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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Unbundling of Outpatient Hospice Related Services
_0122
Automated
Part A Outpatient
Region-1
1 - All Region 1 states
11/28/2018

Unbundling of Outpatient Hospice Related Services

Issue Name: Unbundling of Outpatient Hospice Related Services
Issue Number: _0122
Review Type Automated
Provider Type: Part A Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/28/2018
Date Revised:
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(dd)(1) Hospice Care; Hospice Program 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. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 4. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §418- Hospice Care 7. CMS Claims Processing Manual, Chapter 11- Processing Hospice Claims, §10- Overview, §40.2- Processing Professional Claims for Hospice Beneficiaries, §50- Billing and Payment for Services Unrelated to Terminal Illness 8. CMS Benefit Policy Manual 100-02, Chapter 9- Coverage of Hospice Services under Hospital Insurance, §10- Requirements, General"
Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month
_0112
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
11/12/2018

Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month

Issue Name: Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month
Issue Number: _0112
Review Type Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/12/2018
Date Revised:
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review).
Description: A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. If a home dialysis patient receives dialysis in a dialysis center or other outpatient facility during the month, the MCP physician or practitioner is paid the management fee for the home dialysis patient and cannot bill the ESRD-related service codes for managing center based patients. Affected codes: 90951 - 90962
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 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §140- Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis; §140.1- Payment for ESRD-Related Services Under the Monthly Capitation Payment (Center Based Patients); and §140.4- Controlling Claims Paid Under the Monthly Capitation Payment Method 7. American Medical Association (AMA), Current Procedural Terminology 2015 to current"
Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding
_0120
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
11/02/2018

Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding

Issue Name: Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding
Issue Number: _0120
Review Type Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/02/2018
Date Revised:
Dates Service: Less than 3 years
Description: Carriers may not pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period. E&M Codes Included in the Global Package billed with Modifier 57 will be recovered as overpayments as they are not allowed for surgical procedures with a 0 or 10 global surgical period. E&M codes listed in 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. Medicare Claims Processing Manual, Chapter 12- Physician/ Non Physician Practitioner, § 30.6.6.C- Payment for Evaluation and Management Services Provided During Global Period of Surgery, CPT modifier ‘57’ – Decision for Surgery Made Within Global Surgical Period"
Arthroscopic Extensive Shoulder Debridement: Incorrect Coding
_0118
Automated
Physician/Non- physician Practitioner (NPP); Outpatient Hospital (For claims prior to 10/01/2017. After 10/01/2017, denial of 29823 made no change in APC.)
Region-1
1 - All Region 1 states
10/19/2018

Arthroscopic Extensive Shoulder Debridement: Incorrect Coding

Issue Name: Arthroscopic Extensive Shoulder Debridement: Incorrect Coding
Issue Number: _0118
Review Type Automated
Provider Type: Physician/Non- physician Practitioner (NPP); Outpatient Hospital (For claims prior to 10/01/2017. After 10/01/2017, denial of 29823 made no change in APC.)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2018
Date Revised:
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder. If another arthroscopy procedure is billed and paid for the same day, on the same shoulder, for the same beneficiary, on the same date of service, the extensive debridement (code 29823) is not separately payable and CPT code 29823 will be denied. Separate reporting of extensive debridement only applies to three CPT codes: 29824, 29827, and 29828. Affected codes: When CPT code 29823 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29822 and/or 29825 for the same date of service, for the same beneficiary, for the same shoulder, if the provider or facility was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29822, and/or 29825, then 29823 will be denied.
References: "1. Title XVIII of the Social Security Act (SSA), Section 1833(e) and 1862(a)(1)(A) – Payment of Benefits 2. 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 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 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations §§411.15(k)(1)- Particular Services Excluded from Coverage, 424.5(a)(6)- Basic Conditions 6. Internet Only Manual, CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage §20 –Services Not Reasonable and Necessary. 7. National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014- current 8. AMA CPT Codebook"
Automated Arthroscopic Limited Debridement
_0117
Automated
Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered  prior to 10/1/2017 due to change from T (multiple surg payment)  to J1 (APC payment).
Region-1
1 - All Region 1 states
10/19/2018

Automated Arthroscopic Limited Debridement

Issue Name: Automated Arthroscopic Limited Debridement
Issue Number: _0117
Review Type Automated
Provider Type: Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered  prior to 10/1/2017 due to change from T (multiple surg payment)  to J1 (APC payment).
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2018
Date Revised:
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822). Code 29822, is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same beneficiary at the same encounter. Affected codes: When CPT code 29822 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828 for the same date of service, for the same beneficiary, for the same shoulder, at the same encounter, if the provider was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, and/or 29828, then 29822 will be denied.
References: Title XVIII of the Social Security Act (SSA), Section 1833(e) and 1862(a)(1)(A); 42 Code of Federal Regulations §§411.15(k)(1), 424.5(a)(6); Internet Only Manual, CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16 §20.; National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014- current
Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered
_0115
Automated
Physician Claims
Region-1
1 - All Region 1 states
10/16/2018

Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered

Issue Name: Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered
Issue Number: _0115
Review Type Automated
Provider Type: Physician Claims
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/16/2018
Date Revised:
Dates Service: Claims having a “claim paid date” which is on or after October 1, 2015 (ICD-10 codes only)
Description: Home Visits for physician services should not overlap an active Inpatient Stay. Providers cannot billed for services that are rendered. Affected codes: See Appendix D in downloadable Excel file
References: "1. Title XVIII of the Social Security Act Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. Medicare Claims Processing Manual: Publication 100-04; Chapter 1, § 120.2 (B) 6. Medicare Claims Processing Manual (CMS Publication 100-04), Chapter 26 (Completing and Processing Form CMS-1500 Data Set), §10.5- Place of Service Codes and Definitions 7. Medicare Benefit Policy Manual (CMS Publication 100-02), Chapter 15 (Covered Medical and Other Health Services), §30- Physician Services 8. Medicare Claims Processing Manual: Publication 100-04; Chapter 1 (General Billing Requirements), § 120.2 (B) Exact Duplicates: Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers"
Improperly Paid Modifiers TC and 26
_0116
Automated
Professional Services (Physician/Non-Physician Practitioner)
Region-1
1 - All Region 1 states
10/12/2018

Improperly Paid Modifiers TC and 26

Issue Name: Improperly Paid Modifiers TC and 26
Issue Number: _0116
Review Type Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Date Revised:
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review)
Description: HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed. Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied.
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: CMS Publication 100-04; Chapter 23; Addendum - MPFSDB Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf
Transthoracic Echocardiography: Medical Necessity
_0111
Complex
Inpatient Hospital, Outpatient Hospital, SNF
Region-1
1 - All Region 1 states
10/12/2018

Transthoracic Echocardiography: Medical Necessity

Issue Name: Transthoracic Echocardiography: Medical Necessity
Issue Number: _0111
Review Type Complex
Provider Type: Inpatient Hospital, Outpatient Hospital, SNF
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Date Revised:
Dates Service: For Palmetto LCD specific questions- Claims billed on or after 9/18/2017
Description: "Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary. Affected codes: 93303, 93304, 93306, 93307, 93308 C8921, C8922, C8923, C8924"
References: "1. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 2. Title XVIII, §§1862(a)(1)(A) and (a)(7) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §410.32(a)- Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions 6. 42 Code of Federal Regulations (CFR) §411.15(k)(1)- Particular Services Excluded from Coverage 7. Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 15 (Covered Medical and Other Health Services), §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests 8. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 9 (Rural Health Clinics/Federally Qualified Health Centers), §100- Frequency of Billing and Same Day Billing 9. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 12 (Physicians/Nonphysician Practitioners), §30.4- Cardiovascular System (Codes 92950- 93799) 10. CGS, Local Coverage Determination (LCD) L34338: Effective 10/01/2015; Revision 10/01/2018 11. First Coast, Local Coverage Determination (LCD) L33768: Effective 10/01/2015; Revision 10/01/2018 12. NGS, Local Coverage Determination (LCD) L33577: Effective 10/01/2015; Revision 10/01/2018 13. Palmetto, Local Coverage Determination (LCD) L37379; Effective date 9/18/2017; Revision 3/28/2019 14. American Medical Association (AMA), Current Procedural Terminology Manual, Coding Guidelines"
Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements
_0073
Complex
Inpatient Rehabilitation Facility, Inpatient
Region-1
1 - All Region 1 states
10/12/2018

Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements

Issue Name: Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements
Issue Number: _0073
Review Type Complex
Provider Type: Inpatient Rehabilitation Facility, Inpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Date Revised:
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Inpatient hospital services furnished to a patient in an inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary
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 412.604(c)- Completion of patient assessment instrument 6. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system 7. 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, and (5)- Interdisciplinary Team Approach to Care 8. Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.3- Documentation Requirements for Therapy Services 10. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS 11. 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 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements"