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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Ambulatory Surgical Center Coding Validation
_0153
Complex
ASC
Region-1
1 - All Region 1 states
05/26/2019

Ambulatory Surgical Center Coding Validation

Issue Name: Ambulatory Surgical Center Coding Validation
Issue Number: _0153
Review Type Complex
Provider Type: ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/26/2019
Date Revised:
Dates Service: 3 Years
Description: Ambulatory Surgical Center coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the CPT/HCPCS coding and associated modifiers by reviewing the procedures affecting or potentially affecting payment. Affected codes: Claims with payment indicator A2; G2; J8
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. 42 CFR § 414.B Payment for Part B Medical and Other Health Services- Coding and Ancillary Policies 6. 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 7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions §3.6.2.4- Coding Determinations 8. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package 9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; 40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; 40.5- Payment for Multiple Procedures 10. American Medical Association (AMA), Current Procedure Terminology 11. ASC Payment System; Addendum AA; Payment indicators: G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate).ASC Payment rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html 12. National Correct Coding Initiative Policy Manual 13. American Medical Association CPT Assistant 14. American Hospital Association Coding Clinic for HCPCS"
Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services
_0154
Complex
Ambulance
Region-1
1 - All Region 1 states
05/20/2019

Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services

Issue Name: Medical Necessity for Advanced Life Support (ALS) and Basic Life Support (BLS) Non-Emergency Ambulance Services
Issue Number: _0154
Review Type Complex
Provider Type: Ambulance
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/20/2019
Date Revised:
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: "Medicare pays for nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation are contraindicated (i.e. would endanger the beneficiary). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment. Origin or Destination Descriptions D Diagnostic or therapeutic site other than P (physician’s office) or H (hospital) when these are used as origin codes E Residential, domiciliary, or custodial facility (other than a SNF) G Hospital-based ESRD facility H Hospital I Site of transfer (e.g., an airport or a helicopter pad) between modes of ambulance transport J Freestanding ESRD facility N SNF P Physician’s office R Residence S Scene of accident or acute event X Intermediate stop at physician’s office on way to hospital (destination code only)"
References: "1. Social Security Act (SSA) § 1833 (e) Payment of Benefits. 2. SSA 1862(a)(1) states that no payment may be made under part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 3. SSA 1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in the regulations. 4. SSA 1834(l) (10)-(16) Fee Schedule for Ambulance Services. 5. 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 6. 42 CFR §405.986 Good Cause for Reopening 7. 42 CFR §424.5 (a)(6) Basic Conditions; Sufficient Information 8. 42 CFR 410.40 (b) Coverage of ambulance services; Levels of service. 9. 42 CFR 410.40 (d)(1) Coverage of ambulance services; Medical necessity requirements. 10. 42 CFR 410.40 (d)(2) Special rule for nonemergency, scheduled, repetitive ambulance services. 11. 42 CFR 410.40 (d)(3) Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis 12. 42 CFR 410.41 (c) Requirements for ambulance suppliers; Billing and reporting requirements. 13. 42 CFR 414.605 Definitions 14. 42 CFR 414.610 Basis of Payment 15. 42 CFR 411.15 (k)(1) Particular Services Excluded from Coverage, Any Services not Reasonable and Necessary. 16. 42 CFR 424.36 Signature Requirements and 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary. 17. IOM, 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 10, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services, Emergency Response, Definition. 18. IOM, 100-04, Medicare Claims Processing Manual, Chapter 15, §30 (A) & (B), Modifiers Specific to Ambulance Service Claims and HCPCS Codes. 19. Novitas LCD L35162, Ambulance Services (Ground Ambulance). Effective Date 10/01/2015. 20. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015."
Mohs Micrographic Surgery (MMS) Incorrect Units Billed
_0150
Complex
Physicians and Non-Physician Practitioners
Region-1
1 - All Region 1 states
04/30/2019

Mohs Micrographic Surgery (MMS) Incorrect Units Billed

Issue Name: Mohs Micrographic Surgery (MMS) Incorrect Units Billed
Issue Number: _0150
Review Type Complex
Provider Type: Physicians and Non-Physician Practitioners
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/30/2019
Date Revised:
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: MMS is a two-step process in which: 1) The tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s); and 2) Additional excision and evaluation is performed until all margins are clear. The physician who performs Mohs surgery carries dual responsibility and is acting as both surgeon and pathologist. Reviewers will determine if the additional Mohs micrographic technique staging unit(s) for HCPCS 17312 and 17314 is/are reported correctly according to the code descriptions. Affected codes: 17311, 17312, 17313, 17314, 17315
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. IOM, 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 6. AHA Coding Clinic for HCPCS, Third Quarter 2013, Volume 13, Number 3, Page 1 Reporting MOHS micrographic surgery (MMS) 7. CPT Assistant, October 2014, Volume 24, Issue 10, Page 14 Frequently Asked Questions, Mohs Surgery, Tissue Block 8. CPT Assistant, November 2006, Volume 16, Issue 11, Pages 1-7 Mohs Micrographic Surgery 9. CPT Assistant, February 2014, Volume 24, Issue 2, Page 10 Coding Clarification: Mohs Surgery "
Complex Physicians/Non-physician practitioners Coding Validation
_0151
Complex
Physician/Non-Physician Practitioner
Region-1
1 - All Region 1 states
04/23/2019

Complex Physicians/Non-physician practitioners Coding Validation

Issue Name: Complex Physicians/Non-physician practitioners Coding Validation
Issue Number: _0151
Review Type Complex
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/23/2019
Date Revised:
Dates Service: "Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date. "
Description: The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Documentation will be reviewed to determine if professional services that affecting MPGS payment meet Medicare coverage criteria and applicable coding guidelines. Affected Codes: CMS MPFS status code “A”
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. 42 Code of Federal Regulations (CFR) §414 Payment for Part B Medical and other Health Services, Subpart A – General Provisions, Subpart B – Physicians and other Practitioners, Subpart E – Determination of Reasonable Charges under ESRD Program 6. 42 CFR §414.40 Coding and Ancillary Policies 7. 42 CFR §415 Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings 8. 42 CFR §419.44 Payment Reductions for Procedures 9. IOM, 100-04, Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners 10. IOM, 100-04, Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements 11. IOM, 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 12. American Medical Association (AMA), Current Procedural Terminology (CPT) 13. AMA, HCPCS Level II 14. AMA CPT Assistant 15. National Correct Coding Initiatives (NCCI) Policy Manual 16. 1995 & 1997 Documentation Guidelines for Evaluation & Management Services 17. CMS Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html"
Medical Necessity and Coding of Chest X-Rays
_0136
Complex
Outpatient hospital
Region-1
1 - All Region 1 states
04/25/2019

Medical Necessity and Coding of Chest X-Rays

Issue Name: Medical Necessity and Coding of Chest X-Rays
Issue Number: _0136
Review Type Complex
Provider Type: Outpatient hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/25/2019
Date Revised:
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR.
Description: Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. This review will ensure chest x-rays are paid when billed appropriately and only when medically necessary.
References: "1. SSA, §1862(a)(1)(A), §1862(a)(7) – Exclusions from coverage 2. SSA, §1833(e) – Payment of benefits 3. 42 CFR §411.15(a)(1) – Particular services excluded from coverage; Routine physical checkups. 4. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations 5. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.4-80.4.4, Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician 9. CMS Manual System, Pub, 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.1, Definitions. 10. CMS Manual System, Pub. 100-04, Program Integrity Manual, Chapter 3 §3.2.3.8 - No Response or Insufficient Response to Additional Documentation Requests 11. CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3, Diagnoses Code Requirement. 12. CPT Manual"
Subsequent Hospital Visit and Discharge Day Management on the Same Day
_0149
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
04/18/2019

Subsequent Hospital Visit and Discharge Day Management on the Same Day

Issue Name: Subsequent Hospital Visit and Discharge Day Management on the Same Day
Issue Number: _0149
Review Type Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/18/2019
Date Revised:
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: Per Medicare Claims Processing Manual Chapter 12, Section 30.6.9.2 (C), CMS does not reimburse both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. CPT codes 99231 – 99233 will be considered overpayments and will be recovered. Affected Codes: 99231, 99232. 99233; anchor codes 99238, 99239
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 Claims Processing Manual; Publication 100-04; Chapter 12, Section 30.6.9.2 (C) Subsequent Hospital Visit and Discharge Management on Same Day"
ASC Services During a Covered Part A SNF Stay
_0142
Automated
"Ambulatory Surgery Center (ASC) SNF"
Region-1
1 - All Region 1 states
04/01/2019

ASC Services During a Covered Part A SNF Stay

Issue Name: ASC Services During a Covered Part A SNF Stay
Issue Number: _0142
Review Type Automated
Provider Type: "Ambulatory Surgery Center (ASC) SNF"
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/01/2019
Date Revised:
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates for years: 2015, 2016, 2017 and 2018 are overpayments and will be recovered.Affected codes: See 0142 Appendix D
References: "1) Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2) 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 3) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing, § 20.1.2: Other Excluded Services Beyond the Scope of a SNF Part A Benefit https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 4) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing, § 110.2.7: Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 5) OIG Report: Payments for Ambulatory Surgical Center Services Provided to Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A in Calendar Years 2006 through 2008 (A-01-0900521) December 2010 https://oig.hhs.gov/oas/reports/region1/10900521.pdf 6) SNF Consolidated Billing – Annual Updates for Part A MAC – 2015, 2016, 2017 and 2018 https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2015-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2017-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-A-MAC-Update.html 7) SNF Consolidated Billing – General Explanation of the Major Categories for Skilled Nursing Facility – https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2018-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2016-General-Explanations.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2015-General-Explanation.pdf "
Endovenous Radiofrequency Ablation and Endovenous Laser Treatment (ERFA and EVLT) for Lower Extremity Varicose Veins
_0145
Complex
Outpatient Hospital, Professional Services, and Ambulatory Surgical Centers
Region-1
1 - All Region 1 states
03/31/2019

Endovenous Radiofrequency Ablation and Endovenous Laser Treatment (ERFA and EVLT) for Lower Extremity Varicose Veins

Issue Name: Endovenous Radiofrequency Ablation and Endovenous Laser Treatment (ERFA and EVLT) for Lower Extremity Varicose Veins
Issue Number: _0145
Review Type Complex
Provider Type: Outpatient Hospital, Professional Services, and Ambulatory Surgical Centers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/31/2019
Date Revised:
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Exclude claims with a DOS prior to 10/1/2015.
Description: Claims for ERFA and EVLT for Lower Extremity Varicose Veins are not deemed to be medically necessary will be denied based on the guidelines outlined in the Noridian LCDs L34209 and L34010, First Coast LCDs L33762, LCAs A56064 and A55963, NGS L33575 and A52870, Novitas L34924 and A55229, Palmetto L33454, WPS L34536, and CGS L34082
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. CGS LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 1/1/2018 7. First Coast LCD L33762- Treatment of Varicose Veins of the Lower Extremity; Effective 10/1/2015; Revised 01/22/2019 8. NGS LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 1/1/2018 9. Noridian LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 1/1/2018 10. Noridian LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 1/1/2018 11. Novitas LCD L34924- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 10/1/2015, Revised 5/17/2018 12. 12. Palmetto LCD L33454- Varicose Veins of the Lower Extremities; Effective 10/1/2015, Revised 4/22/2019 13. WPS LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 10/01/2018 14. First Coast LCA A55963- Treatment of Varicose Veins of the Lower Extremity- revision to the Part A/B LCD; Effective 4/17/2018 15. First Coast LCA A56064- Treatment of Varicose Veins of the Lower Extremity- revision to the Part A/B LCD; Effective 7/10/2018 16. NGS LCA A52870- Varicose Veins of the Lower Extremity, Treatment of- Supplemental Instructions Article; Effective 10/1/2015; Revised 1/1/2018 17. Novitas A55229- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 8/11/2016; Revised 5/17/2018"
Medical Necessity Pulmonary Rehabilitation
_0140
Complex
Hospital Outpatient and Professional Services
Region-1
1 - All Region 1 states
03/27/2019

Medical Necessity Pulmonary Rehabilitation

Issue Name: Medical Necessity Pulmonary Rehabilitation
Issue Number: _0140
Review Type Complex
Provider Type: Hospital Outpatient and Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/27/2019
Date Revised:
Dates Service: Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: "Pulmonary rehabilitation is a physician-supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Medical Documentation will be reviewed to determine if pulmonary rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria."
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. Social Security Act (SSA) § 1861 (s)(2)(CC)(fff)- Part E- Miscellaneous Provisions- Definitions of Services, Institutions, ETC.- Pulmonary Rehabilitation Program 4. 42 C.F.R. §§ 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 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 8. CMS Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 231 9. CMS Claim Processing Manual, Pub. 100-04, Chapter 32, Section 140 10. CMS Transmittal R1966CP- Pulmonary Rehabilitation (PR) Services; Issued Date 5/7/2010, Implementation Date 10/4/2010 11. Noridian LCA A52770 Pulmonary Rehabilitation; original effective date: 10/01/2015; Revision Date: 10/08/2018 12. Noridian LCA A56152 Pulmonary Rehabilitation; original effective date: 10/08/2018"