issue Name: Urological Supplies Effective 8/1/2018
Issue Number: _0103
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/19/2018
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Documentation will be reviewed to determine if Urological Supplies meets coverage criteria and is medically reasonable and necessary. For affected codes download xls file and see appendix D.
References: Title VIII of the Social Security Act, Section 1862(a)(1)(A) ; Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit; 42 CFR 424.57(c)(12) ; CMS, IOM 100-08, Chapter 3, Section 3.3.2.4 ; CMS, IOM 100-08, Chapter 5, Section 5.2.1-8; 5.3; 5.8 ; Local Coverage Determination (LCD) L33803- Urological Supplies: Effective date 10/01/2015; Revised 01/01/2017 ; Local Coverage Article (LCA) A52521- Urological Supplies- Policy Article: Effective date 10/01/2015; Revised 01/01/2017 ; Local Coverage Article (LCA) A55426- Standard Doc Requirements for All Claims Submitted to DME MACs: Effective date 01/01/2017; Revised 12/21/2017
Home Use of Oxygen: Medical Necessity and Certification
_0102
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/12/2018

Home Use of Oxygen: Medical Necessity and Certification

Issue Name: Home Use of Oxygen: Medical Necessity and Certification
Issue Number: _0102
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/12/2018
Dates Service: Less than 3 years and after September 30, 2015
Description: Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary. Affected code E1390
References: 1.      Title XVIII, Social Security, §1833€; 2.      Title XVIII, Social Security, §1861(s)(6); 3.      Title XVIII, Social Security, §1862(a)(1)(A) ; 4.      42 C.F.R. sections 405.980 (b) & (c) and section 405.986 ; 5.      42 CFR 424.57(a)(12)6.      CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2 ; 7.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20; 100.2.3; 8.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 30.6; 130.6; 9.      CMS, IOM Publication 100-02, Benefit Policy Manual 15; 110; 10.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26; 11.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9.1; 12.  Local Coverage Determination L33797: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 13.  Local Coverage Article A52514: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 14.  CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017
MSU Overpayments
_0097
Automated
Professional Services (Physician/Non-Physician Practitioner) who perform surgical procedures
Region-1
1 - All Region 1 states
06/29/2018

MSU Overpayments

Issue Name: MSU Overpayments
Issue Number: _0097
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner) who perform surgical procedures
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/29/2018
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: Multiple surgeries are separate procedures performed on the same patient at the same operative session or on the same day for which separate payment may be allowed. When multiple surgical procedures are performed Medicare Physician Fee Schedule (MPFS) rules state that the second and any subsequent procedures are subject to reduced reimbursement. The Medicare Physician Fee Schedule data Base (MPFSDB) Multiple Procedure Indicators reflect the reduction amount, if any, that is applicable for the surgical procedure. Reducible procedure are ranked in descending order by the Medicare Fee Schedule amount. Payment the the procedure with the highest value is based on 100% of the fee schedule amount. Subsequent procedures are paid based on 50 of the fee schedule amount. Overpayment occur when secondary/subsequent procedure claim lines are not properly reduced due to incorrect primary procedure ranking determinations. Affected code(s): All surgical CPT codes with Multiple Surgery Indicator '2' (Multiple Procedure payment adjustment) found in the MPFSDB. Code list avail in the downloadable excel file, Appendix D tab.
References: 1.  Title XVIII of the Social Security Act: Section 1833€; 2. Title XVIII of the Social Security Act: Section 1862(a)(1)(A); 3. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.6; Claims for Multiple Surgeries; 4.  Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23, § 30; Physician Fee Schedule; Addendum - MPFSDB Record Layouts