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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Nebulizer Drugs
_0026
Complex
DME by Supplier, DME by Provider
Region-5
5 - Nationwide
04/14/2017

Nebulizer Drugs

Issue Name: Nebulizer Drugs
Issue Number: _0026
Review Type: Complex
Provider Type: DME by Supplier, DME by Provider
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/14/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: Documentation will be reviewed to: determine if the Nebulizer Related Drugs meet Medicare coverage criteria; validate the drug dosage administered versus dosage billed; determine if medically reasonable and necessary. Affected codes: J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7626, J7631, J7639, J7644, J7669, J7682, J7686, Q0474, J7620
References: CMS IOM, Pub. 100-03, Chapter 1, Part 4, Section 200.2, Effective Date: 09-10-07 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf CMS IOM, Pub. 100-03, Chapter 1, Part 4, Section 280.1, Effective Date: 05-05-05 http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ncd103c1_Part4.pdf, Nationwide LCD L33370, Original Effective Date: 10/01/2015 https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370&ver=4&Date=&DocID=L33370&bc=iAAAAAgAAAAAAA%3d%3d&, CGS LCD L5007, Original Effective Date: 04/01/1997; Retired Date: 09/30/2015 http://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=5007&ContrID=140, NGS: LCD L27226, Original Effective Date: 04/01/1997, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=27226&lcd_version=53&basket=lcd%3A27226%3A53%3ANebulizers%3ADME+MAC%3ANational+Government+Services%7C%7C+Inc%2E+%2817003%29%3A, Noridian: LCD L11488, Original Effective Date: 04/01/1997, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=11488&lcd_version=91&basket=lcd%3A11488%3A91%3ANebulizers%3ADME+MAC%3ANoridian+Healthcare+Solutions%7C%7C+LLC+%2819003%29%3A, NHIC: LCD L11499, Original Effective Date: 04/01/1997, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewlcd.asp?lcd_id=11499&lcd_version=99&basket=lcd%3A11499%3A99%3ANebulizers%3ADME+MAC%3ANHIC%7C%7C+Corp%2E+%2816003%29%3A, Nationwide Article A52466, Original Effective Date: 10/01/2015, Revision Date: 07/01/2016 https://www.cms.gov/medicare-coverage-database/license/cpt-license.aspx?from=~/overview-and-quick-search.aspx&npage=/medicare-coverage-database/details/article-details.aspx&articleId=52466&ver=9&LCDId=33370&Date=&DocID=L33370&bc=iAAAAAgAIAAAAA%3d%3d&, NHIC Article A24944, Original Effective Date: 04/01/2005, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle.asp?article_id=24944&article_version=39&show=all, NGS Article A47233, Original Effective Date: 04/01/2005, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=47233&article_version=29&contractor_id=138, Noridian Article A24942, Original Effective Date: 04/01/2005, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle.asp?article_id=24942&article_version=46&show=all, CGS Article A24623, Original Effective Date: 04/01/2005, Revision Date: 10/31/2014, Retired Date: 09/30/2015 http://localcoverage.cms.gov/mcd_archive/viewarticle_popup.asp?from=basket&type=article&page=viewlmrp.asp&article_id=24623&article_version=44&contractor_id=140, CMS IOM, Medicare Claims Processing Manual, (MCPM), Publ. 100-04, Chapter 20, §100 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c20.pdf, CMS IOM, Medicare Program Integrity Manual (MPIM), Publ. 100-08, Chapter 5, §5.2 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c05.pdf. 
Complex Group 2 Support Surfaces Without Correct Diagnosis of Condition WOPD
_0029
Complex
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
02/15/2017

Complex Group 2 Support Surfaces Without Correct Diagnosis of Condition WOPD

Issue Name: Complex Group 2 Support Surfaces Without Correct Diagnosis of Condition WOPD
Issue Number: _0029
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/15/2017
Dates Service: Claims having a "Claims paid date" with dates of service prior to 01/01/2016
Description: Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: E0277, E0371, E0372, E0373.
References: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, 42 C.F.R section 424.57 (12), CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26 revision 750 effective 11/20/2017, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.3 revision 693, 5.7 revision 733 effective 07/27/2017, 5.8 revision 750 effective 11/20/2017, and 5.9 revision 242 effective 03/01/2008, NHIC LCD L5068 - Effective 10/1/1993; Retired 9/30/2015, CGS LCD L11564 - Effective 10/1/1993; Retired 9/30/2015, Noridian LCD L11579 - Effective 10/1/1993; Retired 9/30/2015, National Government Services (NGS) LCD L27009 - Effective 10/1/1993; Retired 9/30/2015, Nationwide LCD L33642 – Revised 05/25/2017, Nationwide Policy Article A52490, Revised 05/25/2017, Noridian Policy Article A35422; Effective 10/1/2005; Retired 9/30/2015, NHIC Policy Article A35350, Effective 10/1/2005; Retired 9/30/2015, CGS Policy Article A35357, Effective 10/1/2005; Retired 9/30/2015, NGS Policy Article A47114, Effective 10/1/2005; Retired 9/30/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) effective 01/01/2017, revised 11/20/2017.
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.
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. 
Panretinal (Scatter) Laser Photocoagulation - Excess Frequency
_0047
Automated
Outpatient Hospital (OPH), Physician/Non-physician Practitioner
Region-1
J6, JK, J15
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), Physician/Non-physician Practitioner
Region: Region-1
State: J6, JK, J15
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: Claims for CPT code 67228 (Treatment of extensive or progressive retinopathy [eg, diabetic retinopathy], photocoagulation), billed more frequently than once per eye within the global surgery period will be denied, based on CGS LCDs L34064 and L31888 (Retired) and NGS LCDs L33628 and L28497 (Retired), as applicable.
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, §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 - Effective – 10/01/2015 (Revised 10/1/2016); National Government Services (NGS) LCD L28497 (Retired 9/30/2015); NGS LCD L33628- Effective -- 10/01/2015 (Revised 10/1/2016)
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)
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).
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.