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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Medical Necessity Cardiac Rehabilitation
_0135
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
03/07/2019

Medical Necessity Cardiac Rehabilitation

Issue Name: Medical Necessity Cardiac Rehabilitation
Issue Number: _0135
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/07/2019
Dates Service: 3 years
Description: Cardiac rehabilitation (CR) is a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcome assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.
References: Social Security Act § 1862 (a)(1)(A); Social Security Act § 1833 (e); Social Security Act § 1861 (s)(2)(CC)(e); 42 .F.R. §§ 410.49 ; CMS National Coverage Determinations (NCD), Pub. 100-03, Section 20.10.1, 20.31, 20.31.1, 20.31.2, and 20.31.3; CMS Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 232; CMS Claim Processing Manual, Pub. 100-04, Chapter 32, Section 140; CMS Transmittal R1974CP, Issued /21/2010, Implementation Date 10/4/2010; CMS Transmittal R126BP, Issued 5/21/2010, Implementation Date 10/4/2010; CMS Transmittal R339PI, Issued 5/21/2010, Implementation Date 10/4/2010; Palmetto LCD L34412 Cardiac Rehabilitation, Effective Date 10/1/2015; Palmetto LCA A53775 Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Supplemental Instruction Article, Effective Date 10/1/2015
Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
_0138
Automated
Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region-1
1 - All Region 1 states
02/19/2019

Skilled Nursing Facility (SNF) Consolidated Billing for Therapies

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
Issue Number: _0138
Review Type: Automated
Provider Type: Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement for services furnished to SNF Part B residents. Affected codes: Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing tables (See Appendix D in downloadable file for a detailed list of CPT/HCPCS including descriptions).
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 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 Claims Processing Manual: Publication 100-04; Chapter 6; 10.3 – Types of Services Subject to the Consolidated Billing Requirement for SNF; 20.5- Therapy Services; Medicare Claims Processing Manual: Publication 100-04; Chapter 7; 110, Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay
Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
_0125
Automated
Professional Services and CAHs type of bill 85x identified by revenue codes 96x, 97x or 98x
Region-1
1 - All Region 1 states
02/21/2019

Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)

Issue Name: Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
Issue Number: _0125
Review Type: Automated
Provider Type: Professional Services and CAHs type of bill 85x identified by revenue codes 96x, 97x or 98x
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/21/2019
Dates Service: Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review).
Description: Medicare reimbursement for telehealth services include subsequent hospital care services and subsequent nursing facility care services. However, subsequent hospital care visits are limited to one telehealth visit every three days for hospital inpatients and one subsequent nursing facility telehealth visit every 30 days for nursing facility residents. Affected codes: Telehealth eligible CPT Codes 99231, 99232, 99233, 99307, 99308, 99309, 99310
References: "1. 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services 7. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.3 - List of Medicare Telehealth Services 8. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.2 -Eligibility Criteria 9. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.6 -Payment Methodology for Physician/Practitioner at the Distant 10. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners"
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."
Panniculectomy: Medical Necessity and Documentation Requirements
_0130
Complex
Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region-1
1 - All Region 1 states
02/12/2019

Panniculectomy: Medical Necessity and Documentation Requirements

Issue Name: Panniculectomy: Medical Necessity and Documentation Requirements
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. 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. Title XVIII of the Social Security Act (SSA): 1862(a)(10) 4. 42 CFR §411.15 Particular services excluded from coverage, (k)(1) 5. 42 CFR §424.5 Basic conditions, (a)(6) Sufficient information 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. 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 9. Medicare Benefit Policy Manual, Chapter 16- General Exclusion from Coverage, §10- General Exclusions from Coverage, §20- Services Not Reasonable and Necessary 10. Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage, §120 – Cosmetic Surgery 11. Medicare Claims Processing Manual Chapter 12 Physicians/Nonphysician Practitioners, §40.6 Claims for Multiple Surgeries (A) General 12. National Correct Coding Initiative Policy Manual, Chapter 6 Surgery: Digestive System CPT Codes 40000 - 49999, E Abdominal Procedures, 7, Revised 1/1/2019 13. National Correct Coding Initiative Policy Manual, Chapter 6 Surgery: Digestive System CPT Codes 40000 - 49999, E Abdominal Procedures, 8, Revised 1/1/2019 14. Novitas LCD L35090: Cosmetic and Reconstructive Surgery, Effective 10/1/2015; Revised 4/14/2017 15. WPS L34698: Cosmetic and Reconstructive Surgery, Effective 10/01/2015; Revised 01/01/2018; 02/01/2016; 10/01/2016; 01/01/2017 16. Palmetto GBA L33428: Cosmetic and Reconstructive Surgery, Effective 10/01/2015; Revised 10/1/2018 17. Noridian LCD L35163: Plastic Surgery, Effective 10/1/2015; Revised 10/10/2017 18. Noridian LCD L37020: Plastic Surgery, Effective 10/10/2017 19. 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"