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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Implantable Automatic Defibrillators
_0093
Complex
Outpatient Hospital, ASC, Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
05/15/2018

Implantable Automatic Defibrillators

Issue Name: Implantable Automatic Defibrillators
Issue Number: _0093
Review Type: Complex
Provider Type: Outpatient Hospital, ASC, Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/15/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and prior to 2/15/2018
Description: The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications as published in the CMS National Coverage Determinations (NCD) Manual, Publication 100-03, Section 20.4 and CMS IOM 100-04, Ch. 32 §§270,270.1,270.2. Affected Codes: 33240, 33241, 33243, 33244, 33249.
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 National Coverage Determination (NCD) Manual: Chapter 1, Part 1, Section 20.4- Implantable Automatic Defibrillators, Effective 2/15/2018 7. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270- Claims Processing for Implantable Automatic Defibrillators 8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270.1- Coding Requirements for Implantable Automatic Defibrillators 9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270.2- Billing Requirements for Patients Enrolled in a Data Collection System
Group 3 Pressure Reducing Support Surfaces
_0094
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
05/15/2018

Group 3 Pressure Reducing Support Surfaces

Issue Name: Group 3 Pressure Reducing Support Surfaces
Issue Number: _0094
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/15/2018
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 Group 3 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0194 Air Fluidized Bed.
References: "Title XVIII, Social Security, §1833(e)- Payment of Benefits; Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer; Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews; Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening; Code of Federal Regulations, 42 CFR; section 410.38(g)(3)- Durable Medical Equipment: Scope and Conditions; Items Requiring a Written Order, Face-to-face Encounter Requirements; Code of Federal Regulations, 42 CFR; section 410.38(g)(4)- Durable Medical Equipment: Scope and Conditions, Items Requiring a Written Order; Written Order Issuance Requirements; Code of Federal Regulations, 42 CFR; section 424.57 (12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges; Medicare Benefit Policy Manual, Chapter 15, Section 110- Durable Medical Equipment – GeneralTitle XVIII, Social Security, §1833(e)- Payment of Benefits; Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer; Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews; Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening; Code of Federal Regulations, 42 CFR; section 410.38(g)(3)- Durable Medical Equipment: Scope and Conditions; Items Requiring a Written Order, Face-to-face Encounter Requirements; Code of Federal Regulations, 42 CFR; section 410.38(g)(4)- Durable Medical Equipment: Scope and Conditions, Items Requiring a Written Order; Written Order Issuance Requirements; Code of Federal Regulations, 42 CFR; section 424.57 (12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges; Medicare Benefit Policy Manual, Chapter 15, Section 110- Durable Medical Equipment – General; Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8- Air-Fluidized Beds; 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, Chapter 5, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery; Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Rules Concerning Orders, Face-to-Face Encounter Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Rules Concerning Orders, Date and Timing Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7- Rules Concerning Orders, Requirement of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.8- Rules Concerning Orders, 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; Nationwide Local Coverage Determination (LCD) L33692, Pressure Reducing Support Surfaces - Group 3 Effective 10/1/2015; Revised 01/01/2017; Policy Article A52468, Pressure Reducing Support Surfaces - Group 3 Effective 10/01/2015; Revised 01/01/2017; Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 08/28/2018"
Duplicate Payment - Exact
_0091
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
05/11/2018

Duplicate Payment - Exact

Issue Name: Duplicate Payment - Exact
Issue Number: _0091
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/11/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Duplicate claims are any claims paid across more than one claim number for the same Beneficiary, CPT/HCPCS code and service date by the same provider. Affected Codes: All CPT, HCPCS Codes
References: Title XVIII of the Social Security Act: Section 1833€ , Medicare Financial Management Manual: Publication 100-06; Chapter 3, Section 10.2, Medicare Claims Processing Manual: Publication 100-04; Chapter 1, § 120.2 (B), Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 20.4.2, Medicare Claims Processing Manual: Publication 100-04; Chapter 26, § 10.5.
Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array
_0092
Complex
Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region-1
1 - All Region 1 states
05/08/2018

Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array

Issue Name: Medical Necessity Review Percutaneous Implantation of Neurostimulator Electrode Array
Issue Number: _0092
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/08/2018
Dates Service: Claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: Providers that submit and were paid for code, 64553 and/ or code 64555 must support in the documentation that the code billed was actually the service rendered and that all coverage criteria were met.
References: "Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10). 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 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 Definitions42 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 Part 42 CFR §405.986- Good Cause for reopening Centers for Medicare & Medicaid Services, Internet Only Manual 100-3, National Coverage Determination 160.7.1 (Updated through Rev. 149, Issued: 11-30-12, Effective: 06-08-12, Implementation: 01-07-13) Centers for Medicare & Medicaid Services, Internet Only Manual 100-3, National Coverage Determination §30.3 Rev. 1, 10-03-03) American Medical Association Current Procedural Terminology Manual/ Healthcare Common Procedure Coding System 2014 to current"
Technical Component of Lab/Pathology for Inpatient and Outpatient Hospitals
_0090
Automated
Physician/Non-Physician Practitioner; Lab; IDTF (Independent Diagnostic Testing Facility)
Region-1
1 - All Region 1 states
04/03/2018

Technical Component of Lab/Pathology for Inpatient and Outpatient Hospitals

Issue Name: Technical Component of Lab/Pathology for Inpatient and Outpatient Hospitals
Issue Number: _0090
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner; Lab; IDTF (Independent Diagnostic Testing Facility)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/03/2018
Dates Service: Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational letter date.
Description: The technical component (TC) of lab/pathology services furnished to patients in an inpatient or outpatient hospital setting are not separately payable. All Lab/Pathology CPT/HCPCS codes with TC/PC Indicator 1 or 3. See Appendix D for complete list of codes.
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 12 Physician/Non-Physician Practitioners, § 60 (B) Payment for Technical Component (TC) Services 7. Medicare Claims Processing Manual 100-04; Chapter 23; File Layout"
Ventilators Subject to ACA Requirements Prior to January 1, 2016
_0082
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
03/14/2018

Ventilators Subject to ACA Requirements Prior to January 1, 2016

Issue Name: Ventilators Subject to ACA Requirements Prior to January 1, 2016
Issue Number: _0082
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/14/2018
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. Affected Codes: E0450, E0460, E0461, E0463, E0464.
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 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (3)- Face-to-Face Encounter Requirements 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (4)- Written Order Issuance Requirements 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges, (c)- Application Certification Standards, (12) Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.4- Written Orders Prior to Delivery, §5.2.5- Face to Face Encounter Requirements, §5.2.6- Date and Timing Requirements, §5.2.7- Requirement of New Order, §5.2.8- Refills of DMEPOS Items Supplied on a Recurring Basis, §5.7- Documentation in the Patient’s Medical Record, §5.8- Supplier Documentation, and §5.9- Evidence of Medical Necessity. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Lab Services Rendered During an Inpatient Stay
_0085
Automated
Lab and Outpatient
Region-1
1 - All Region 1 states
03/19/2018

Lab Services Rendered During an Inpatient Stay

Issue Name: Lab Services Rendered During an Inpatient Stay
Issue Number: _0085
Review Type: Automated
Provider Type: Lab and Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Laboratory services are covered under Part A, excluding anatomic pathology services and certain clinical pathology services, therefore if billed separately should be denied as unbundled services. See 0085 Appendix D for affected codes.
References: "1. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 2. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 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 3, §10.4- Payment of Nonphysician Services for Inpatients 7. CPT Coding Book"
Cataract Removal Excessive Units - Partial Denial
_0083
Automated
Professional Services, Outpatient, ASC
Region-1
1 - All Region 1 states
03/19/2018

Cataract Removal Excessive Units - Partial Denial

Issue Name: Cataract Removal Excessive Units - Partial Denial
Issue Number: _0083
Review Type: Automated
Provider Type: Professional Services, Outpatient, ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Cataract removal cannot be performed more than once on the same eye on the same date of service. This query identifies overpayments where providers are billing for more than one unit of cataract removal for the same eye, on the same line of the claim. Affected codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
References:      Title XVIII of the Social Security Act: Section 1833€, Title XVIII of the Social Security Act: Section 1862(a)(1)(A), National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D) .
Cataract Removal Excessive Units - Full Denial
_0084
Automated
Physician/Non-Physician Practitioner, Outpatient, ASC
Region-1
1 - All Region 1 states
03/19/2018

Cataract Removal Excessive Units - Full Denial

Issue Name: Cataract Removal Excessive Units - Full Denial
Issue Number: _0084
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner, Outpatient, ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: CPT Codes describing cataract extraction are mutually exclusive of one another. Only one code from the affected CPT code range may be reported per date of service and for each eye. Affected Codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984.
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. National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D) "