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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Medical Necessity Vertebroplasty and Kyphoplasty
_0139
Complex
Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
02/19/2019

Medical Necessity Vertebroplasty and Kyphoplasty

Issue Name: Medical Necessity Vertebroplasty and Kyphoplasty
Issue Number: _0139
Review Type: Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date and on/or after 10/01/2015
Description: Medical documentation will be reviewed for correct coding and to determine if vertebroplasty was medically necessary. Affected codes: 22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327 see Appendix D in downloadable xls file
References: "1. Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10). 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 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 4. 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 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions42 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 Part 6. 42 CFR §405.986- Good Cause for reopening 7. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§10 General exclusions from coverage 8. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§20 Services not reasonable and Necessary 9. First Coast Service Options (FCSO) Local overage Determination (LCD) Vertebroplasty, Vertebral Augmentation, percutaneous L34976: Effective 10/01/2015; revised 4/17/18. 10. Novitas LCD L35130 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 05/04/2017. 11. Palmetto LCD L33473 Vertebroplasty/Kyphoplasty: Effective 10/01/2015; Revised 08/09/2018. 12. WPS LCD L34592 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 2/1/18. 13. NGS LCD L33569 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015. 14. Noridian LCD, Percutaneous Vertebral Augmentation, L34106, Effective 10/01/2015 15. Noridian LCD, Percutaneous Vertebral Augmentation, L34228, Effective 10/01/2015 16. CGS LCD, Vertebroplasty and Vertebral Augmentation, L34048, effective 10/01/2015 17. Annual American Medical Association: CPT Manual."
Complex Medical Necessity Panniculectomy
_0130
Complex
Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region-1
1 - All Region 1 states
02/12/2019

Complex Medical Necessity Panniculectomy

Issue Name: Complex Medical Necessity Panniculectomy
Issue Number: _0130
Review Type: Complex
Provider Type: Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/12/2019
Dates Service: Include claims that have a “claim paid date” which is less than 3 years prior to the ADR date.
Description: Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if is incidental to another procedure, is not separately coded per Coding Guidelines. Affected codes: 15830, 15847, 12031, 12032, 12034, 12035, 12036, 12037, 13100, 13101, 13102, 14000, 14001, 14302, 49491, 49492, 49495, 49496, 49500, 49501, 49505, 49507, 49520, 49521, 49525, 49540, 49550, 49553, 49555, 49557, 49560, 49561, 49565, 49566, 49568, 49570, 49572, 49580, 49582, 49585, 49587
References: "1. Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10) 2. 42 CFR §§405.980(b) and (c); 405.986; 411.15(k)(1); 424.5(a)(6) 3. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §§10, 20 4. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §120 – Cosmetic Surgery 5. National Correct Coding Initiative Policy Manual, Chapter 6, E, 7 6. National Correct Coding Initiative Policy Manual, Chapter 6, E, 8 (2018-2019) 7. Medicare Claims Processing Manual Chapter 12, §40.6 (A) 8. Novitas LCD L35090: Effective 10/1/2015; Revised 4/14/2017 9. WPS L34698: Effective 10/01/2015; Revised 01/01/2018; 02/01/2016; 10/01/2016; 01/01/2017 10. Palmetto GBA L33428: Effective 10/01/2015; Revised 10/1/18 11. Noridian LCD L35163: Effective 10/1/2015; Revised 10/10/2017 12. Noridian LCD L37020: Effective 10/10/2017 13. Annual American Medical Association: CPT Manual"
Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility
_0132
Automated
Physician/ Non-Physician Practitioner
Region-1
1 - All Region 1 states
02/14/2019

Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility

Issue Name: Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility
Issue Number: _0132
Review Type: Automated
Provider Type: Physician/ Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
Dates Service: Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational letter date
Description: CMS will not pay a physician for an emergency department visit or an office visit and a comprehensive nursing facility assessment on the same day. Bundle E/M visits on the same date provided in sites other than the nursing facility into the initial nursing facility care code when performed on the same date as the nursing facility admission by the same physician. Affected codes: CPT 99201 -99215, 99281 – 99285
References: Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215), (C) ; Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.11 Emergency Department Visits (Codes 99281 - 99288), (D) Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission; Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.13 Nursing Facility Services, (A) Visits to Perform the Initial Comprehensive Assessment and Annual Assessments
Cryosurgery of the Prostate Medical Necessity
_0134
Complex
Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
02/14/2019

Cryosurgery of the Prostate Medical Necessity

Issue Name: Cryosurgery of the Prostate Medical Necessity
Issue Number: _0134
Review Type: Complex
Provider Type: Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
Dates Service: 3 years
Description: Claims for Cryosurgery of the Prostate are not deemed to be medically necessary based on the guidelines outlined in the Centers for Medicare and Medicaid National Coverage Determination Manual (Publication 100-03, Part 4, § 230.9).
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 §405.986 Good Cause for Reopening ; 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; CMS National Coverage Determinations Manual (NCD), Pub 100-03, Part 4, §230.9 Cryosurgery of Prostate (Rev. 1, 10-03-03).; CMS Claims Processing Manual, Pub 100-04, Ch. 32, §180 Cryosurgery of the Prostate Gland (Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07).
Issue Name Pneumatic Compression Device
_0131
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide
01/23/2019

Issue Name Pneumatic Compression Device

Issue Name: Issue Name Pneumatic Compression Device
Issue Number: _0131
Review Type: Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/23/2019
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date and prior to 12/01/2015
Description: Pneumatic Compression Devices, HCPCS Codes E0651 and E0652, may have been provided to patients where all Medicare coverage criteria were not met. This review will determine if the pneumatic compression device 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. Affected code E0651 and E0652
References: Title XVIII, Social Security, §1833(e) ; 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, (IOM) Publication 100-03, Chapter 1, Part 4, Section 280.6, Pneumatic Compression Devices; 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, (IOM) Publication 100-8, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9; Local Coverage Determination (LCD) L33829 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2017; MAC Policy Article A52488 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2017; CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 05/07/2018
PET Scans Paid without Tracer Codes for IDTF (Independent Diagnostic Testing Facility) Providers
_0133
Automated
IDTF (Independent Diagnostic Testing Facility), Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
01/30/2019

PET Scans Paid without Tracer Codes for IDTF (Independent Diagnostic Testing Facility) Providers

Issue Name: PET Scans Paid without Tracer Codes for IDTF (Independent Diagnostic Testing Facility) Providers
Issue Number: _0133
Review Type: Automated
Provider Type: IDTF (Independent Diagnostic Testing Facility), Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/30/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: "All PET Scans require the use of radiopharmaceutical diagnostic imaging agent (tracer). Affected codes: PET SCAN CPT Codes - 78491, 78492, 78459, 78608, 78811, 78812, 78813, 78814, 78815, 78816 and temporary codes effective 1/1/2018 A9587 and A9598 Tracer Codes – A9515, A9526, A9552, A9555, A9580, A9586, A9587, and A9588"
References: "1) Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 13, § 60.3.1 – Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005 3) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 13, § 60.3.2 – Tracer Codes Required for Positron Emission Tomography (PET Scans); effective 01-01-18 4) CMS Manual System – Transmittal 3911; Change Request 10319 – Subject: New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes; effective 01-01-18"
Hyperbaric Oxygen Therapy (HBOT) For Diabetic Wounds
_0129
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
01/29/2019

Hyperbaric Oxygen Therapy (HBOT) For Diabetic Wounds

Issue Name: Hyperbaric Oxygen Therapy (HBOT) For Diabetic Wounds
Issue Number: _0129
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/29/2019
Dates Service: 3 years from initial determination date
Description: For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere pressure. The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Medical records will be reviewed to determine if Hyperbaric Oxygen Therapy (HBOT) is medically necessary according to Medicare coverage indications. Affected code: G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
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  ; 42 Code of Federal Regulations §424.5- Basic Conditions, (a)(6)- Sufficient Information ; 42 Code of Federal Regulations §411.15- Particular Services Excluded from Coverage, (k)- Any Services not Reasonable and Necessary, (1); CMS National Coverage Determination Manual, Ch.1, §20.29 Hyperbaric Oxygen Therapy, Effective date 08/11/1997; Annual American Medical Association CPT Manual, Coding Guidelines
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)