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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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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. Palmetto LCD L33454- Varicose Veins of the Lower Extremities; Effective 10/1/2015, Revised 11/12/2018 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"
Unbundling of MRI Procedures
_0147
Automated
Professional Services (Physician/Non-Physician Practitioner), Outpatient Hospital
Region-1
1 - All Region 1 states
03/27/2019

Unbundling of MRI Procedures

Issue Name: Unbundling of MRI Procedures
Issue Number: _0147
Review Type Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner), Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/27/2019
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: When a more extensive MRI is performed on the same site as a less extensive MRI, the less extensive MRI is bundled into the more extensive MRI. Affected codes: See 0147 Appendix D
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 Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30 (H) (Most Extensive Procedures) and J. With/Without Procedures (Effective 10/1/03) 7. CMS Publication 100-04; Chapter 23, § 20.9.2 Fee Schedule Administration and Coding Requirements 8. NCCI Policy Manual for Medicare Services Chapter 1 A 9. CPT Manual year 2015 to current"
Unbundling of CT Scans
_0146
Automated
All Provider Specialties
Region-1
1 - All Region 1 states
03/26/2019

Unbundling of CT Scans

Issue Name: Unbundling of CT Scans
Issue Number: _0146
Review Type Automated
Provider Type: All Provider Specialties
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/26/2019
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: When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan. Affected codes: See 0146 Appendix D
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 Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30 (H) (Most Extensive Procedures) and J. With/Without Procedures (Effective 10/1/03) 7. CMS Publication 100-04; Chapter 23, § 20.9.2 Fee Schedule Administration and Coding Requirements 8. NCCI Policy Manual for Medicare Services Chapter 1 A 9. CPT Manual year 2015 to current Edit Parameters: 1. Assigned Claims Only 2. Provider Types: Professional Services (Physician/non-physician practitioner) and Outpatient Hospital 3. Error Code: 6000 – Unbundling service – included in allowable for another billed service 4. Exclude claims that have a “paid claim date” which is more than 3 years prior to the Informational Letter Date (automated review). 5. Algorithm identifies all Paid Part B Professional Claims and Outpatient Hospital Claims (Bill Type 12X, 13X), or Provider Types Outpatient Hospital and Professional Services (Physician/non- physician practitioner) with (Allowed Amt>$0.00) for CPT codes listed as Most Extensive Code billed on the same day as one or both of the corresponding Less Extensive Code(s) in the Appendix D table ""Most Extensive CT Scan Procedure Table"" for the same beneficiary, same group practice (Based on Tax ID and Specialty Code) and admit date and discharge date. • The CPT code identified as the Most Extensive Code is the valid, anchor claim. • The CPT code(s) identified as the Less Extensive Code(s), for the identified Most Extensive code, is the finding, overpaid claim. 6. Algorithm excludes claims that do not have matching 26/TC modifiers, in any position, for each of the code combinations. Both the finding and anchor claim must have the same Modifier, either 26 or TC. 7. Exclude all Prior Authorization claims identified with a valid Unique Tracking Number (UTN) 8. Algorithm excludes findings for the following modifiers on either the anchor or findings claim: • 59 – Distinct Procedural Service • 76- Repeat Procedure by Same Physician • 77- Repeat Procedure by Another Physician • XE - Separate Encounter, Service that is distinct - occurred during separate encounter • XS - Separate Structure, Service that is distinct - performed on a separate organ/structure • XP - Separate Practitioner, Service that is distinct - performed by a different practitioner • XU - Unusual Non-Overlapping service, use of a service that is distinct – does not overlap usual components of the main source • GA - Waiver of Liability Statement issued as required by payer policy • GX - Notice of Liability issued, voluntary under payer policy • Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study • Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study 9. Algorithm excludes any claims that will have an overpayment adjustment of less than $25. 10. Exclude all claims identified with a valid Unique Tracking Number (UTN)."
Medical Necessity Cardiac Rehabilitation
_0135
Complex
Outpatient Hospital
Region-1
1 - All Region 1 states
03/07/2019

Medical Necessity Cardiac Rehabilitation

Issue Name: Medical Necessity Cardiac Rehabilitation
Issue Number: _0135
Review Type Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/07/2019
Date Revised:
Dates Service: 3 years
Description: Cardiac rehabilitation (CR) is a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcome assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria.
References: Social Security Act § 1862 (a)(1)(A); Social Security Act § 1833 (e); Social Security Act § 1861 (s)(2)(CC)(e); 42 .F.R. §§ 410.49 ; CMS National Coverage Determinations (NCD), Pub. 100-03, Section 20.10.1, 20.31, 20.31.1, 20.31.2, and 20.31.3; CMS Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 232; CMS Claim Processing Manual, Pub. 100-04, Chapter 32, Section 140; CMS Transmittal R1974CP, Issued /21/2010, Implementation Date 10/4/2010; CMS Transmittal R126BP, Issued 5/21/2010, Implementation Date 10/4/2010; CMS Transmittal R339PI, Issued 5/21/2010, Implementation Date 10/4/2010; Palmetto LCD L34412 Cardiac Rehabilitation, Effective Date 10/1/2015; Palmetto LCA A53775 Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation Supplemental Instruction Article, Effective Date 10/1/2015
Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
_0138
Automated
Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region-1
1 - All Region 1 states
02/19/2019

Skilled Nursing Facility (SNF) Consolidated Billing for Therapies

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing for Therapies
Issue Number: _0138
Review Type Automated
Provider Type: Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
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: Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement for services furnished to SNF Part B residents. Affected codes: Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing tables (See Appendix D in downloadable file for a detailed list of CPT/HCPCS including descriptions).
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 ; 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   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 Claims Processing Manual: Publication 100-04; Chapter 6; 10.3 – Types of Services Subject to the Consolidated Billing Requirement for SNF; 20.5- Therapy Services; Medicare Claims Processing Manual: Publication 100-04; Chapter 7; 110, Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay
Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
_0125
Automated
Professional Services (Physician/non-physician practitioner)
Region-1
1 - All Region 1 states
02/21/2019

Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)

Issue Name: Excessive Units of Subsequent Hospital and Nursing Facility Care Services (Telehealth)
Issue Number: _0125
Review Type Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/21/2019
Date Revised:
Dates Service: Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review).
Description: Medicare reimbursement for telehealth services include subsequent hospital care services and subsequent nursing facility care services. However, subsequent hospital care visits are limited to one telehealth visit every three days for hospital inpatients and one subsequent nursing facility telehealth visit every 30 days for nursing facility residents. Affected codes: Telehealth eligible CPT Codes 99231, 99232, 99233, 99307, 99308, 99309, 99310
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;42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, ;ecisions, 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 ;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 Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services (Rev. 3476, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16); Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.3 - List of Medicare Telehealth Services (Rev. 3476, Issued: 03-11-16, Effective: 01-01-15, Effective: 04-11-16); Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.2 - Eligibility Criteria (Rev. 2848, Issued 12-30-13; Effective 01-01-14; Implementation 01-06-14)/ (3) Originating site defined; Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section; 190.6 - Payment Methodology for Physician/Practitioner at the Distant ; Site (Rev. 3586, Issued: 08-12-16, Effective: 01-01-17, Implementation: 01-03-17); 10. Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.6.1 - Submission of Telehealth Claims for Distant Site Practitioners (Rev. 3817; Issued; 07-28-17 Effective; 01-01-18 Implementation: 01-02-18)
Medical Necessity Vertebroplasty and Kyphoplasty
_0139
Complex
Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
02/19/2019

Medical Necessity Vertebroplasty and Kyphoplasty

Issue Name: Medical Necessity Vertebroplasty and Kyphoplasty
Issue Number: _0139
Review Type Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Date Revised:
Dates Service: Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date and on/or after 10/01/2015
Description: Medical documentation will be reviewed for correct coding and to determine if vertebroplasty was medically necessary. Affected codes: 22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327
References: Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10). 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 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 Definitions42 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 Part ; 42 CFR §405.986- Good Cause for reopening ; CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§10 General exclusions from coverage ; CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§20 Services not reasonable and Necessary ; First Coast Service Options (FCSO) Local overage Determination (LCD) Vertebroplasty, Vertebral Augmentation, percutaneous L34976: Effective 10/01/2015; revised 4/17/18.; Novitas LCD L35130 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 05/04/2017.; Palmetto LCD L33473 Vertebroplasty/Kyphoplasty: Effective 10/01/2015; Revised 08/09/2018.; WPS LCD L34592 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 2/1/18.; NGS LCD L33569 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015.; Noridian LCD, Percutaneous Vertebral Augmentation, L34106, Effective 10/01/2015; Noridian LCD, Percutaneous Vertebral Augmentation, L34228, Effective 10/01/2015; CGS LCD, Vertebroplasty and Vertebral Augmentation, L34048, effective 10/01/2015; Annual American Medical Association: CPT Manual.