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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Ambulance during Inpatient Hospital Stay
_0054
Automated
Ambulance Providers
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: 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.
Add-on Codes Paid without Primary Code and/or denied Primary Code
_0050
Automated
Physician; Professional Services/Outpatient Hospital Services
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: 1
State: 1 - All Region 1 states
Date Approved: 05/04/2017
Dates Service: 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.
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.
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)
Automated DME Billed While Inpatient
_0019
Automated
DME by Supplier, DME by Physician
5
5 - Nationwide
02/16/2017

Automated DME Billed While Inpatient

Issue Name: Automated DME Billed While Inpatient
Issue Number: _0019
Review Type: Automated
Provider Type: DME by Supplier, DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 02/16/2017
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: A supplier (includes physician furnishing DME) may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two(2) days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility. To see Affected Codes, download the .xls file and reference the 0019 Appendix D tab
References: Social Security Act, Volume 1, 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); CMS Internet-Only Manuals (IOMs), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110; CMS Internet-Only Manuals (IOMs), Publication 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Sections 240.2, 240.2, 280.1, 280.2, 280.3, 280.6, and 280.7; CMS Internet-Only Manuals (IOMs) Publication 100-04, Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Sections 10.2, 30.6, 100.2.2, and 110.3; CMS Internet-Only Manuals (IOMs) Publication 100-04, Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Sections 10.2, 30.6, 100.2.2, and 110.3; CMS Internet-Only Manuals (IOMs), Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3 
Panretinal (Scatter) Laser Photocoagulation - Excess Frequency
_0047
Automated
Outpatient Hospital (OPH), and Physician/ Non-physician Practitioner
1
1 - All Region 1 states
04/28/2017

Panretinal (Scatter) Laser Photocoagulation - Excess Frequency

Issue Name: Panretinal (Scatter) Laser Photocoagulation - Excess Frequency
Issue Number: _0047
Review Type: Automated
Provider Type: Outpatient Hospital (OPH), and Physician/ Non-physician Practitioner
Region: 1
State: 1 - All Region 1 states
Date Approved: 04/28/2017
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: Potential incorrect billing occurred when Panretinal (Scatter) Laser Photocoagulation (CPT code 67228) is paid more than once, per eye, within the global surgery period (90 days for DOS prior to 1/1/2016 and 10 days for DOS 1/1/2016 and after). Affected Codes: 67228.
References: Title XVIII of the Social Security Act (SSA): §1833(e),Title XVIII of the Social Security Act (SSA): §1862(a)(1)(A), CMS Publication 100-08, Program Integrity Manual, Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), §&3.5.1 (Re-opening Claims) and §3.6 (Determinations Made During Review), CGS Administrators, LLC (CGS) Local Coverage Determination (LCD) L31888 (Retired 9/30/2015), CGS LCD L34064 (Revised 10/1/2016), National Government Services (NGS) LCD L28497 (Retired 9/30/2015), NGS LCD L33628 (Revised 10/1/2016). 
Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)
_0014
Automated
DME by Supplier, DME by Physician
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: 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 
New Patient Visits
_0043
Automated
Physician/Non- Physician Practitioner
1
1 - All Region 1 states
03/09/2017

New Patient Visits

Issue Name: New Patient Visits
Issue Number: _0043
Review Type: Automated
Provider Type: Physician/Non- Physician Practitioner
Region: 1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
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: Identification of overpayments made when providers report visits with new-patient Evaluation and Management (E/M) codes for patients who do not meet the definition of a new patient. Claims are recouped when a provider bills a new-patient visit code and the same provider or a provider from the same group practice. Affected Codes: 92002, 92004, 99012, 9904, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226, 99231, 99233, 99234, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254, 99255, 99281, 99283, 99284, 99285, 99291, 99292, 99304, 99305, 99306, 99307, 99308, 99308, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99354, 99355, 99381, 99382, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99401, 99042, 99403, 99404, 99460, 99461, 99462, 99463, 99465, 99466, 99467, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479, 99480, G0245, G0246, G0402, G0438, G0439.
References: Internet Only Manual, CMS Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30.6.7.A (Definition of New Patient for Selection of E/M Visit Code) (Effective 1/1/2016), 30.6.1.1 (Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV]) (Effective 1/27/2014), and 30.6.9 (Payment for Inpatient Hospital Visits – General) (Effective 1/1/2011)
Office Visits Billed for Hospital Inpatients
_0042
Automated
Professional Services (Physician/Non- Physician Practitioner)
1
1 - All Region 1 states
03/09/2017

Office Visits Billed for Hospital Inpatients

Issue Name: Office Visits Billed for Hospital Inpatients
Issue Number: _0042
Review Type: Automated
Provider Type: Professional Services (Physician/Non- Physician Practitioner)
Region: 1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
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: If evaluation and management service are being rendered to patients admitted to an inpatient hospital setting, then CPT Codes 99221-99223, 99231-99233 and 99238-99239 are to be used. CPT codes 99201-99215 are to be used for evaluation and management service provided in the physician's office, in an outpatient or other ambulatory facility.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.9.1, 30.6.2 and 30.6.10
Not a New Patient
_0039
Automated
Physician; Professional Services
1
1 - All Region 1 states
03/09/2017

Not a New Patient

Issue Name: Not a New Patient
Issue Number: _0039
Review Type: Automated
Provider Type: Physician; Professional Services
Region: 1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
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: Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any face-to-face service from the physician or physician group practice (limited to physicians of the same specialty) within the previous 3 years. This query identifies claims for patients who have been seen by the same provider in the last 3 years but for which the provider is billing a new (instead of established) visit code. Findings are limited to line with overpayments only. Affected Codes: 92002, 92004, 99201-99205, 99341-99345.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.7 (A).
Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services
_0027
Complex
Outpatient Hospital (OPH), Physician
1
1 - All Region 1 states
04/25/2017

Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services

Issue Name: Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services
Issue Number: _0027
Review Type: Complex
Provider Type: Outpatient Hospital (OPH), Physician
Region: 1
State: 1 - All Region 1 states
Date Approved: 04/25/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: To identify claims where modifier -59 has been inappropriately appended when Endomyocardial Biopsies and Right Heart Catheterizations are billed together. Affected Codes: 93451.
References: Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A), NCCI Manuals, 2015, 2016, 2017, and 2018 Chapter 1 & Chapter 11, 3. CPT Manual