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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Cataract Removal Excessive Units - Full Denial
_0084
Automated
Physician/Non-Physician Practitioner, Outpatient, ASC
Region-1
1 - All Region 1 states
03/19/2018

Cataract Removal Excessive Units - Full Denial

Issue Name: Cataract Removal Excessive Units - Full Denial
Issue Number: _0084
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner, 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: CPT Codes describing cataract extraction are mutually exclusive of one another. Only one code from the affected CPT code range may be reported per date of service and for each eye. 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)
Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission
_0086
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
03/19/2018

Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission

Issue Name: Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission
Issue Number: _0086
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
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: 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.
References: Title XVIII of the Social Security Act: Section 1833€, Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.8 (D)
CSW (Clinical Social Workers) during Inpatient Hospital
_0089
Automated
Clinical Social Workers
Region-1
1 - All Region 1 states
03/19/2018

CSW (Clinical Social Workers) during Inpatient Hospital

Issue Name: CSW (Clinical Social Workers) during Inpatient Hospital
Issue Number: _0089
Review Type: Automated
Provider Type: Clinical Social Workers
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: Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facilities PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility. Affected Codes: 90801, 90899. {sucjoatru CPT Codes: 90785-90899
References: "42 CFR 409.10 (a)(4), 42 CFR 410.73, 42 CFR 412.50 (b), Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Title XVIII of the Social Security Act, Section 1861 (hh) and (hh)(2). [42 U.S.C. 13951], Medicare Benefit Policy Manual 100-02; Chapter 15, Section 170, Medicare Claims Processing Manual 100-04; Chapter 3, Section 10.4, WPS Local Coverage Article A54829; Effective 02/01/2016
Ancillary Services Billed Without an Approved Surgical Procedure
_0088
Automated
Ambulatory Surgery Center (ASC)
Region-1
1 - All Region 1 states
03/16/2018

Ancillary Services Billed Without an Approved Surgical Procedure

Issue Name: Ancillary Services Billed Without an Approved Surgical Procedure
Issue Number: _0088
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/16/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Covered ancillary items and services identified in Appendix D are not payable if there is no approved ASC surgical procedure on the same claim or in history for the same date of service and same provider.
References:    Title XVIII of the Social Security Act: Section 1833€ , Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 14, § 40
Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD
_0087
Automated
Professional Services(Physician/Non-Physician Practitioner); Laboratory
Region-1
Professional Services (Physician/Non-Physician Practitioner)
03/16/2018

Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD

Issue Name: Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD
Issue Number: _0087
Review Type: Automated
Provider Type: Professional Services(Physician/Non-Physician Practitioner); Laboratory
Region: Region-1
State: Professional Services (Physician/Non-Physician Practitioner)
Date Approved: 03/16/2018
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 ESRD PPS includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Should these laboratory services, and limited drugs be provided to a beneficiary, but are not related to the treatment for ESRD, the claim lines must be submitted with the new AY modifier to allow for separate payment outside of ESRD prospective payment system. Affected codes: See 0087 Appendix D code list.
References:   Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual 100-04; Chapter 8, Section 60.1 (effective 4/01/2015), 3. ESRD PPS Consolidated Billing (files for 2014 – 2017) www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
Complex Negative Pressure Wound Therapy Pumps-DWO
_0081
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/26/2018

Complex Negative Pressure Wound Therapy Pumps-DWO

Issue Name: Complex Negative Pressure Wound Therapy Pumps-DWO
Issue Number: _0081
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/26/2018
Dates Service: Less than 3 years and on or after 5/25/2017
Description: Medical Necessity Review Negative Pressure Wound Therapy Pumps - Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in Local Coverage Determination (LCD) L33821 (related MAC Policy Article A52511). Affected Codes: E2402 - NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE A6550 - WOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDES ALL SUPPLIES AND ACCESSORIES A7000 - CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833€, Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, §110, Durable Medical Equipment – General, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 34, §10.6.1, Timeframes for Contractor Initiated Reopenings and 10.6.2, Timeframes for Party Requested Reopenings Revision for both sections, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, §§5.7, Documentation in the Patient's Medical Record, 5.8, Supplier Documentation (Rev. 612, Effective 9/29/2015), and 5.9, Evidence of Medical Necessity, Chapter Revision 623 11/03/2015, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, §§ 3.3.2 (Rev. 377, Effective 6/28/2011), Medical Review Guidance, §3.3.2.4 (Rev. 604, Effective 8/25/2015), Signature Requirements, and §3.4.1.1, Linking LCD and NCD ID numbers to Edits, Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017.
Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
_0080
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/20/2018

Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO

Issue Name: Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
Issue Number: _0080
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/20/2018
Dates Service: Less than 3 years and on or after 5/25/2017
Description: Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0277, E0371, E0372, E0373.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833€, Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, §110, Durable Medical Equipment – General, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 34, §10.6.1, Timeframes for Contractor Initiated Reopenings and 10.6.2, Timeframes for Party Requested Reopenings Revision for both sections, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, §§5.7, Documentation in the Patient's Medical Record, 5.8, Supplier Documentation (Rev. 612, Effective 9/29/2015), and 5.9, Evidence of Medical Necessity, Chapter Revision 623 11/03/2015, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, §§ 3.3.2 (Rev. 377, Effective 6/28/2011), Medical Review Guidance, §3.3.2.4 (Rev. 604, Effective 8/25/2015), Signature Requirements, and §3.4.1.1, Linking LCD and NCD ID numbers to Edits, Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017.
Complex Cardiac Pacemaker Review
_0078
Complex
Outpatient, Ambulatory Surgery Center
1
1 - All Region 1 States
02/15/2018

Complex Cardiac Pacemaker Review

Issue Name: Complex Cardiac Pacemaker Review
Issue Number: _0078
Review Type: Complex
Provider Type: Outpatient, Ambulatory Surgery Center
Region: 1
State: 1 - All Region 1 States
Date Approved: 02/15/2018
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 Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. Affected Codes: 33206, 33207, 33208.
References: Social Security Act (Section 1862(a)(1)(A), 42 CFR §§405.980(b) and ©, 42 CFR §§ 405.986, CMS Pub. 100-03, Medicare National Coverage Determinations (NCD), Ch. 1, Part 1, §20.8.3, Effective Date of this Version 8/13/2013, Cahaba Local Coverage Article A54949, Effective Date 4/15/2016, First Coast Local Coverage Article A54926, Effective date 5/1/2016, NGS Local Coverage Article A54909, Effective Date 4/15/2016, Novitas Local Coverage Article A54982, Effective Date 5/1/2016, Palmetto Local Coverage Article A54831, Effective Date 01/13/2016, WPS Local Coverage Article A54958, Effective Date 5/15/2016, CGS Local Coverage Article A54961, Effective 05/01/2016, Annual American Medical Association CPT Manual, Coding Guidelines
Evaluation and Management (E/M)Same Day as Dialysis
_0076
Automated
Physician/Non-Physician practitioner(NPP)
1
1 - All Region 1 States
01/16/2018

Evaluation and Management (E/M)Same Day as Dialysis

Issue Name: Evaluation and Management (E/M)Same Day as Dialysis
Issue Number: _0076
Review Type: Automated
Provider Type: Physician/Non-Physician practitioner(NPP)
Region: 1
State: 1 - All Region 1 States
Date Approved: 01/16/2018
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: Except When Reported with Modifier 25, Payment for certain evaluation and management services is bundled into the payment for dialysis serices 90935, 90937, 90945, 90947. Affected Codes: 99201 -99205, 99211-99215, 99221-99223, 99238-99239, 99241-99245, 99251-99255, and 99291-99292
References: Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual: Publication 100-04; Chapter 8, § 170 (B); 3. Medicare Claims Processing Manual: Publication 100-04; Chapter 12, §30.6.10