Skip to main content

CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

Filter By:
Issue Name Sort by Descending or Ascending
Issue Number Sort by Descending or Ascending
Review Type Sort by Descending or Ascending
Provider Type Sort by Descending or Ascending
Region Sort by Descending or Ascending
State Sort by Descending or Ascending
Date Approved Sort by Descending or Ascending
Details
Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)
_0077
Automated
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
01/15/2018

Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)

Issue Name: Annual Wellness Visits (AWV) billed sooner than 11 whole months of the Initial Preventative Physical Examination (IPPE)
Issue Number: _0077
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/15/2018
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: The Annual Wellness Visit (AWV) is not payable if an Initial Preventative Physical Examination (IPPE) has been paid within the previous 11 whole months. Affected Codes: G0439, G0402.
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. 42 CFR §411.15- Particular Services Excluded from Coverage, (a)(1)- Routine Checkups 7. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)- Any Services that are not Reasonable and Necessary, (15) 8. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit (AWV)"
Drugs and Biologicals Excessive or Insufficient Drug Units Billed
_0074
Complex
Outpatient Hospital & Physician
Region-1
1 - All Region 1 states
01/11/2018

Drugs and Biologicals Excessive or Insufficient Drug Units Billed

Issue Name: Drugs and Biologicals Excessive or Insufficient Drug Units Billed
Issue Number: _0074
Review Type: Complex
Provider Type: Outpatient Hospital & Physician
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/11/2018
Dates Service: Claims paid within 3 years from initial determination date
Description: Drugs and Biologicals should be billed in multiples of the dosage specified in the HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate, discarded drug waste. If the drug dose used in the care of a patient is not a multiple of the HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, registered pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units. Affected Codes: C9025, C9295, J0129, J0178, J0256, J0583, J0585, J0894 J0897, J1300, J1459, J1561, J1566, J1569, J1572, j1745, J2323, J2353, J2357, J2505, J2778, J2796, J2997, J3101, J3262, J3487, J7325, J9035, J9041, J9043, J9055, J9171, J9228, J9263, J9264, J9299, J9303, J9305, J9306, J9310, J9351, J9355, Q2050,.
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. CMS IOM 100-04, Medicare Claims Processing Manual Chapter 17 - Drugs and Biologicals §10 Payment Rules for Drugs and Biologicals; §40 Discarded Drugs and Biologicals; §70 Claims Processing Requirements – General; and §90.2 Drugs, Biologicals, and Radiopharmaceuticals 7. Medicare Alpha-Numeric HCPCS File 8. Annual American Medical Association: CPT Manual 9. Annual HCPCS Level II Manual 10. Medicare Part B Drug Average Sales Price; ASP Pricing File 11. U.S. National Library of Medicine DailyMed 12. Attached list of HCPCS Codes for Drugs and Biologicals
E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)
_0034
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
01/11/2018

E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)

Issue Name: E&M Codes billed within a Procedure Code with a 90 Day Global Period (major surgeries)
Issue Number: _0034
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/11/2018
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: "This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 90 days. Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 090 include only E & M services on the day before the procedure, the day of the procedure and up to 90 days post-operative days. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Evaluation & Management (E & M) codes as per the attached list; and All CPT and HCPCS codes with MPFSDB Global Days values of 090. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350, 99374, 99375.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, . Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)
_0033
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
All Region 1 states
01/11/2018

E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)

Issue Name: E&M Codes billed within a Procedure Code with a 10 Day Global Period (other minor procedures)
Issue Number: _0033
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: All Region 1 states
Date Approved: 01/11/2018
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: This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 10 days. Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 010 include only E & M services on the day of the procedure and up to 10 post-operative days. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350, 99374, 99375.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
Ventilators Subject to DWO Requirements on or after January 1, 2016
_0079
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
01/11/2018

Ventilators Subject to DWO Requirements on or after January 1, 2016

Issue Name: Ventilators Subject to DWO Requirements on or after January 1, 2016
Issue Number: _0079
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/11/2018
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 Ventilators meet coverage criteria and/or are medically reasonable and necessary. E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube); E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell).
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(a) - Payment for Durable Medical Equipment; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(6) - Payment for Other Items of Durable Medical Equipment; 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(n) - Durable Medical Equipment Definition ; 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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General ; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.5- Intrapulmonary Percussive Ventilator; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List; 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 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 5.7- 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 L33800: Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2017; 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
E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures
_0032
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
01/10/2018

E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures

Issue Name: E&M Codes billed within a Procedure Code with a 0 Day Global Period (Endoscopies or some minor surgical procedures
Issue Number: _0032
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/10/2018
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: This Query identifies E&M Services that are incorrectly billed within the codes that have a Global Days designation of 0 days. Affected Codes: 92012, 92014, 99211, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99238, 99239, 99241, 99242, 99243, 99245, 99251, 99252, 99253, 99254, 99255, 99291, 99292, 99315, 99316, 99347, 99348, 99349, 99350 99374, 99375, Under the Medicare Physician Fee Physician (MPFS) rules, most surgical procedures include pre-operative and post-operative Evaluation & Management services. These E & M services are referred to as 'Global Days'. Procedures with MPFS global days of 000 include only E & M services rendered on the day of surgery. Physicians can indicate that E & M services rendered during the global period are unrelated to the surgical procedure by submitting modifiers 24 (unrelated Evaluation and Management Service By Same Physician During Post-operative Period), 25 (Significant Evaluation and Management Service By Same Physician on Date of Global Procedure) and 57 (Decision For Surgery Made within Global Surgical Period) on the E & M service. Affected Codes: Evaluation & Management (E & M) codes as per the attached list; and All CPT and HCPCS codes with MPFSDB Global Days values of 000.
References: Social Security Act, Section 1833. [42 U.S.C. 1395l] €, Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries (Rev. 2997, Issued: 07-25-14, Effective: Upon implementation of ICD-10; 01-01- 2012 - ASC X12, Implementation: 08-25-2014 - ASC X12; Upon Implementation of ICD-10), Chapter 23, Addendum – MPFSDB Record Layouts (Rev. 3876, Issued:10-06-17, -Implementation: 04-02-18)
Complex Home Health Review: Documentation and Medical Necessity
_0075
Complex
Home Health Agencies
Region-5
All HHA MACs except for the following demonstration states: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia
01/10/2018

Complex Home Health Review: Documentation and Medical Necessity

Issue Name: Complex Home Health Review: Documentation and Medical Necessity
Issue Number: _0075
Review Type: Complex
Provider Type: Home Health Agencies
Region: Region-5
State: All HHA MACs except for the following demonstration states: Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia
Date Approved: 01/10/2018
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. Affected Codes: Revenue Codes: 027X, 042X, 043X, 044X, 023X, 055X, 056X, 057X.
References: 1. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1814(a)(2)(C) - Conditions of and Limitations on payment for services 2. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services 3. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1835(a)(2)(A) – Procedure for payment of claims of providers of services 4. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services 5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(o) – Home Health Agency 6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(r) - Physician 7. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(aa)(5) – Rural Health Clinic Services and Federally Qualified Health Center Services 8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(gg)(2) – Certified Nurse-Midwife Services 9. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1891 – Conditions of Participation for home health agencies; Home health quality 10. 42 CFR 409.41 – Requirement for Payment 11. 42 CFR 409.42 – Beneficiary qualifications for coverage of services 12. 42 CFR 409.43 – Plan of care requirements 13. 42 CFR 409.44 – Skilled services requirements 14. 42 CFR 409.45 – Dependent services requirements 15. 42 CFR 409.46 – Allowable administrative costs 16. 42 CFR 409.47 – Place of service requirements 17. 42 CFR §424.22(a)(1)(i)-(v) – Requirement for home health services 18. IOM, 100-01 Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 Physician Certification and Recertification of Services, Section 10 Certification and Recertification by Physicians for Hospital Services – General, Subsection 10.2 Who May Sign Certification or Recertification 19. IOM, 100-01 Medicare General Information, Eligibility and Entitlement Manual Chapter 4 Physician Certification and Recertification of Services, Section 30 Certification and Recertification by Physicians for Home Health Services, Subsection 30.1 Content of Physician’s Certification 20. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.1.1 Patient Confined to the Home 21. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.2.1 Content of the Plan of Care 22. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.5.1.1 Face-to-Face Encounter 23. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.5.1.2 Supporting Documentation Requirements
Respiratory Assist Device
_0069
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
12/17/2017

Respiratory Assist Device

Issue Name: Respiratory Assist Device
Issue Number: _0069
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 12/17/2017
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 Respiratory Assist Devices meet coverage criteria and /or are medically reasonable and necessary. Affected Codes: E0470 - Respiratory Assist Device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device); E0471 - Respiratory Assist Device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
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(a)( (7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment; 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 §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(1) - Items Requiring a Written Order; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(2) - Specified Covered Items; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(3) - Face to Face Encounter Requirements; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(4)- Written Order Issuance Requirements; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(5) - Supplier Order and Documentation Requirements; 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 5.2.4(C) - Rules Concerning Orders, Written Orders Prior to Delivery; Written Orders for Certain Covered Durable Medical Equipment ; Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Face-to-Face Encounter Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements; 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 Determination (LCD) L33800: Effective 10/1/2015, Revision 01/01/2017.; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Respiratory Assist Device- Policy Article A52517: Effective 10/1/2015, Revision 01/01/2017; 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
Outpatient Service Overlapping or During an Inpatient Stay
_0072
Automated
Hospital Outpatient, Hospital Inpatient Part B
Region-1
1 - All Region 1 states
10/26/2017

Outpatient Service Overlapping or During an Inpatient Stay

Issue Name: Outpatient Service Overlapping or During an Inpatient Stay
Issue Number: _0072
Review Type: Automated
Provider Type: Hospital Outpatient, Hospital Inpatient Part B
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/26/2017
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: Payment may not be made for outpatient services overlapping or during an inpatient stay. See appendix D for affected code list in the downloadable Excel file.
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 Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2 (A)- Exact Duplicate Claims- Submission of Institutional Claims 7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3.B- Outpatient Services Treated as Inpatient Services- Preadmission Diagnostic Testing 8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling 9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §200.2- Hospital Dialysis Services for Patients with and without End-Stage Renal Disease (ESRD) 10. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4- CWF Editing of Ambulance Claims for Inpatients 11. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §10.2- Billing Requirements 12. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments 13. Medical Benefit Policy Manual, Chapter 6- Hospital Services Covered under Part B, §10.2- Other Circumstances in Which Payment Cannot Be Made Under Part A 14. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Services & §20- Coverage Guidelines for Ambulance Service Claims 15. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §20- Coverage Guidelines for Ambulance Service Claims"