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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Medical Necessity: Parenteral Nutrition
_0106
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Medical Necessity: Parenteral Nutrition

Issue Name: Medical Necessity: Parenteral Nutrition
Issue Number: _0106
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Dates Service: Excludes claims with DOS prior to 10/1/15 and not more than 3 years prior to the ADR date
Description: This review will determine if Parenteral Nutrition 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. B4164,B4168,B4172,B4176,B4178,B4181,B4185,B4189,B4193,B4197,B4199, B4216,B4220,B4222,B4224,B5000,B5100,B5200
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) - Payment for Durable Medical Equipment 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(j) - Requirements for Suppliers of Medical Equipment and Supplies 7. 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 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(n) - Durable Medical Equipment Definition 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 10. 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 11. 42 CFR §405.986 - Good Cause for Reopening 12. 42 CFR §424.57 - Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 13. 42 CFR §424.57(c) - Application Certification Standards 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120 Prosthetic Devices 15. CMS NCD Manual, Chapter 1, Part 3, Section 180.2- Enteral and Parenteral Nutritional Therapy 16. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 17. 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 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 20. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 21. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 24. Medicare Program Integrity Manual, Chapter 5, Section 5.3 - Certificates of Medical Necessity (CMNs) and DME Information Forms 25. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 26. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 27. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 28. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33798: Parenteral Nutrition: Effective Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2017 29. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Parenteral Nutrition - Policy Article A52515: Effective 10/1/2015, Revision 01/01/2019 30. 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"
Physician Services during Hospice Period
_0105
Automated
Physician/Non-Physician Practitioner
Region-1
Region 1 - All States
08/16/2018

Physician Services during Hospice Period

Issue Name: Physician Services during Hospice Period
Issue Number: _0105
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: Region 1 - All States
Date Approved: 08/16/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
Description: Physician services billed during an active hospice period should be paid by the Hospice provider if services are related to the hospice beneficiary's terminal condition or if a physician is employed or paid under arrangement by the beneficiary's hospice provider. Medicare should not be billed for either of the aforementioned scenarios. Affected codes: Any codes except codes G0008, G0009, G0010, 90460, 90461, 90471, 90472, 90655, 90656, 90657, 90661, 90662, 90673, 90685, 90686, 90687, 90688, Q2034, Q2035, Q2036, Q2037, Q2038, Q2039, 90732, 90740, 90743, 90744, 90746, 90747, 90748
References: "1) Title 18, Section 1861 (dd) of the Social Security Act, Hospice Care; Hospice Program 2) CMS 100-02 Medicare Benefit Policy Manual, Chapter 9. Coverage of Hospice Services, Section 10 - Requirements; 3) CMS 100-02 Medicare Benefit Policy Manual, Chapter 9, Section 40.1.3 - Physician Services; 4) CMS 100-04 Medicare Claims Processing Manual, Chapter 11, Section 10, Overview 5) CMS 100-04 Medicare Claims Processing Manual, Chapter 11, Section 40.2, Processing Professional Claims for Hospice Beneficiaries 6) CMS 100-04 Medicare Claims Processing Manual, Chapter 11, Section 50, Billing and Payment for Services Unrelated to Terminal Illness 7) Code of Federal Regulations Title 42 PART 418.402-HOSPICE CARE-Individual Liability for Services that are not considered hospice care 8) CMS Pub. 100-04 Medicare Claims Processing Manual,, Chapter 11, Section 20.1 & 30.3"
Outpatient Hospital APC Coding Validation
_0101
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
07/26/2018

Outpatient Hospital APC Coding Validation

Issue Name: Outpatient Hospital APC Coding Validation
Issue Number: _0101
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment. Affected codes: Claims with status indicators (SI) = J1, T, S, and K
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- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations § 414 Payment for Part B Medical and Other Health Services 4. 42 Code of Federal Regulations § 419 Prospective Payment System for Hospital Outpatient Department Services 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 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 8. IOM, 100-04, Medicare Claims Processing Manual, Chapter 4, Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§ 10.1- 10.5- 20, 40-61, 100, 120, 150-240, 270, and 300. 9. IOM, 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 10. American Medical Association (AMA), Current Procedure Terminology, Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1) , APCs for Hospital Part B services paid through a comprehensive APC (SI = J1), Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies (SI = T), Pass-Through Drugs and Biologicals (SI=G), and Nonpass-Through Drugs and Biologicals (SI=K) 11. AMA CPT Assistant 12. National Correct Coding Initiative Policy Manual 13. Integrated OCE (IOCE) CMS Specifications Appendix L: Comprehensive APC Assignment Logic (OPPS Only, V16.0, Effective 01/01/2015 through V20.0 Effective 01/01/2019), Appendix D: Computation of Discounting Fraction (OPPS only), and Appendix P: Pass-Through Drugs and Biologicals Processing (OPPS Only, V17.2). 14. CMS Hospital Outpatient PPS, Addendum B Updates, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html"
Add-on codes paid without Primary Code and/or denied Primary Code – by ASC
_0104
Automated
Ambulatory Surgery Center (ASC)
Region-1
1 - All Region 1 states
07/26/2018

Add-on codes paid without Primary Code and/or denied Primary Code – by ASC

Issue Name: Add-on codes paid without Primary Code and/or denied Primary Code – by ASC
Issue Number: _0104
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
Description: CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also paid. ASC providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Affected codes see Appendix D.
References: "1. Social Security Act, Section 1833. Payment of Benefits [42 U.S.C. 1395l] (e) 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12: Physicians/Nonphysician Practitioners, § 30: Correct Coding Policy 3. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01: General Billing Requirements § 70 : Time Limitations for Filing Part A and Part B Claims 4. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16: Laboratory Services § 40.8: Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 5. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29: Appeals of Claims Decisions § 240 (revised 7/23/2013): Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals 6. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html 7. AMA CPT Code book"
Urological Supplies Effective 8/1/2018
_0103
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/19/2018

Urological Supplies Effective 8/1/2018

Issue Name: Urological Supplies Effective 8/1/2018
Issue Number: _0103
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/19/2018
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Documentation will be reviewed to determine if Urological Supplies meets coverage criteria and is medically reasonable and necessary. For affected codes download xls file and see appendix D.
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(a) - Payment for Durable Medical Equipment; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section ; 834(a)(2) - Payment for Inexpensive and Other Routinely Purchased Durable Medical Equipment; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(E)- Payment for Prosthetic Devices and Orthotics and Prosthetics; 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; Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit; 42 CFR 424.57(c)(12) Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; Application certification standards; 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 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, §120 Prosthetic Devices ; 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written 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 Determination L33803: Urological Supplies, Effective 10/01/2015; Revised 1/01/2017; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52521: Urological Supplies, Effective 10/01/2015; Revised 1/01/2017; 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
Home Use of Oxygen: Medical Necessity and Certification
_0102
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/12/2018

Home Use of Oxygen: Medical Necessity and Certification

Issue Name: Home Use of Oxygen: Medical Necessity and Certification
Issue Number: _0102
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/12/2018
Dates Service: Less than 3 years and after September 30, 2015
Description: Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary. Affected code E1390
References: 1.      Title XVIII, Social Security, §1833€; 2.      Title XVIII, Social Security, §1861(s)(6); 3.      Title XVIII, Social Security, §1862(a)(1)(A) ; 4.      42 C.F.R. sections 405.980 (b) & (c) and section 405.986 ; 5.      42 CFR 424.57(a)(12)6.      CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2 ; 7.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20; 100.2.3; 8.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 30.6; 130.6; 9.      CMS, IOM Publication 100-02, Benefit Policy Manual 15; 110; 10.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26; 11.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9.1; 12.  Local Coverage Determination L33797: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 13.  Local Coverage Article A52514: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 14.  CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017
Add On Paid without a Primary and or Denied Code by Clinical Laboratory
_0100
Automated
Laboratory
Region-1
1 - All Region 1 states
06/21/2018

Add On Paid without a Primary and or Denied Code by Clinical Laboratory

Issue Name: Add On Paid without a Primary and or Denied Code by Clinical Laboratory
Issue Number: _0100
Review Type: Automated
Provider Type: Laboratory
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/21/2018
Dates Service: Excludes claims that have a “claim paid date” which is > 3 years prior to the informational Letter date and a “claim paid date” after 2/01/2017.
Description: CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. Clinical Laboratory providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied.
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: CMS Publication 100-04; Chapter 12, § 30 D. Coding Services Supplemental to Principal Procedure (Add-On Codes) Code; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70 Time Limitations for Filing Part A and Part B Claims; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8 Date of Service (DOS) for Clinical Laboratory and Pathology Specimens; Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 (revised 7/23/2013); https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Add-On-Code-Edits.html
Skilled Nursing Facility (SNF) Consolidated Billing
_0099
Automated
Outpatient Facility
Region-1
1 - All Region 1 states
06/20/2018

Skilled Nursing Facility (SNF) Consolidated Billing

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing
Issue Number: _0099
Review Type: Automated
Provider Type: Outpatient Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/20/2018
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: "Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A SNF stay are included in a bundled prospective payment. Entities that provide these services should look to the SNF for payment. Under the consolidated billing requirement, the SNF must submit all Medicare. Affected Codes - See Appendix D.
References: Title XVIII of the Social Security Act: Section 1833(d); Medicare Claims Processing Manual: Publication 100-04; Chapter 6; § 10.1- 20.6
Unbundling of Critical Care
_0098
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
06/16/2018

Unbundling of Critical Care

Issue Name: Unbundling of Critical Care
Issue Number: _0098
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/16/2018
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: Certain services when performed on the day a physician bills for critical care are included in the critical care service and should not be reported separately. Code list avail in the downloadable excel file, Appendix D tab.
References: Title XVIII of the Social Security Act – Payment of Benefits, Section 1833(e); 2) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12- Physicians/Nonphysician Practitioners, § 30.6.12 (J) – Critical Care Services and Other Procedures Provided on the Same Day by the Same Physician as Critical Care Codes 99291-99292- effective 7/25/14