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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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). 
Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses - CLOSED ISSUE
_0048
Automated
DME by Supplier, DME by Physician
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: 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. 
Multiple DME Rentals in One Month
_0046
Automated
DME by Supplier, DME by Physician
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: 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).
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) .
Automated Inpatient Psych Billed without Source of Admission Equal to “D”
_0022
Automated
Inpatient Hospital, Inpatient Psychiatric Facility
1
1 - All Region 1 states
02/09/2017

Automated Inpatient Psych Billed without Source of Admission Equal to “D”

Issue Name: Automated Inpatient Psych Billed without Source of Admission Equal to “D”
Issue Number: _0022
Review Type: Automated
Provider Type: Inpatient Hospital, Inpatient Psychiatric Facility
Region: 1
State: 1 - All Region 1 states
Date Approved: 02/09/2017
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: Under the Medicare PPS for inpatient psychiatric facilities (IPF), CMS makes an additional payment to an IPF or a distinct part unit (DPU) for the first day of a beneficiary's stay to account for emergency department costs if the IPF has a qualifying emergency department. However, CMS does not make this payment if the beneficiary was discharged from the acute care section of a hospital to its own hospital based IPF. In that case, the costs of emergency department services are covered by the Medicare payment that the acute hospital received for the beneficiary's inpatient acute stay.Source of admission code 'D' has been designated for usage when a patient is discharged from an acute hospital to their own psychiatric DPU. This code will prevent the additional payment for the beneficiary's first day of coverage at the DPU. An overpayment occurs when source of admission code 'D' is not billed for these transfer claims.
References: Claims Processing Manual (100-04), Chapter 3, Section 190.6.4, Claims Processing Manual (100-04), Chapter 3, Section 190.6.4.1
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
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).
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
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)
Visits to Patients in Swing Beds
_0038
Automated
Physician; Professional Services
1
1 - All Region 1 states
02/23/2017

Visits to Patients in Swing Beds

Issue Name: Visits to Patients in Swing Beds
Issue Number: _0038
Review Type: Automated
Provider Type: Physician; Professional Services
Region: 1
State: 1 - All Region 1 states
Date Approved: 02/23/2017
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 the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply. Affected codes: 99221-99223, 99231-99233, 99238-99239.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.9.