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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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: Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And Informational Letter date after 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: Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And Informational Letter date after 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
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: "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 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 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 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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written 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 Determinations L33318: Knee Orthoses, Effective 10/01/2015; Revised 10/16/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52465: Knee Orthoses, Effective 10/01/2015; Revised 01/01/2017 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"
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: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
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 APC Coding Validation
_0101
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
07/26/2018

Outpatient Hospital APC Coding Validation

Issue Name: Outpatient Hospital 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: 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.. See affected codes in Appendix D of the downloadable Excel file
References: 42 Code of Federal Regulations § 414 Payment for Part B Medical and Other Health Services 42 Code of Federal Regulations § 419 Prospective Payment System for Hospital Outpatient Department Services IOM, 100-04, Medicare Claims Processing Manual, Chapter 4, Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§ 10.1- 10.5- 20, 40-61, 100, 120, 150-240, 270, and 300. IOM, 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations American Medical Association (AMA), Current Procedure Terminology, Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1) , APCs for Hospital Part B services paid through a comprehensive APC (SI = J1), Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies (SI = T), Pass-Through Drugs and Biologicals (SI=G), and Nonpass-Through Drugs and Biologicals (SI=K) AMA CPT Assistant National Correct Coding Initiative Policy Manual 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), Appendix D: Computation of Discounting Fraction (OPPS only), and Appendix P: Pass-Through Drugs and Biologicals Processing (OPPS Only, V17.2). CMS Hospital Outpatient PPS, Addendum B Updates, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
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