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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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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. 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(a) - Payment for Durable Medical Equipment 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(6) - Payment for Other Items of Durable Medical Equipment 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 7. 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 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(n) - Durable Medical Equipment Definition 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 10. 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 11. 42 CFR §405.986 - Good Cause for Reopening 12. 42 CFR §424.57 - Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 13. 42 CFR §424.57(c) - Application Certification Standards 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120 Prosthetic Devices 15. CMS NCD Manual, Chapter 1, Part 3, Section 180.2- Enteral and Parenteral Nutritional Therapy 16. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 17. 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 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 20. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 21. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 24. Medicare Program Integrity Manual, Chapter 5, Section 5.3 - Certificates of Medical Necessity (CMNs) and DME Information Forms 25. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 26. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 27. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 28. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33798: Parenteral Nutrition: Effective Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2017 29. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Parenteral Nutrition - Policy Article A52515: Effective 10/1/2015, Revision 01/01/2019 30. 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 01/01/2019"
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: Medical Necessity and Documentation Requirements
_0094
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
05/15/2018

Group 3 Pressure-Reducing Support Surfaces: Medical Necessity and Documentation Requirements

Issue Name: Group 3 Pressure-Reducing Support Surfaces: Medical Necessity and Documentation Requirements
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: "1. Title XVIII, Social Security, §1833(e)- Payment of Benefits 2. Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer 3. Code of Federal Regulations, 42 CFR sections 405.980 (b) & (c)- Reopenings of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews 4. Code of Federal Regulations, 42 CFR sections 405.986- Good Cause for Reopening 5. 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 6. 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 7. 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 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 110- Durable Medical Equipment – General 9. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8- Air-Fluidized Beds 10. Medicare Claims Processing Manual, Chapter 30- Financial Liability Protections, Section 50.13.4- Supplier’s Right to Recovery Resalable Items for Which Refund Has Been Made 11. Medicare Program Integrity Manual, Chapter 4- Program Integrity, Section 4.26- Supplier Proof of Delivery Documentation Requirements 12. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery 13. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.5- Rules Concerning Orders, Face-to-Face Encounter Requirements 14. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.6- Rules Concerning Orders, Date and Timing Requirements 15. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.7- Rules Concerning Orders, Requirement of New Orders 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.8- Rules Concerning Orders, Refills of DMEPOS Items Provided on a Recurring Basis 17. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity 20. CGS and Noridian LCD L33692- Pressure Reducing Support Surfaces - Group 3 Effective 10/1/2015; Revised 01/01/2019 21. CGS and Noridian Local Coverage Article A52468- Pressure Reducing Support Surfaces - Group 3 Effective 10/01/2015; Revised 01/01/2019 22. CGS and Noridian Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 01/01/2019"
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: 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 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 §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (3)- Face-to-Face Encounter Requirements 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (4)- Written Order Issuance Requirements 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges, (c)- Application Certification Standards, (12) Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.4- Written Orders Prior to Delivery, §5.2.5- Face to Face Encounter Requirements, §5.2.6- Date and Timing Requirements, §5.2.7- Requirement of New Order, §5.2.8- Refills of DMEPOS Items Supplied on a Recurring Basis, §5.7- Documentation in the Patient’s Medical Record, §5.8- Supplier Documentation, and §5.9- Evidence of Medical Necessity. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
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: "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 L33821: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52511: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 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 01/01/2019"
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 January 1, 2016
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: "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 Determination L33642: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52490: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 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"
Ventilators Subject to DWO Requirements on or after January 1, 2016
_0079
Complex
DME by supplier; DME by physician
Region-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: 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: 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 1834(a)(6) - Payment for Other Items of Durable Medical Equipment; 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(n) - Durable Medical Equipment Definition ; 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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General ; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.5- Intrapulmonary Percussive Ventilator; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List; 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 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 5.7- 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 L33800: Respiratory Assist Device, 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
Complex Home Health Review: Documentation and Medical Necessity
_0075
Complex
Home Health Agencies
Region-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: 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, 023X, 055X, 056X, 057X.
References: 1. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1814(a)(2)(C) - Conditions of and Limitations on payment for services 2. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services 3. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1835(a)(2)(A) – Procedure for payment of claims of providers of services 4. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services 5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(o) – Home Health Agency 6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(r) - Physician 7. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(aa)(5) – Rural Health Clinic Services and Federally Qualified Health Center Services 8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(gg)(2) – Certified Nurse-Midwife Services 9. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1891 – Conditions of Participation for home health agencies; Home health quality 10. 42 CFR 409.41 – Requirement for Payment 11. 42 CFR 409.42 – Beneficiary qualifications for coverage of services 12. 42 CFR 409.43 – Plan of care requirements 13. 42 CFR 409.44 – Skilled services requirements 14. 42 CFR 409.45 – Dependent services requirements 15. 42 CFR 409.46 – Allowable administrative costs 16. 42 CFR 409.47 – Place of service requirements 17. 42 CFR §424.22(a)(1)(i)-(v) – Requirement for home health services 18. IOM, 100-01 Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 Physician Certification and Recertification of Services, Section 10 Certification and Recertification by Physicians for Hospital Services – General, Subsection 10.2 Who May Sign Certification or Recertification 19. IOM, 100-01 Medicare General Information, Eligibility and Entitlement Manual Chapter 4 Physician Certification and Recertification of Services, Section 30 Certification and Recertification by Physicians for Home Health Services, Subsection 30.1 Content of Physician’s Certification 20. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.1.1 Patient Confined to the Home 21. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.2.1 Content of the Plan of Care 22. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.5.1.1 Face-to-Face Encounter 23. IOM, 100-02 Medicare Benefit Policy Manual, Chapter 7 Home Health Services, Section 30 Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection 30.5.1.2 Supporting Documentation Requirements