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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Initial Hydration, Infusion and Chemotherapy Administration
_0071
Automated
Professional Services (Physician/Non-Physician Practitioner)
1
1 - All Region 1 states
10/05/2017

Initial Hydration, Infusion and Chemotherapy Administration

Issue Name: Initial Hydration, Infusion and Chemotherapy Administration
Issue Number: _0071
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: 1
State: 1 - All Region 1 states
Date Approved: 10/05/2017
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 administering multiple infusions, injections or combinations, the physician should only report one ""initial"" service code unless protocol requires that two separate IV sites must be used. For these separate identifiable services, physicians need to report with using modifier 59, XE, XS, XP or XU. ""CPT/HCPCS codes 96360 – Intravenous infusion, hydration, initial, 31 minutes to 1 hour, 96365 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (Specify substance or drug); initial, up to 1 hour, 96369 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s), 96374 – Intravenous push, single or initial substance/drug, 96409 –
References: 1)              Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.5 €, effective 6/26/2006
Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)
_0077
Automated
Physician/Non-Physician Practitioner
1
1 - All Region 1 states
01/15/2018

Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)

Issue Name: Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)
Issue Number: _0077
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: 1
State: 1 - All Region 1 states
Date Approved: 01/15/2018
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 Annual Wellness Visit (AWV) is not payable if an Initial Preventative Physical Examination (IPPE) has been paid within the previous 11 whole months. Affected Codes: G0438, G0439, G0402.
References: Title XVIII of the Social Security Act: Section 1833€, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 18, § 140 effective 1/1/2011, 42 CFR Section 1861 411.15(a)(1) and 411.15 (k)(15).
Drugs and Biologicals Excessive or Insufficient Drug Units Billed
_0074
Complex
Outpatient Hospital & Physician
1
1 - All Region 1 States
01/11/2018

Drugs and Biologicals Excessive or Insufficient Drug Units Billed

Issue Name: Drugs and Biologicals Excessive or Insufficient Drug Units Billed
Issue Number: _0074
Review Type: Complex
Provider Type: Outpatient Hospital & Physician
Region: 1
State: 1 - All Region 1 States
Date Approved: 01/11/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units. Affected Codes: C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894 J0897, J1300, J1459, J1561, J1566, J1569, J1572, j1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9033, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050, J9034.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, 42 CFR §405.980 (b) and ©, 42 CFR §405.986, CMS IOM 100-04, Ch. 17, §§10, 40, 70 and 90.2, Medicare Alpha-Numeric HCPCS File, Annual American Medical Association: CPT Manual, Annual HCPCS Level II Manual, Medicare Part B Drug Average Sales Price; ASP Pricing File, U.S. National Library of Medicine DailyMed, Attached list of HCPCS Codes for Drugs and Biologicals.
E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)
_0034
Automated
Professional Services (Physician/Non-Physician Practitioner)
1
All States Region 1
01/11/2018

E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)

Issue Name: E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)
Issue Number: _0034
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: 1
State: All States Region 1
Date Approved: 01/11/2018
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: "This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 90 days. Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 090 include only E & M services on the day before the procedure, the day of the procedure and up to 90 days post-operative days. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Evaluation & Management (E & M) codes as per the attached list; and All CPT and HCPCS codes with MPFSDB Global Days values of 090. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350, 99374, 99375.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, . Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)
_0033
Automated
Professional Services (Physician/Non-Physician Practitioner)
1
All Region 1 States
01/11/2018

E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)

Issue Name: E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)
Issue Number: _0033
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: 1
State: All Region 1 States
Date Approved: 01/11/2018
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: This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 10 days. Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 010 include only E & M services on the day of the procedure and up to 10 post-operative days. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350, 99374, 99375.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
Ventilators Subject to DWO Requirements on or after January 1, 2016
_0079
Complex
DME by supplier; DME by physician
5
5 - Nationwide
01/11/2018

Ventilators Subject to DWO Requirements on or after January 1, 2016

Issue Name: Ventilators Subject to DWO Requirements on or after January 1, 2016
Issue Number: _0079
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5 - Nationwide
Date Approved: 01/11/2018
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 Ventilators meet coverage criteria and/or are medically reasonable and necessary. E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube); E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell).
References: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, 42 CFR 424.57(a)(12), Title XVIII, Social Security, §1833€, Title XVIII, Social Security, §1862(a)(1)(A), 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, CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20, CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1 and §240.5, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017.
E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures
_0032
Automated
Professional Services (Physician/Non-Physician Practitioner)
1
1 - All Region 1 States
01/10/2018

E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures

Issue Name: E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures
Issue Number: _0032
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: 1
State: 1 - All Region 1 States
Date Approved: 01/10/2018
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: This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 0 days. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99245, 99251, 99252, 99253, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350 99374, 99375, Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 000 include only E & M services rendered on the day of surgery. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Affected Codes: Evaluation & Management (E & M) codes as per the attached list; and All CPT and HCPCS codes with MPFSDB Global Days values of 000.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
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, 023X, 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.