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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Complex Home Health Review: Documentation and Medical Necessity
_0075
Complex
Home Health Agencies
5
All HHA MACs except for the following demonstration states: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia
01/10/2018

Complex Home Health Review: Documentation and Medical Necessity

Issue Name: Complex Home Health Review: Documentation and Medical Necessity
Issue Number: _0075
Review Type: Complex
Provider Type: Home Health Agencies
Region: 5
State: All HHA MACs except for the following demonstration states: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia
Date Approved: 01/10/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Medical Necessity and Documentation Review. Affected Codes: Revenue Codes: 027X, 042X, 043X, 044X, 055X, 056X, 057X.
References: SSA XVIII, §1814(a)(2)(C), SSA XVIII, §1815, SSA XVIII, §1835(a)(2)(A), SSA XVIII, §1861(m), SSA XVIII, §1861(o), SSA XVIII, §1861®, SSA XVIII, §1861(aa)(5), SSA XVIII, §1861(gg)(2), SSA XVIII, §1891, 42 CFR §409.41 - 42 CFR §409.47, CFR 42 §424.22(a)(1)(i)-(v), IOM 100-01, Chapter 4, §10.2, IOM 100-01, Chapter 4, §30.1, IOM 100-02, Chapter 7, §30.1.1, IOM 100-02, Chapter 7, §30.2.1, IOM 100-02, Chapter 7, §30.5.1.1, IOM 100-02, Chapter 7, §30.5.1.2
_Respiratory Assist Device
_0069
Complex
DME by supplier; DME by physician
5
5-Nationwide
12/17/2017

_Respiratory Assist Device

Issue Name: _Respiratory Assist Device
Issue Number: _0069
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5-Nationwide
Date Approved: 12/17/2017
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 Respiratory Assist Devices meet coverage criteria and /or are medically reasonable and necessary. Affected Codes: E0470 - Respiratory Assist Device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device); E0471 - Respiratory Assist Device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
References: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, 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, CGS and Noridian Healthcare Solutions LCD L33800: Effective 10/01/2015, CGS LCD L5023: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, NGS LCD L27228: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015,NHIC LCD L11504: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, Noridian LCD L11493: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, CGS and Noridian Healthcare Solutions Article A52517: Effective 10/01/2015, CGS Article A23974: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, NGS Article A47231: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, NGS Article A47231: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, Noridian Article A23902: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017.
Outpatient Service Overlapping or During an Inpatient Stay
_0072
Automated
Hospital Outpatient, Hospital Inpatient Part B
1
1 - All Region 1 States
10/26/2017

Outpatient Service Overlapping or During an Inpatient Stay

Issue Name: Outpatient Service Overlapping or During an Inpatient Stay
Issue Number: _0072
Review Type: Automated
Provider Type: Hospital Outpatient, Hospital Inpatient Part B
Region: 1
State: 1 - All Region 1 States
Date Approved: 10/26/2017
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: Payment may not be made for outpatient services overlapping or during an inpatient stay.
References: Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: Publication 100-04; Ch. 1, §120.2 (A), Ch.3, §40.3B Ch. 4, §200.2, Ch. 18, §10.2, Medicare Financial Management Manual: Publication 100-06; Ch. 3, §10.2, Medical Benefit Policy Manual: Publication 100-2; Ch. 6, §10.2.
Critical Care Billed on the Same Day as Emergency Room Services
_0070
Automated
Physician/Non-Physician Practitioner
1
1 - All Region 1 States
10/19/2017

Critical Care Billed on the Same Day as Emergency Room Services

Issue Name: Critical Care Billed on the Same Day as Emergency Room Services
Issue Number: _0070
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: 1
State: 1 - All Region 1 States
Date Approved: 10/19/2017
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: Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician or physician group with the same specialty to the same patient. Affected Codes: 99281, 99282, 99283, 22984, 99285.
References: Title XVIII of the Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.12 (H) & (I)
Excessive Units - Untimed Therapy
_0060
Automated
Outpatient Hospital; Part B Professional Services; Outpatient Non-Hospital Facility; Skilled Nursing Facility (SNF); Outpatient Rehab Facility (ORF); Comprehensive Outpatient Rehab Facility (CORF); Physician and Non-Physician Practitioner/ Provider Specialty;
1
1 - All Region 1 states
09/20/2017

Excessive Units - Untimed Therapy

Issue Name: Excessive Units - Untimed Therapy
Issue Number: _0060
Review Type: Automated
Provider Type: Outpatient Hospital; Part B Professional Services; Outpatient Non-Hospital Facility; Skilled Nursing Facility (SNF); Outpatient Rehab Facility (ORF); Comprehensive Outpatient Rehab Facility (CORF); Physician and Non-Physician Practitioner/ Provider Specialty;
Region: 1
State: 1 - All Region 1 states
Date Approved: 09/20/2017
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: "When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider should enter a 1 in the units bill column per date of service. Affected Codes: ""92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97028, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, G0281, G0283, G0329. For CPT Codes 97001, 97002, 97003, 97004 only select claims with dates of service prior to 01/01/2017. For CPT Codes 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168 only select claims with dates of service on or after 01/1/2017.
References: Title XVIII of the Social Security Act: Section 1833€, Title XVIII of the Social Security Act: Section 1862(a) (1) (A), CMS Pub 100-04, Ch. 5, § 20.2, 4. American Medical Association (AMA), Current Procedure Terminology 2014 to current, Medicare Benefit Policy Manual: Chapter 15, Sections 220 and 230, CMS Pub 100-04 CR 9698 December 1, 2016 (Transmittal 3670)
Complex PAP Devices for the Treatment of Obstructive Sleep Apnea
_0066
Complex
DME by supplier; DME by physician
5
5 - Nationwide
09/19/2017

Complex PAP Devices for the Treatment of Obstructive Sleep Apnea

Issue Name: Complex PAP Devices for the Treatment of Obstructive Sleep Apnea
Issue Number: _0066
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5 - Nationwide
Date Approved: 09/19/2017
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 PAP Devices for the Treatment of Obstructive Sleep Apnea meet coverage criteria and /or are medically reasonable and necessary. Affected Codes: E0601 and E0470.
References: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, CMS IOM 100-03, Medicare National Coverage Determination Manual, NCD Section 240.4, Effective date 04/04/2005, CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110,CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, 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, CGS and Noridian Healthcare Solutions LCD L33718: Effective 10/01/2015, CGS LCD L11518: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, NGS LCD L27230: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, NHIC LCD L11528: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, Noridian LCD L171: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, CGS and Noridian Healthcare Solutions Article A52467: Effective 10/01/2015, CGS Article A20195: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, NGS Article A47228: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, NHIC Article A19815: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, Noridian Article A19827: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017
Arthroscopic Limited Shoulder Debridement
_0057
Complex
Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non- physician Practitioner (NPP)
1
1 - All Region 1 states
09/11/2017

Arthroscopic Limited Shoulder Debridement

Issue Name: Arthroscopic Limited Shoulder Debridement
Issue Number: _0057
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non- physician Practitioner (NPP)
Region: 1
State: 1 - All Region 1 states
Date Approved: 09/11/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822). Code 29822, is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same beneficiary at the same encounter. Affected Codes: When CPT code 29822 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828 for the same date of service, for the same beneficiary, for the same shoulder, at the same encounter, if the provider or facility was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, and/or 29828, then 29822 will be denied. es:
References: Title XVIII of the Social Security Act (SSA), Section 1833(e) and 1862(a)(1)(A), 42 Code of Federal Regulations §§411.15(k)(1), 424.5(a)(6), Internet Only Manual, CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 16 §20, National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014- January 1, 2017.
Inpatient Psychiatric Facility Services - Complex Review
_0067
Complex
Inpatient Hospital
1
1 - Region 1 All states
09/08/2017

Inpatient Psychiatric Facility Services - Complex Review

Issue Name: Inpatient Psychiatric Facility Services - Complex Review
Issue Number: _0067
Review Type: Complex
Provider Type: Inpatient Hospital
Region: 1
State: 1 - Region 1 All states
Date Approved: 09/08/2017
Dates Service: Less than 3 years (after 10/01/2015)
Description: Inpatient hospital services furnished to a patient of an inpatient psychiatric facility will be reviewed to determine that services were medically reasonable and necessary
References: Title XVIII of the Social Security Act (SSA): Section 1833(e), Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A), Title VIII of the Social Security Act (SSA): Section 1814 (a)(2)(A) and (4), Title XVIII of the Social Security Act (SSA): Section 1835 (a) , CMS Publication 100-01, Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, MS Publication 100-02, Medicare Benefit Policy Manual, Chapter 2,7. CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 3 Federal Regulation References, 42 CFR 409.62; 42; CFR 412.404; CFR 424.14; 42 CFR 412.27 and 42 CFR 482.61, Fourth Edition, Text Revision of the American Psychiatric Associations Diagnostic and Statistical Manual, ICD-10-CM codebook, Chapter 5 – Mental Disorders.
DME CPAP without Obstructive Sleep Apnea Diagnosis
_0065
Automated
DME Supplier, DME by Physician
5
5 - Nationwide
09/08/2017

DME CPAP without Obstructive Sleep Apnea Diagnosis

Issue Name: DME CPAP without Obstructive Sleep Apnea Diagnosis
Issue Number: _0065
Review Type: Automated
Provider Type: DME Supplier, DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 09/08/2017
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: To identify improper payments for automated claims for CPAP with the missing diagnosis of Obstructive sleep apnea, for DME Suppliers and DME by Physician, using error code 2500, including all places of services for Part B DME claims. Affected Codes: E0601/
References: CMS Pub. 100-3, (Medicare National Coverage Determinations Manual), Section 240.4