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 Posted Sort by Descending or Ascending
Details
Home Use of Oxygen: Medical Necessity and Certification
_0102
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/11/2018

Home Use of Oxygen: Medical Necessity and Certification

Issue Name: Home Use of Oxygen: Medical Necessity and Certification
Issue Number: _0102
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/11/2018
Date Revised:
Dates Service: Less than 3 years and after September 30, 2015
Description: Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary. Affected code E1390
References: 1.      Title XVIII, Social Security, §1833€; 2.      Title XVIII, Social Security, §1861(s)(6); 3.      Title XVIII, Social Security, §1862(a)(1)(A) ; 4.      42 C.F.R. sections 405.980 (b) & (c) and section 405.986 ; 5.      42 CFR 424.57(a)(12)6.      CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2 ; 7.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20; 100.2.3; 8.      CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 30.6; 130.6; 9.      CMS, IOM Publication 100-02, Benefit Policy Manual 15; 110; 10.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26; 11.  CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9.1; 12.  Local Coverage Determination L33797: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 13.  Local Coverage Article A52514: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015; 14.  CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017
Group 3 Pressure Reducing Support Surfaces
_0094
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
05/15/2018

Group 3 Pressure Reducing Support Surfaces

Issue Name: Group 3 Pressure Reducing Support Surfaces
Issue Number: _0094
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/15/2018
Date Revised:
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 Group 3 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0194 Air Fluidized Bed.
References: Title XVIII, Social Security, §1833€, Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c) and section 405.986, Code of Federal Regulations, 42 CFR; section 410.38(g)(3), Code of Federal Regulations, 42 CFR; section 410.38(g)(4), Code of Federal Regulations, 42 CFR; section 424.57 (12), Medicare Benefit Policy Manual, Chapter 15, Section 110, Durable Medical Equipment – General, Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8, Air-Fluidized Beds, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 30 Section 50.13.4, Supplier’s Right to Recovery Resalable Items for Which Refund Has Been Made, Medicare Program Integrity Manual, (IOM) Publication 100-8, Chapter 4, Section 4.26, Supplier Proof of Delivery Documentation Requirements, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, Nationwide Local Coverage Determination (LCD) L33692, Pressure Reducing Support Surfaces - Group 3 Effective 10/1/2015; Revised 01/01/2017, Policy Article A52468, Pressure Reducing Support Surfaces - Group 3 Effective 10/01/2015 Revised 01/01/2017.
Ventilators Subject to ACA Requirements Prior to January 1, 2016
_0082
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
03/14/2018

Ventilators Subject to ACA Requirements Prior to January 1, 2016

Issue Name: Ventilators Subject to ACA Requirements Prior to January 1, 2016
Issue Number: _0082
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/14/2018
Date Revised:
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. Affected Codes: E0450, E0460, E0461, E0463, E0464.
References: Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c) and section 405.986, Code of Federal Regulations, 42 CFR; section 410.38(g)(3), Code of Federal Regulations, 42 CFR; section 410.38(g)(4), Code of Federal Regulations, 42 CFR; section 424.57 (a)(12), Title XVIII, Social Security, §1833(e), Title XVIII, Social Security, §1862(a)(1)(A), CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20, CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1.
Complex Negative Pressure Wound Therapy Pumps-DWO
_0081
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/26/2018

Complex Negative Pressure Wound Therapy Pumps-DWO

Issue Name: Complex Negative Pressure Wound Therapy Pumps-DWO
Issue Number: _0081
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/26/2018
Date Revised:
Dates Service: Less than 3 years and on or after 5/25/2017
Description: Medical Necessity Review Negative Pressure Wound Therapy Pumps - Potential incorrect billing occurred when claims for Negative Pressure Wound Therapy Pumps were billed without an indication supporting Medical Necessity as outlined in Local Coverage Determination (LCD) L33821 (related MAC Policy Article A52511). Affected Codes: E2402 - NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, STATIONARY OR PORTABLE A6550 - WOUND CARE SET, FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP, INCLUDES ALL SUPPLIES AND ACCESSORIES A7000 - CANISTER, DISPOSABLE, USED WITH SUCTION PUMP, EACH.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833€, Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, §110, Durable Medical Equipment – General, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 34, §10.6.1, Timeframes for Contractor Initiated Reopenings and 10.6.2, Timeframes for Party Requested Reopenings Revision for both sections, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, §§5.7, Documentation in the Patient's Medical Record, 5.8, Supplier Documentation (Rev. 612, Effective 9/29/2015), and 5.9, Evidence of Medical Necessity, Chapter Revision 623 11/03/2015, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, §§ 3.3.2 (Rev. 377, Effective 6/28/2011), Medical Review Guidance, §3.3.2.4 (Rev. 604, Effective 8/25/2015), Signature Requirements, and §3.4.1.1, Linking LCD and NCD ID numbers to Edits, Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017.
Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
_0080
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
02/20/2018

Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO

Issue Name: Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
Issue Number: _0080
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/20/2018
Date Revised:
Dates Service: Less than 3 years and on or after 5/25/2017
Description: Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: E0277, E0371, E0372, E0373.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833€, Medicare Benefit Policy Manual, (IOM) Publication 100-02, Chapter 15, §110, Durable Medical Equipment – General, Medicare Claims Processing Manual, (IOM) Publication 100-04, Chapter 34, §10.6.1, Timeframes for Contractor Initiated Reopenings and 10.6.2, Timeframes for Party Requested Reopenings Revision for both sections, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 5, §§5.7, Documentation in the Patient's Medical Record, 5.8, Supplier Documentation (Rev. 612, Effective 9/29/2015), and 5.9, Evidence of Medical Necessity, Chapter Revision 623 11/03/2015, Medicare Program Integrity Manual, (IOM) Publication 100-08, Chapter 3, §§ 3.3.2 (Rev. 377, Effective 6/28/2011), Medical Review Guidance, §3.3.2.4 (Rev. 604, Effective 8/25/2015), Signature Requirements, and §3.4.1.1, Linking LCD and NCD ID numbers to Edits, Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017.
Ventilators Subject to DWO Requirements on or after January 1, 2016
_0079
Complex
DME by supplier; DME by physician
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: 5
State: 5 - Nationwide
Date Approved: 01/11/2018
Date Revised:
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: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, 42 CFR 424.57(a)(12), Title XVIII, Social Security, §1833€, Title XVIII, Social Security, §1862(a)(1)(A), CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20, CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1 and §240.5, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017.
Complex Home Health Review: Documentation and Medical Necessity
_0075
Complex
Home Health Agencies
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: 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
Date Revised:
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, 055X, 056X, 057X.
References: SSA XVIII, §1814(a)(2)(C), SSA XVIII, §1815, SSA XVIII, §1835(a)(2)(A), SSA XVIII, §1861(m), SSA XVIII, §1861(o), SSA XVIII, §1861®, SSA XVIII, §1861(aa)(5), SSA XVIII, §1861(gg)(2), SSA XVIII, §1891, 42 CFR §409.41 - 42 CFR §409.47, CFR 42 §424.22(a)(1)(i)-(v), IOM 100-01, Chapter 4, §10.2, IOM 100-01, Chapter 4, §30.1, IOM 100-02, Chapter 7, §30.1.1, IOM 100-02, Chapter 7, §30.2.1, IOM 100-02, Chapter 7, §30.5.1.1, IOM 100-02, Chapter 7, §30.5.1.2
_Respiratory Assist Device
_0069
Complex
DME by supplier; DME by physician
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: 5
State: 5-Nationwide
Date Approved: 12/17/2017
Date Revised:
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: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, CGS and Noridian Healthcare Solutions LCD L33800: Effective 10/01/2015, CGS LCD L5023: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, NGS LCD L27228: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015,NHIC LCD L11504: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, Noridian LCD L11493: Effective date: 10/01/1999, Revision 12/01/2014, Retired 09/30/2015, CGS and Noridian Healthcare Solutions Article A52517: Effective 10/01/2015, CGS Article A23974: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, NGS Article A47231: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, NGS Article A47231: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, Noridian Article A23902: Effective date: 01/01/2005, Revision 12/01/2014, Retired 09/30/2015, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017.
Complex PAP Devices for the Treatment of Obstructive Sleep Apnea
_0066
Complex
DME by supplier; DME by physician
5
5 - Nationwide
09/19/2017

Complex PAP Devices for the Treatment of Obstructive Sleep Apnea

Issue Name: Complex PAP Devices for the Treatment of Obstructive Sleep Apnea
Issue Number: _0066
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5 - Nationwide
Date Approved: 09/19/2017
Date Revised:
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 PAP Devices for the Treatment of Obstructive Sleep Apnea meet coverage criteria and /or are medically reasonable and necessary. Affected Codes: E0601 and E0470.
References: 42 C.F.R. sections 405.980 (b) & (c) and section 405.986, CMS IOM 100-03, Medicare National Coverage Determination Manual, NCD Section 240.4, Effective date 04/04/2005, CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110,CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26, CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9, CGS and Noridian Healthcare Solutions LCD L33718: Effective 10/01/2015, CGS LCD L11518: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, NGS LCD L27230: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, NHIC LCD L11528: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, Noridian LCD L171: Effective date: 10/01/1993, Revision 10/31/2014, Retired 09/30/2015, CGS and Noridian Healthcare Solutions Article A52467: Effective 10/01/2015, CGS Article A20195: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, NGS Article A47228: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, NHIC Article A19815: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, Noridian Article A19827: Effective date: 07/01/2004, Revision 10/31/2014, Retired 09/30/2015, CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017, Revision 06/01/2017