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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Off-the-Shelf Knee Orthosis
_0144
Complex
DME by Supplier/ DME by Physician
Region-5
5 - Nationwide
03/15/2019

Off-the-Shelf Knee Orthosis

Issue Name: Off-the-Shelf Knee Orthosis
Issue Number: _0144
Review Type Complex
Provider Type: DME by Supplier/ DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/15/2019
Date Revised:
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Off-the-Shelf Knee Orthoses may have been provided to beneficiaries where all Medicare coverage requirements were not met. This review will determine if the orthoses 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 requirements will be denied. Affected codes: L1812, L1820, L1830, L1831, L1833, L1836, L1848, L1850, L1851 and L1852
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), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. 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 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 10. 42 CFR §424.57(c)- Application Certification Standards 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 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 14. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 15. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 20. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 21. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 22. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L33318, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date 10/16/2017 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52456, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date: 01/01/2017 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018"
Issue Name Pneumatic Compression Device
_0131
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide
01/23/2019

Issue Name Pneumatic Compression Device

Issue Name: Issue Name Pneumatic Compression Device
Issue Number: _0131
Review Type Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/23/2019
Date Revised:
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date and prior to 12/01/2015
Description: Pneumatic Compression Devices, HCPCS Codes E0651 and E0652, may have been provided to patients where all Medicare coverage criteria were not met. This review will determine if the pneumatic compression device 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. Affected code E0651 and E0652
References: Title XVIII, Social Security, §1833(e) ; 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, (IOM) Publication 100-03, Chapter 1, Part 4, Section 280.6, Pneumatic Compression Devices; 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, (IOM) Publication 100-8, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9; Local Coverage Determination (LCD) L33829 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2017; MAC Policy Article A52488 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2017; CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 05/07/2018
Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)
_0128
Automated
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
01/01/2019

Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)

Issue Name: Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime (RUL)
Issue Number: _0128
Review Type Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/01/2019
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: Claims for more than one spinal orthosis within the reasonable useful lifetime (Spinal Orthosis within the Reasonable Useful Lifetime [RUL]), will be denied. Affected codes: L0627, L0631, L0637, L0642, L0648, L0650
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; 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 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies; 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 Definitions; 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and edeterminations 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; 42 CFR §414.210- General Payment Rules; 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; 42 CFR §424.57(c)- Application Certification Standards; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General; 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 Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements ; Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis; Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018
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: "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 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 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 Definitions 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 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 42 CFR §424.57(c)- Application Certification Standards 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 Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determinations L33318: Knee Orthoses, Effective 10/01/2015; Revised 10/16/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52465: Knee Orthoses, Effective 10/01/2015; Revised 01/01/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018"
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: 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 1834(a) - Payment for Durable Medical Equipment; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section ; 834(a)(2) - Payment for Inexpensive and Other Routinely Purchased Durable Medical Equipment; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(E)- Payment for Prosthetic Devices and Orthotics and Prosthetics; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies; 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 Definitions; Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit; 42 CFR 424.57(c)(12) Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; Application certification standards; 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 ; 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; 42 CFR §424.57(c)- Application Certification Standards; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120 Prosthetic Devices ; 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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis; Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33803: Urological Supplies, Effective 10/01/2015; Revised 1/01/2017; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52521: Urological Supplies, Effective 10/01/2015; Revised 1/01/2017; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 08/28/2018
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(e)- Payment of Benefits; Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer; Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews; Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening; Code of Federal Regulations, 42 CFR; section 410.38(g)(3)- Durable Medical Equipment: Scope and Conditions; Items Requiring a Written Order, Face-to-face Encounter Requirements; Code of Federal Regulations, 42 CFR; section 410.38(g)(4)- Durable Medical Equipment: Scope and Conditions, Items Requiring a Written Order; Written Order Issuance Requirements; Code of Federal Regulations, 42 CFR; section 424.57 (12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges; Medicare Benefit Policy Manual, Chapter 15, Section 110- Durable Medical Equipment – GeneralTitle XVIII, Social Security, §1833(e)- Payment of Benefits; Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer; Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews; Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening; Code of Federal Regulations, 42 CFR; section 410.38(g)(3)- Durable Medical Equipment: Scope and Conditions; Items Requiring a Written Order, Face-to-face Encounter Requirements; Code of Federal Regulations, 42 CFR; section 410.38(g)(4)- Durable Medical Equipment: Scope and Conditions, Items Requiring a Written Order; Written Order Issuance Requirements; Code of Federal Regulations, 42 CFR; section 424.57 (12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges; 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-Rules Concerning Orders, Written Orders Prior to Delivery; Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Rules Concerning Orders, Face-to-Face Encounter Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Rules Concerning Orders, Date and Timing Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7- Rules Concerning Orders, Requirement of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.8- Rules Concerning Orders, Refills of DMEPOS Items Provided on a Recurring Basis; Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity; 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; Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 08/28/2018"