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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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) "
Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission
_0086
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
03/19/2018

Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission

Issue Name: Observation Evaluation & Management (E&M) codes billed Same Day as Inpatient Admission
Issue Number: _0086
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
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: Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill observation care codes (initial, subsequent and/or discharge management) for services on the date that he or she admits the patient to inpatient status. Affected Codes: 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226.
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. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 7. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 8. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 9. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 10. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 12 (Physicians/Nonphysician Practitioners), §30.6.8(D)- Admission to Inpatient Status Following Observation Care"
CSW (Clinical Social Workers) during Inpatient Hospital
_0089
Automated
Clinical Social Workers
Region-1
1 - All Region 1 states
03/19/2018

CSW (Clinical Social Workers) during Inpatient Hospital

Issue Name: CSW (Clinical Social Workers) during Inpatient Hospital
Issue Number: _0089
Review Type: Automated
Provider Type: Clinical Social Workers
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: Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facilities PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility. Affected Codes: Psychiatry CPT Codes 90785 - 90899 (See attached table - Appendix D) 96150-96154 and Q3014 for WPS contract states.
References: "1. Title XVIII, §§1861(hh) and (hh)(2) of the Social Security Act- Clinical Social Worker; Clinical Social Worker Services 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 4. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 5. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 6. 42 Code of Federal Regulations (CFR) §409.10(a)(4)- Included Services- Medical Social Services 7. 42 Code of Federal Regulations (CFR) §410.73- Clinical Social Worker Services 8. 42 Code of Federal Regulations (CFR) §412.50(b)- Furnishing of Inpatient Hospital Services Directly or Under Arrangements 9. Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15 (Covered Medical and Other Health Services), §170- Clinical Social Worker (CSW) Services 10. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 3 (Inpatient Hospital Billing), §10.4- Payment of Nonphysician Services for Inpatients 11. WPS, Local Coverage Article A54829: Effective 2/01/2016; Revision 3/01/2018 "
Ancillary Services Billed Without an Approved Surgical Procedure
_0088
Automated
Ambulatory Surgery Center (ASC)
Region-1
1 - All Region 1 states
03/16/2018

Ancillary Services Billed Without an Approved Surgical Procedure

Issue Name: Ancillary Services Billed Without an Approved Surgical Procedure
Issue Number: _0088
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/16/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Covered ancillary items and services identified in Appendix D are not payable if there is no approved ASC surgical procedure on the same claim or in history for the same date of service and same provider. Affected codes: 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226
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. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 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. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 10. Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15 (Covered Medical and Other Health Services), §260- Ambulatory Surgical Center Services 11. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 14 (Ambulatory Surgery Centers), §40- Payment for Ambulatory Surgery"
Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD
_0087
Automated
Professional Services(Physician/Non-Physician Practitioner); Laboratory
Region-1
1 - All Region 1 states
03/16/2018

Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD

Issue Name: Labs Subject to Part B Consolidated Billing for Clinical Labs - ESRD
Issue Number: _0087
Review Type: Automated
Provider Type: Professional Services(Physician/Non-Physician Practitioner); Laboratory
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/16/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: The ESRD PPS includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Should these laboratory services, and limited drugs be provided to a beneficiary, but are not related to the treatment for ESRD, the claim lines must be submitted with the new AY modifier to allow for separate payment outside of ESRD prospective payment system. Affected codes: Labs subject to ESRD Consolidated Billing" for CY 2014-2018 found on www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
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 Benefit Policy Manual, CMS Publication 100-02, Chapter 11 (End Stage Renal Disease), §20.2- Laboratory Services 7. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 8 (Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims), §60.1- Lab Services 8. ESRD PPS Consolidated Billing (files for 2014 – 2019) www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html"
Complex Negative Pressure Wound Therapy Pumps-DWO
_0081
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/26/2018

Complex Negative Pressure Wound Therapy Pumps-DWO

Issue Name: Complex Negative Pressure Wound Therapy Pumps-DWO
Issue Number: _0081
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/26/2018
Dates Service: Less than 3 years and on or after 5/25/2017
Description: Medical Necessity Review Negative Pressure Wound Therapy Pumps - Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in Local Coverage Determination (LCD) L33821 (related MAC Policy Article A52511). Affected Codes: E2402 - NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE A6550 - WOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDES ALL SUPPLIES AND ACCESSORIES A7000 - CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH.
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(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. 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 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 10. 42 CFR §424.57(c)- Application Certification Standards 11. 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 12. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 14. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 15. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 20. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 21. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 22. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33821: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52511: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 25. 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"
Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
_0080
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/20/2018

Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO

Issue Name: Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
Issue Number: _0080
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/20/2018
Dates Service: Less than 3 years and on or after January 1, 2016
Description: Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0277, E0371, E0372, E0373.
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(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 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 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 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 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 L33642: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52490: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 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"