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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
DME While in Hospice
_0114
Automated
DME Supplier/DME by Physician
Region-5
5 - Nationwide
09/20/2018

DME While in Hospice

Issue Name: DME While in Hospice
Issue Number: _0114
Review Type Automated
Provider Type: DME Supplier/DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/20/2018
Date Revised:
Dates Service: Less than 3 years prior to the Initial Finding Letter date
Description: All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D of the downloadable Excel file.
References: 1. Code of Federal Regulations 42, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals; 2. CMS Pub. 100-2, Medicare Benefit Policy Manual, Chapter 9, Coverage of Hospice Services Under Hospital Insurance, Section 10; 3. CMS Pub. 100-4, Medicare Claims Processing Manual, Chapter 11, Processing Hospice Claims, Section 10, Section 30.3, Section 40.2; 4. CMS Pub 100-4, Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Section 10.2
Custom Fabricated Knee Orthosis: Medical Necessity
_0107
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Custom Fabricated Knee Orthosis: Medical Necessity

Issue Name: Custom Fabricated Knee Orthosis: Medical Necessity
Issue Number: _0107
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Date Revised:
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Claims for Custom Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied. Affected codes L1844, L1846
References: 1. Social Security Act, Section 1833 (e); Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment., 2. 42 Code of Federal Regulations (C.F.R.) §§405.980 (b) and ©, 3. 42 C.F.R. §405.986, 4.  42 CFR 424.57, 5.  CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Sections 4.26, 4.26.1; Chapter 5, Sections 5.2, 5.7, and 5.8. , 6. Nationwide LCD L33318, Effective Date 10/01/2015; Revision Effective Date 10/16/2017, 7.  Nationwide A52465 Local Coverage Article: Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 01/01/2017, 8. CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) Effective 01/01/2017, Revised 12/21/2017
Medical Necessity: Parenteral Nutrition
_0106
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/14/2018

Medical Necessity: Parenteral Nutrition

Issue Name: Medical Necessity: Parenteral Nutrition
Issue Number: _0106
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Date Revised:
Dates Service: Excludes claims with DOS prior to 10/1/15 and not more than 3 years prior to the ADR date
Description: This review will determine if Parenteral Nutrition is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. B4164,B4168,B4172,B4176,B4178,B4181,B4185,B4189,B4193,B4197,B4199, B4216,B4220,B4222,B4224,B5000,B5100,B5200
References: 1. Title VIII of the Social Security Act, Section 1862(a)(1)(A), 2. Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit, 3. CFR 42: Section 424.57(12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges, 4. CMS NCD Manual, Chapter 1, Part 3, Section 180.2 (Rev. 173, Issued: 09-04-14, Effective: Upon Implementation of ICD-10, 5. Benefit Policy Manual, Chapter 15, Section 120, 6. Program Integrity Manual 3.3.2.4-Signature Requirements Issued: 10-20-17; Effective: 11-20-17; Implementation 11-20-17, 7. Program Integrity Manual 5.2.2-Verbal and Preliminary Written Order Issued 10-09-15; Effective: 11-10-15; Implementation: 11-10-15, 8. Program Integrity Manual 5.2.6 - Date and Timing Requirements Issued: 05-26-17; Effective: 06-27-17; Implementation: 06-27-17), 9. Program Integrity Manual 5.2.8-Refills of DMEPOS Items Provided on a Recurring Basis Issued: 02-19-16; Effective: 03-19-16; Implementation: 03-19-16, 10. Program Integrity Manual 5.3-Certificates of Medical Necessity (CMNs) and DME Information Forms 9DIFs) Issued 10-27-17; Effective: 11-28-17; Implementation: 11-28-17, 11. Program Integrity Manual 5.5.8-Supplier Documentation Issued 10-20-17; Effective: 11-20-17; Implementation 11-20-17, 12. CMS Pub 100-04, Claims Manual, Chapter 20, Rev 3824, 08-02-17, 13. LCD 33798 Effective date 10/01/2015, Revision 01/01/2017, 14. Article 52515: Effective date 10/01/2015, Revision 01/01/2017, 15. Article 55426: Effective date 01/01/2017, Revision 12/21/2017
Urological Supplies Effective 8/1/2018
_0103
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/19/2018

Urological Supplies Effective 8/1/2018

Issue Name: Urological Supplies Effective 8/1/2018
Issue Number: _0103
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/19/2018
Date Revised:
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Documentation will be reviewed to determine if Urological Supplies meets coverage criteria and is medically reasonable and necessary. For affected codes download xls file and see appendix D.
References: Title VIII of the Social Security Act, Section 1862(a)(1)(A) ; Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit; 42 CFR 424.57(c)(12) ; CMS, IOM 100-08, Chapter 3, Section 3.3.2.4 ; CMS, IOM 100-08, Chapter 5, Section 5.2.1-8; 5.3; 5.8 ; Local Coverage Determination (LCD) L33803- Urological Supplies: Effective date 10/01/2015; Revised 01/01/2017 ; Local Coverage Article (LCA) A52521- Urological Supplies- Policy Article: Effective date 10/01/2015; Revised 01/01/2017 ; Local Coverage Article (LCA) A55426- Standard Doc Requirements for All Claims Submitted to DME MACs: Effective date 01/01/2017; Revised 12/21/2017
Home Use of Oxygen: Medical Necessity and Certification
_0102
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
07/12/2018

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: 07/12/2018
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.