Skip to main content

CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

Filter By:
Issue Name Sort by Descending or Ascending
Issue Number Sort by Descending or Ascending
Review Type Sort by Descending or Ascending
Provider Type Sort by Descending or Ascending
Region Sort by Descending or Ascending
State Sort by Descending or Ascending
Date Approved Sort by Descending or Ascending
Details
Home Visits Physician Services Overlapping Inpatient Stay
_0115
Automated
Physician Claims
Region-1
1 - All Region 1 states
10/16/2018

Home Visits Physician Services Overlapping Inpatient Stay

Issue Name: Home Visits Physician Services Overlapping Inpatient Stay
Issue Number: _0115
Review Type: Automated
Provider Type: Physician Claims
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/16/2018
Dates Service: Claims having a “claim paid date” which is on or after October 1, 2015 (ICD-10 codes only)
Description: Home Visits for physician services should not overlap an active Inpatient Stay. Providers cannot billed for services that are rendered. Affected codes: See Appendix D in downloadable Excel file
References: Title XVIII of the Social Security Act: Section 1833(e); Medicare Claims Processing Manual: Publication 100-04; Chapter 1, § 120.2 (B)
Improperly Paid Modifiers TC and 26
_0116
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
10/12/2018

Improperly Paid Modifiers TC and 26

Issue Name: Improperly Paid Modifiers TC and 26
Issue Number: _0116
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review)
Description: HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed. Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied.
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 Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf
Transthoracic Echocardiography: Medical Necessity
_0111
Complex
Inpatient Hospital, Outpatient Hospital, SNF
Region-1
1 - All Region 1 states
10/12/2018

Transthoracic Echocardiography: Medical Necessity

Issue Name: Transthoracic Echocardiography: Medical Necessity
Issue Number: _0111
Review Type: Complex
Provider Type: Inpatient Hospital, Outpatient Hospital, SNF
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: For Palmetto LCD specific questions- Claims billed on or after 9/18/2017
Description: "Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary. Affected codes: 93303, 93304, 93306, 93307, 93308 C8921, C8922, C8923, C8924"
References: "1. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 2. Title XVIII, §§1862(a)(1)(A) and (a)(7) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §410.32(a)- Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions 6. 42 Code of Federal Regulations (CFR) §411.15(k)(1)- Particular Services Excluded from Coverage 7. Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15 (Covered Medical and Other Health Services), §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests 8. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 9 (Rural Health Clinics/Federally Qualified Health Centers), §100- Frequency of Billing and Same Day Billing 9. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 12 (Physicians/Nonphysician Practitioners), §30.4- Cardiovascular System (Codes 92950- 93799) 10. CGS, Local Coverage Determination (LCD) L34338: Effective 10/01/2015; Revision 10/01/2018 11. First Coast, Local Coverage Determination (LCD) L33768: Effective 10/01/2015; Revision 10/01/2018 12. NGS, Local Coverage Determination (LCD) L33577: Effective 10/01/2015; Revision 10/01/2018 13. Palmetto, Local Coverage Determination (LCD) L37379; Effective date 9/18/2017; Revision 3/28/2019 14. American Medical Association (AMA), Current Procedural Terminology Manual, Coding Guidelines"
Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary
_0073
Complex
Inpatient Rehabilitation Facility, Inpatient
Region-1
1 - All Region 1 states
10/12/2018

Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary

Issue Name: Inpatient Rehabilitation Facility (IRF) Stays: Meeting Requirements to be considered Reasonable and Necessary
Issue Number: _0073
Review Type: Complex
Provider Type: Inpatient Rehabilitation Facility, Inpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: Inpatient hospital services furnished to a patient in an inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary
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 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system; 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, and (5)- Interdisciplinary Team Approach to Care; Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.3- Documentation Requirements for Therapy Services; Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS; Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements
DME While in Hospice
_0114
Automated
DME Supplier/DME by Physician
Region-5
5 - Nationwide
09/20/2018

DME While in Hospice

Issue Name: DME While in Hospice
Issue Number: _0114
Review Type: Automated
Provider Type: DME Supplier/DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/20/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review).
Description: All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services or any claims billed after the admit date of a patient to Hospice services and null discharge date (when patient status code is 30), will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII, §1861(dd)(1) of the Social Security Act- Hospice Care; Hospice Program 3. 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 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 6. 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 7. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 8. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 9. Code of Federal Regulations 42, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals 10. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 11. 42 CFR §424.57(c)- Application Certification Standards 12. CMS Pub. 100-2, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance, Section 10 13. CMS Pub. 100-4, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims, Section 10, Section 30.3, Section 40.2 14. CMS Pub 100-4, Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Section 10.2"
Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial
_0110
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/20/2018

Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing Part B - Partial
Issue Number: _0110
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And Informational Letter date after January 1, 2016.
Description: Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Admin. Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Affected codes: CPT/HCPCS codes listed on the Appendix D of the downloadable Excel file - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier. (https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation.html)
References: 1. Title XVIII, §§1833(d) and (e) of the Social Security Act- 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 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 6. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement 7. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation - https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html
Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full
_0109
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/20/2018

Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full
Issue Number: _0109
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Admin. Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Affected Codes: All CPT/HCPCS codes Excluding those service codes listed in 109 Appendix D of the downloadable Excel file.
References: "1. Title XVIII, §§1833(d) and (e) of the Social Security Act- 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 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 6. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement 7. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html"
Facility vs Non-Facility Reimbursement
_0108
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
09/14/2018

Facility vs Non-Facility Reimbursement

Issue Name: Facility vs Non-Facility Reimbursement
Issue Number: _0108
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/14/2018
Dates Service: Time Period Being Reviewed (look-back period) Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The rate, facility or nonfacility, which a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. Download Excel file for affected POS code list in _0108 Appendix D
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: Publication 100-04; Chapter 12, § 20.4.2
Custom Fabricated Knee Orthosis: Medical Necessity
_0107
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Custom Fabricated Knee Orthosis: Medical Necessity

Issue Name: Custom Fabricated Knee Orthosis: Medical Necessity
Issue Number: _0107
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Dates Service: Less than 3 years
Description: Claims for Custom Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied. Affected codes L1844 - KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED; L1846 - KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED
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. 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 1834(a)(4) - Payment for Certain Customized Items 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(6) - Payment for Other Items of Durable Medical Equipment 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h) - Payment for Prosthetic Devices and Orthotics and Prosthetics 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1) - General Rule for Payment 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F) - Special Payment Rules for Certain Prosthetics and Custom Fabricated Orthotics 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F)(ii) - Description of custom-fabricated item. 10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F)(iii) - Qualified practitioner defined 11. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 12. 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 13. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(n) - Durable Medical Equipment Definition 14. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 15. 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 16. 42 CFR §405.986 - Good Cause for Reopening 17. 42 CFR §424.57 - Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 18. 42 CFR §424.57(c) - Application Certification Standards 19. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 20. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 21. 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 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 24. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 25. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 26. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 27. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 28. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33318: Knee Orthoses: Effective Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2019 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Knee Orthoses - Policy Article A52465: Effective 10/1/2015, Revision 01/01/2019 32. 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 01/01/2019"