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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
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
Annual Wellness Visits (AWV)
_0028
Automated
Physician/Non- Physician Practitioner
1
1 - All Region 1 states
03/30/2017

Annual Wellness Visits (AWV)

Issue Name: Annual Wellness Visits (AWV)
Issue Number: _0028
Review Type: Automated
Provider Type: Physician/Non- Physician Practitioner
Region: 1
State: 1 - All Region 1 states
Date Approved: 03/30/2017
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: HCPCS code G0438 (Annual wellness visit; includes a personalized prevention plan of service [pps], initial visit) is a "one time" allowed Medicare benefit per beneficiary. Affected Codes: G0438.
References: Title XVIII of the Social Security Act, §§1861(s)(2)(FF) and 1861(hhh), Internet Only Manual, CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 280.5 (Annual Wellness Visit [AWV] Providing Personalized Prevention Plan Services [PPPS]) (Effective 5/10/2013), Internet Only Manual, CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] (Effective 1/27/2014), Internet Only Manual, CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 18, Sections 140 – 140.8 (Effective 1/1/2011). 
Trastuzumab (Herceptin), J9355 - Multi-Dose Vial Wastage, Dose vs. Units Billed
_0036
Complex
Physician; Outpatient hospital; Professional services (physician/non-physician practitioner)
1
1 - All Region 1 states
02/21/2017

Trastuzumab (Herceptin), J9355 - Multi-Dose Vial Wastage, Dose vs. Units Billed

Issue Name: Trastuzumab (Herceptin), J9355 - Multi-Dose Vial Wastage, Dose vs. Units Billed
Issue Number: _0036
Review Type: Complex
Provider Type: Physician; Outpatient hospital; Professional services (physician/non-physician practitioner)
Region: 1
State: 1 - All Region 1 states
Date Approved: 02/21/2017
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 the billed amount of trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines. Affected Codes: J9355.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual, 100-04, Chapter 17, Section 40, CDC: Questions about Multi-dose vials, Package label (manufacturer website): Herceptin
Excessive Units of Hospital Services
_0037
Automated
Professional Services (Physician/Non- Physician Practitioner)
1
1 - All Region 1 states
02/23/2017

Excessive Units of Hospital Services

Issue Name: Excessive Units of Hospital Services
Issue Number: _0037
Review Type: Automated
Provider Type: Professional Services (Physician/Non- Physician Practitioner)
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: Both Initial Hospital Care codes (CPT codes 99221–99223) and Subsequent Hospital Care codes (CPT Codes 99231 99233) are “per diem” services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. Affected Codes: 99221-99223, 99231-99233.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] (e), Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.9 (A) American Medical Association (AMA), Current Procedure Terminology 2007 to 2016.
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.
Complex Inpatient Hospital MS-DRG Coding Validation
_0001
Complex
Inpatient Hospital (IPH)
1
1 - All Region 1 states
02/01/2017

Complex Inpatient Hospital MS-DRG Coding Validation

Issue Name: Complex Inpatient Hospital MS-DRG Coding Validation
Issue Number: _0001
Review Type: Complex
Provider Type: Inpatient Hospital (IPH)
Region: 1
State: 1 - All Region 1 states
Date Approved: 02/01/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Clinical Validation is not permitted. The RAC may review MS-DRGs 870-872 using ICD-10 when applicable.
References:    Medicare Program Integrity Manual CMS Publication 100-08 Ch. 6.5.3 A-C DRG Validation Review, CMS QIO Manual Section 4130, ICD-9 & 10 CM Coding Manual, ICD-9 & 10 CM Addendums, ICD-9 & 10 CM Official Guidelines for Coding and Reporting, and Addendums, ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums, Coding Clinic for ICD-10-CM and ICD-10-PCS.