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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Complex Blood Glucose Monitors with Integrated Voice Synthesizer Billed Without Indicator of Medical Necessity
_0012
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide
05/08/2017

Complex Blood Glucose Monitors with Integrated Voice Synthesizer Billed Without Indicator of Medical Necessity

Issue Name: Complex Blood Glucose Monitors with Integrated Voice Synthesizer Billed Without Indicator of Medical Necessity
Issue Number: _0012
Review Type: Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/08/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Blood Glucose Monitors with Integrated Voice Synthesizer - Medical documentation will be reviewed to determine if claims for voice synthesized blood glucose monitors were billed without an indication supporting medical necessity. Affected Code; E2100.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833(e), Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 4, Section 4.26, Supplier Proof of Delivery Documentation Requirements, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, Sections 5.2.3, Detailed Written Orders and 5.7, Documentation in the Patient's Medical Record and 5.8, Supplier Documentation and 5.9, Evidence of Medical Necessity, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, Section 3.3, Policies and Guidelines Applied During Review, Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, Section 110, Durable Medical Equipment – General, Medicare National Coverage Determinations Manual (IOM) Publication 100-3, Chapter 1, Section 40.2, Home Blood Glucose Monitors, LCD #s: L11520, L27231, L11530, L196 for services performed prior to 10/1/15, LCD #: L33822 for services performed on or after 10/1/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)
_0014
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
01/05/2017

Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)

Issue Name: Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)
Issue Number: _0014
Review Type: Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/05/2017
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: Glucose Monitors Unbundling - HCPCS codes A4233, A4234, A4235, and A4236, which describe glucose monitor supplies, will be denied when billed with the same date of service as glucose monitor HCPCS codes E0607, E2100 or E2101.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833(e), Title XVIII of the Social Security Act (SSA): Section 1833(e), LCD #s: L11520, L27231, L11530, L196, LCD #: L33822, LCD #s: L11520, L27231, L11530, L196 for services performed on or after 10/1/15, LCD #: L33822 for services performed on or after 7/1/16 
Complex Review Osteogenesis Stimulators
_0030
Complex
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
02/14/2017

Complex Review Osteogenesis Stimulators

Issue Name: Complex Review Osteogenesis Stimulators
Issue Number: _0030
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/14/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Claims for osteogenesis stimulators that do not meet the indications of coverage and/or medical necessity will be denied. Affected Codes: E0747, E0748, E0760.
References: Social Security Act, Section 1833 (e); Section 1834 (a) [42 U.S.C. 1395m], PAYMENT FOR DURABLE MEDICAL EQUIPMENT, CMS 100-08, Medicare PIM, Chapter 4, Section 4.26; Chapter 5, Sections 5.2-5.6, 5.2.2, 5.2.1, 5.2.3.1, 5.2.3, 5.7- 5.9, 5.8, 42 Code of Federal Regulations (C.F.R.) §§405.980 (b) and (c), 42 C.F.R. §405.986, CMS Pub. 100-03, National Coverage Determinations Manual, Part 1, Section 150.2 (Osteogenic Stimulator). Available at: https://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/ncd103c1_Part2.pdf, CGS & Noridian Administrators, LCD L33796: Effective 10/1/2015, Revision 7/1/2016 https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33796&ver=8&Date=&DocID=L33796&bc=iAAAABAAAAAAAA%3d%3d&, CGS & Noridian, Local Coverage Article A52513: Effective 10/01/2015, Revision 07/01/2016 https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52513&ver=4&Date=12%2f21%2f2016&DocID=A52513&bc=hAAAABAAAAAAAA%3d%3d&, NHIC, LCD L11501: Effective 10/1/1993, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=11501&lcd_version=39&show=all, NHIC, Local Coverage Article A35349: Effective 10/01/2005, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=35349&article_version=18&contractor_id=137, CGS, LCD L5012: Effective 10/1/1993, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=5012&lcd_version=53&basket=lcd%3A5012%3A53%3AOsteogenesis+Stimulators%3ADME+MAC%3ACGS+Administrators%7C%7C+LLC+%2818003%29%3A, CGS, Local Coverage Article A25956: Effective 04/27/2005, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=25956&article_version=21&contractor_id=140, NGS, LCD L27026: Effective 10/1/1993, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=27026&lcd_version=23&basket=lcd%3A27026%3A23%3AOsteogenesis+Stimulators%3ADME+MAC%3ANational+Government+Services%7C%7C+Inc%2E+%2817003%29%3A, NGS, Local Coverage Article A47113: Effective 10/01/2005, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=47113&article_version=13&contractor_id=138, Noridian Health Solutions, LCD L11490: Effective 10/1/1993, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=11490&lcd_version=48&basket=lcd%3A11490%3A48%3AOsteogenesis+Stimulators%3ADME+MAC%3ANoridian+Healthcare+Solutions%7C%7C+LLC+%2819003%29%3A, NGS, Local Coverage Article A35423: Effective 04/27/2005, Revision 10/31/2014, Retirement 9/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=35423&article_version=21&contractor_id=139. 
Multiple DME Rentals in One Month
_0046
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
03/31/2017

Multiple DME Rentals in One Month

Issue Name: Multiple DME Rentals in One Month
Issue Number: _0046
Review Type: Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/31/2017
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: Overpayments associated to DMEPOS suppliers billing multiple rentals for the same equipment within the same month (27 days). CPT 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. Code list avail in Appendix D of the downloadable excel file.
References: Social Security Act, Volume I, Title XVIII (Health Insurance for the Aged and Disabled), Section 1834 (Special Payment Rules for Particular Items and Services), Subsections (2)(B); (3)(A); (5)(A); (7)(A)(i)(1); (7)(C)(ii)(1), Code of Federal Regulations, Title 42 (Public Health), Part 405 (Federal Health Insurance for the Aged and Disabled), Subpart I, Subpart Section 405.986, CMS Manual 100-04 (Medicare Claims Processing Manual), Chapter 20 (Durable Medical Equipment, Prosthetics, Orthotics and Supplies), Section(s) 30.2, 30.5, 30.7 and 130.8 (Rev. 3593 08/17/2016), CMS Manual 100-08 (Medicare Program Integrity Manual), Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), Section 3.5, Subsection 3.5.1 and Section 3.6 (Rev. 674 09/02/2016), DMEPOS Fee Schedule 2014 and forward, select codes from Categories FS (Frequency Serviced Items), CR (Capped Rental), and OX (Oxygen & Oxygen Equipment) .
Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses - CLOSED ISSUE
_0048
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
04/12/2017

Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses - CLOSED ISSUE

Issue Name: Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses - CLOSED ISSUE
Issue Number: _0048
Review Type: Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/12/2017
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: Per CMS, this issue has been CLOSED effecitive 09/07/2017 and no longer available for audit. Billing for hospital bds with mattresses and Group I or II support mattress constitutes billing for the same or similar equipment according to Local Coverage Determinations (LCDs) L11557, L11572, L5049, L27216, L11563, L11578, L5067, L27008, L11554, L11579, L5068, L27009 and Articles A36595, A37079, A37213, A47240, A33747, A33678, A33769, A47098, A35357, A35422, A35350, A47114 for initial dates of service prior to 10/01/2015 and LCDs L33820, L33830, L33642 and Articles A52508, A52489, A52490 for initial dates of service on or after 10/01/2015. Recoupment Codes: E0184, E0186, E0187, E0196, E0193, E0277, E0373. Reference Codes: E0250, E0255, E0260, E0265, E0290, E0292, E0294, E0296, E0303, E0304.
References: IOM Publication 100-03, National Coverage Determination Manual, Chapter 1, Part 4, Section 280.7, 2) NHIC LCD L33820 for Hospital Beds and Accessories, and Article (A52508) Effective 10/1/2015; Revised 7/1/2016 (Effective for Noridian), NHIC LCD L33642 for Pressure Reducing Support Surfaces - Group 2 and Article (A52490), Effective 10/1/2015; Revised 7/1/2016 (Effective for Noridian), NHIC LCD L33830 for Pressure Reducing Support Surfaces - Group 1 and Article (A52489), Effective 10/1/2015; Revised 7/1/2016 (Effective for Noridian), NHIC LCD L5049 for Hospital Beds and Accessories, and Article (A37213) Retired 9/30/2015, NHIC LCD L5068 for Pressure Reducing Support Surfaces - Group 2 and Article (A35350), Retired 9/30/2015, NHIC LCD L5067 for Pressure Reducing Support Surfaces - Group 1 and Article (A33769), Retired 9/30/2015, CGS LCD L11557 for Hospital Beds and Accessories, and Article (A36959) Retired 9/30/2015, Noridian LCD 11572 for Hospital Beds and Accessories, and Article (A37079) Retired 9/30/2015, NGS LCD L27216 for Hospital Beds and Accessories, and Article (A47240) Retired 9/30/2015, CGS LCD L11564 for Pressure Reducing Support Surfaces - Group 2 and Article (A35357), Retired 9/30/2015, Noridian LCD L11579 for Pressure Reducing Support Surfaces - Group 2 and Article (A35422), Retired 9/30/2015, NGS LCD L27009 for Pressure Reducing Support Surfaces - Group 2 and Article (A47114), Retired 9/30/2015, CGS LCD L11563 for Pressure Reducing Support Surfaces - Group 1 and Article (A33747), Retired 9/30/2015, Noridian LCD L11578 for Pressure Reducing Support Surfaces - Group 1 and Article (A33678), Retired 9/30/2015, NGS LCD L27008 for Pressure Reducing Support Surfaces - Group 1 and Article (A47098), Retired 9/30/2015. 
Global vs. TC/PC Split Reimbursements
_0051
Automated
Outpatient Hospital (OPH), Physician/Non-physician Practitioner (NPP), Lab/Ambulatory services.
Region-1
1 - All Region 1 states
05/04/2017

Global vs. TC/PC Split Reimbursements

Issue Name: Global vs. TC/PC Split Reimbursements
Issue Number: _0051
Review Type: Automated
Provider Type: Outpatient Hospital (OPH), Physician/Non-physician Practitioner (NPP), Lab/Ambulatory services.
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/04/2017
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 providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or profession (modifier 26) components for the same service. Affected Codes: All codes on Medicare Physicians Fee Schedule with PC/TC Indicator 1. Code list avail in the downloadable excel file, Appendix D tab.
References: Title XVIII of the Social Security Act (SSA), §1833(e), Medicare Fee-for-Service Payment/Physician Fee Schedule PFS Relative Value Files, CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 1(General Billing Requirements), §120 (Detection of Duplicate Claims), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 12 (Physician/Non-physician Practitioners), §20.2 (Relative Value Units), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 13 (Radiology Services and Other Diagnostic Procedures), §20.1 (Professional Component [PC]), 20.2 (Technical Component [TC]), and 20.2.3 (Services Furnished in Leased Departments), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), §80.2.1 (Technical Component [TC] of Physician Pathology Services to Hospital Patients).
Add-on Codes Paid without Primary Code and/or denied Primary Code
_0050
Automated
Physician; Professional Services/Outpatient Hospital Services
Region-1
1 - All Region 1 states
05/04/2017

Add-on Codes Paid without Primary Code and/or denied Primary Code

Issue Name: Add-on Codes Paid without Primary Code and/or denied Primary Code
Issue Number: _0050
Review Type: Automated
Provider Type: Physician; Professional Services/Outpatient Hospital Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/04/2017
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: CPT 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. Affected CPT 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. To see Affected Codes list view in the 0050 Appendix D Tab. Excluded Modifiers: GA, GX, Q0, Q1. Excluded Codes 99292, 96360-96549. Excluded Modifiers: GA, GX, Q0, Q1. Excluded Codes 99292, 96360-96549.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30 D, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 (revised 7/23/2013)
Ambulance during Inpatient Hospital Stay
_0054
Automated
Ambulance Providers
Region-1
1 - All Region 1 states
05/31/2017

Ambulance during Inpatient Hospital Stay

Issue Name: Ambulance during Inpatient Hospital Stay
Issue Number: _0054
Review Type: Automated
Provider Type: Ambulance Providers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/31/2017
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: Ambulance services during an Inpatient stay are included in the facility’s PPS payment and are not separately payable under Part B, excluding the date of admission, date of discharge and any leave of absence days. Ambulance providers are expected to seek reimbursement from the inpatient facility. Affected Codes: A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0140, A0160, A0170, A0180, A0190, A0200, A0210, A225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0424, 0428, A0429, A0430, A0431, A0432, A0433, A0434, A0435, A0436, A0888, A0998, A0999
References: Title XVIII of the Social Security Act: Section 1833(e), Title XVIII of the Social Security Act: Section 1862(a) (1) (A), Medicare Claims Processing Manual: Publication 100-04; Chapter 3, § 10.4, 10.5;, Medicare Claims Processing Manual: Publication 100-04; Chapter 15, § 30.1.4, Medicare Benefit Policy Manual, Publication 100-02; Chapter 10, §10.3.3.
SNF Review: Documentation and Medical Necessity
_0004
Complex
SNF
Region-1
1 - All Region 1 states
06/01/2017

SNF Review: Documentation and Medical Necessity

Issue Name: SNF Review: Documentation and Medical Necessity
Issue Number: _0004
Review Type: Complex
Provider Type: SNF
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/01/2017
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
References: 42 CFR 409.30-409.36, 42 CFR 424.20, 42 CFR 483.20, IOM 100-01, chapter 4, 40.4-40.5, IOM 100-08, chapter 6, 6.1-6.32.2.1 and 6.3, IOM 100-02, chapter 8, 20-40, IOM 100-02, chapter 15, 220.1.3.