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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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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
DME CPAP without Obstructive Sleep Apnea Diagnosis
_0065
Automated
DME Supplier, DME by Physician
5
5 - Nationwide
09/08/2017

DME CPAP without Obstructive Sleep Apnea Diagnosis

Issue Name: DME CPAP without Obstructive Sleep Apnea Diagnosis
Issue Number: _0065
Review Type Automated
Provider Type: DME Supplier, DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 09/08/2017
Date Revised:
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the “Initial Finding” Letter date will be excluded.
Description: To identify improper payments for automated claims for CPAP with the missing diagnosis of Obstructive sleep apnea, for DME Suppliers and DME by Physician, using error code 2500, including all places of services for Part B DME claims. Affected Codes: E0601/
References: CMS Pub. 100-3, (Medicare National Coverage Determinations Manual), Section 240.4
Complex Spinal Orthoses
_0024
Complex
DME by supplier; DME by physician
5
5 - Nationwide
08/02/2017

Complex Spinal Orthoses

Issue Name: Complex Spinal Orthoses
Issue Number: _0024
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: 5
State: 5 - Nationwide
Date Approved: 08/02/2017
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 Spinal Orthoses meet Medicare coverage criteria and/or is medically reasonable and necessary. Affected Codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270.
References: Social Security Act, Section 1833 (e); Section 1834 (a) [42 U.S.C. 1395m], PAYMENT FOR DURABLE MEDICAL EQUIPMENTCMS 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.., 42 Code of Federal Regulations (C.F.R.) §§405.980 (b) and (c), 42 C.F.R. §405.986, CGS Administrators, LCD L11448, Effective 10/1/1993, Revision 5/1/2015, Retired 9/30/2015, CGS A24086 Local Coverage Article: Spinal Orthoses: TLSO and LSO, Effective 1/1/2005, Revision 10/31/2014, Retired 9/30/2015, Nationwide LCD L33790, Effective date 10/01/2015, Nationwide A52500 Local Coverage Article: Spinal Orthoses: TLSO and LSO, Effective date 10/01/2015, National Government Services (NGS) LCD L27017, Effective 10/1/1993, Retired 9/30/2015, NGS Local Coverage Article, A47059, Effective 1/1/2005, Retired 9/30/2015,NHIC LCD L11470, Effective 10/1/1993, Retired 9/30/2015, NHIC Local Coverage Article, A23663, Effective 1/1/2005, Retired 9/30/2015, Noridian LCD L11459, Effective 10/1/1993, Retired 9/30/2015, Noridian Local Coverage Article, A23846, Effective 1/1/2005, Retired 9/30/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Complex Medical Necessity Patient Lifts
_0020
Complex
DME by Supplier, DME by Physician
5
5 - Nationwide
06/01/2017

Complex Medical Necessity Patient Lifts

Issue Name: Complex Medical Necessity Patient Lifts
Issue Number: _0020
Review Type Complex
Provider Type: DME by Supplier, DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 06/01/2017
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: Patient lifts must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined Local Coverage Determinations (LCDs) for Patient Lifts (L33799 and retired LCDs L11577, L27218, L11562, and L5064). Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected Codes: E0630, E0635, E0639, E0640.
References: CGS and Noridian Healthcare Solutions LCD L33799: Effective 10/01/2015, CGS and Noridian Healthcare Solutions Article A52516: Effective 10/01/2015, CGS LCD L11562: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, NHIC LCD L5064: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, NGS LCD L27218: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, Noridian LCD L11577: Effective date: 10/01/1993, Revision 10/31/2004, Retired 09/30/2015, CGS Article A23976: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, NHIC Article A23657: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, NGS Article A47230: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015, Noridian Article A23901: Effective date: 01/01/2005, Revision 10/31/2014, Retired 09/30/2015 
Complex Medical Necessity AFO & KAFO Orthoses
_0013
Complex
DME by Supplier and DME by Physician
5
5 - Nationwide
07/05/2017

Complex Medical Necessity AFO & KAFO Orthoses

Issue Name: Complex Medical Necessity AFO & KAFO Orthoses
Issue Number: _0013
Review Type Complex
Provider Type: DME by Supplier and DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 07/05/2017
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: Ankle-Foot Orthosis and Knee-Ankle-Foot Orthosis must meet basic coverage criteria and subsequent, whether at initial purchase or at any point during a rental period as outlined in CMS Publications and Local Coverage Determination (LCDs) for AFO/KAFO Orthoses. Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.
References: 42 CFR 414.402, Social Security Act, Section 1833 (e), Social Security Act, Section 1842 (p) (4),Social Security Act, Section 1847 (a) (2), Social Security Act, Section 1834 (h) (1) (F) (i) (ii), Social Security Act, Section 1861 (s) (9), Social Security Act, Sec.1834. [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (1) (E) (i) (ii) (v), Social Security Act, Section.1834 [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (7) (C) (i), (ii) and (iii), Social Security Act, Section.1834 [42 U.S.C. 1395m] (a) Payment for Durable Medical Equipment (4), Supplier Standards 42 CFR, 424.57(12), CMS Publication 100-02 Medicare Benefit Policy Manual Chapter 15, Section 110.2 (C), CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 100.2, CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, part C and Chapter 4, Section 4.26, 4.26.1 and Chapter 5, Section 5.2, 5.2.1, 5.2.3, 5.2.4, 5.2.7, 5.7, 5.8 and 5.9, CMS Local Coverage Determinations (LCDs) for AFO, KAFO LCD L142, L11517, L27229, L11527 (superseded/retired issues prior to 10/1/15), CMS Local Coverage Determination (LCD) for AFO, KAFO L33686 for DOS on/after 10/1/15, CMS Policy Article for AFO, KAFO (A19800, A19806, A47227, A19885)(superseded/retired issues prior to 10/1/15), CMS Policy Article for AFO, KAFO (A52457) for DOS on/after 10/1/1, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Complex: Power Mobility Devices Not Subject to PA Demonstration
_0031
Complex
DME Supplier and DME by Physician
5
5 - Nationwide
06/06/2017

Complex: Power Mobility Devices Not Subject to PA Demonstration

Issue Name: Complex: Power Mobility Devices Not Subject to PA Demonstration
Issue Number: _0031
Review Type Complex
Provider Type: DME Supplier and DME by Physician
Region: 5
State: 5 - Nationwide
Date Approved: 06/06/2017
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: Medical Necessity and Documentation Review
References: Code of Federal Regulations (CFR), Title 42, Section 410.38(c) Durable Medical Equipment: Scope and Conditions, Power Mobility Devices (PMD), CMS Publication 100-03 National Coverage Determination (NCD) Manual: Chapter 1, Part 4, §280.3, Mobility Assisted Equipment, (Rev. 37, Effective 5/5/2005, Implemented 7/5/2005), CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §110, Durable Medical Equipment – General, Rev. 10/1/2003, CMS Publication 100-08, Medicare Program Integrity Manual, Chapter 5, §5.2.3, Detailed Written Orders, (Rev 617, Eff 11/10/2015), §5.7, Documentation in the Patient's Medical Record (Rev. 242, Eff 3/1/2008), §5.8, Supplier Documentation (Rev. 612, Eff 9/29/2015), and §5.9.2, Evidence of Medical Necessity: Wheelchair and Power Operated Vehicle (POV) Claims, (Rev. 242, Eff 3/1/2008), Local Coverage Determination (LCD) L33789: Effective 10/1/2015, Local Coverage Determination (LCD) L27239: Effective 10/1/2006, Retired 9/30/2015, Local Coverage Determination (LCD) L21271: Effective 10/1/2006, Retired 9/30/2015, Local Coverage Determination (LCD) L23613: Effective 10/1/2006, Retired 9/30/2015, Local Coverage Article: Power Mobility Devices- Policy Article A52498: Effective 10/1/2015, Local Coverage Article: Power Mobility Devices- Policy Article A47122: Effective 1/1/2015, Retired 9/30/2015, Local Coverage Article: Power Mobility Devices- Policy Article A36239: Effective 1/1/2015, Retired 9/30/2015, Local Coverage Article: Power Mobility Devices- Policy Article A41136: Effective 1/1/2015, Retired 9/30/2015. Affected Codes: K0800-K0802, K0812-K0816, K0820-K0829, K0835-K0843, K0848-K0855, K0890-K0891, K0898