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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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)
Part B Therapies during Inpatient: Unbundling
_0124
Automated
Physical Therapist, Occupational Therapist, Speech language Therapist
Region-1
1 - All A/B MACs
11/29/2018

Part B Therapies during Inpatient: Unbundling

Issue Name: Part B Therapies during Inpatient: Unbundling
Issue Number: _0124
Review Type: Automated
Provider Type: Physical Therapist, Occupational Therapist, Speech language Therapist
Region: Region-1
State: 1 - All A/B MACs
Date Approved: 11/29/2018
Dates Service: Claims having a "claim paid date" which is less than 3 years prior to the informational letter date (automated review).
Description: "HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist or speech language therapist in private practice. Affected Codes: HCPCS/CPT Codes with a PC/TC Indicator of ""7"" in the MPFSDB (See Appendix D for complete list of HCPCS/CPT code and descriptions)"
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: CMS Publication 100-04; Chapter 23, Addendum-MPFSDB File, Layouts, 2001-2018 File Layout"
Excessive Units of Destruction of Premalignant Lesions
_0121
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
12/03/2018

Excessive Units of Destruction of Premalignant Lesions

Issue Name: Excessive Units of Destruction of Premalignant Lesions
Issue Number: _0121
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/03/2018
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 CPT Code descriptions, CPT Code 17000 may only be billed once per date of service; CPT Code 17003 may only be billed thirteen times per date of service and CPT Code 17004 may only be billed once per date of service. Affected codes: 17000, 17003 and/or 17004
References: Title XVIII of the Social Security Act: Section 1833(e); American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current (Destruction, Benign or Premalignant Lesions)
Diagnostic Procedures- Technical Component during Inpatient
_0123
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
12/10/2018

Diagnostic Procedures- Technical Component during Inpatient

Issue Name: Diagnostic Procedures- Technical Component during Inpatient
Issue Number: _0123
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/10/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date (automated reivew)
Description: When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay. Affected codes: CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 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 Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Layouts, 2011-2018 File Layout 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, §30 Services Paid Under the Medicare Physician’s Fee Schedule 7. Medicare Benefit Policy Manual: CMS Publication 100-02; Chapter 15 Covered Medical and Other Health Services, §30.1 Provider-Based Physician Services"