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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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
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: Medical Necessity and Documentation Requirements
_0094
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
05/15/2018

Group 3 Pressure-Reducing Support Surfaces: Medical Necessity and Documentation Requirements

Issue Name: Group 3 Pressure-Reducing Support Surfaces: Medical Necessity and Documentation Requirements
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: "1. Title XVIII, Social Security, §1833(e)- Payment of Benefits 2. Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer 3. Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews 4. Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening 5. 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 6. 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 7. 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 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 110- Durable Medical Equipment – General 9. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8- Air-Fluidized Beds 10. Medicare Claims Processing Manual, Chapter 30- Financial Liability Protections, Section 50.13.4- Supplier’s Right to Recovery Resalable Items for Which Refund Has Been Made 11. Medicare Program Integrity Manual, Chapter 4- Program Integrity, Section 4.26- Supplier Proof of Delivery Documentation Requirements 12. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery 13. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.5- Rules Concerning Orders, Face-to-Face Encounter Requirements 14. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.6- Rules Concerning Orders, Date and Timing Requirements 15. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.7- Rules Concerning Orders, Requirement of New Orders 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.8- Rules Concerning Orders, Refills of DMEPOS Items Provided on a Recurring Basis 17. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity 20. CGS and Noridian LCD L33692- Pressure Reducing Support Surfaces - Group 3 Effective 10/1/2015; Revised 01/01/2019 21. CGS and Noridian Local Coverage Article A52468- Pressure Reducing Support Surfaces - Group 3 Effective 10/01/2015; Revised 01/01/2019 22. CGS and Noridian Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 01/01/2019"
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.
Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements
_0092
Complex
Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region-1
1 - All Region 1 states
05/08/2018

Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements

Issue Name: Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements
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: "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 Manual, Chapter 1, Part 1, §30.3- Acupuncture 7. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.7.1- Assessing Patients Suitability for Electrical Nerve Stimulation Therapy 8. 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)