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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Details
Respiratory Assist Device
_0069
Complex
DME by supplier; DME by physician
Region-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: 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: 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)( (7)(C)(i),(ii) and (iii)- 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(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 §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(1) - Items Requiring a Written Order; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(2) - Specified Covered Items; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(3) - Face to Face Encounter Requirements; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(4)- Written Order Issuance Requirements; 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(5) - Supplier Order and Documentation Requirements; 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 5.2.4(C) - Rules Concerning Orders, Written Orders Prior to Delivery; Written Orders for Certain Covered Durable Medical Equipment ; Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Face-to-Face Encounter Requirements; Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements; 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 Determination (LCD) L33800: Effective 10/1/2015, Revision 01/01/2017.; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Respiratory Assist Device- Policy Article A52517: Effective 10/1/2015, Revision 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
Positive Airway Pressure Devices for Treatment of Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements
_0066
Complex
DME by supplier; DME by physician
Region-5
5 - Nationwide
09/19/2017

Positive Airway Pressure Devices for Treatment of Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements

Issue Name: Positive Airway Pressure Devices for Treatment of Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements
Issue Number: _0066
Review Type Complex
Provider Type: DME by supplier; DME by physician
Region: 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: "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 §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order 10. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(1) - Items Requiring a Written Order 11. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(2) – Specified Covered Items 12. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(3) – Face to Face Encounter Requirements 13. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(4)- Written Order Issuance Requirements 14. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)(5) – Supplier Order and Documentation Requirements 15. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 16. 42 CFR §424.57(c)- Application Certification Standards 17. Medicare National Coverage Determination Manual, NCD §240.4- Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea (OSA) 18. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 20. 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 21. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements"
DME CPAP without Obstructive Sleep Apnea Diagnosis
_0065
Automated
DME Supplier, DME by Physician
Region-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: 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: "1. Medicare National Coverage Determinations Manual: CMS Publication 100-03; Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations; Section 240.4 - Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA); Effective March 13, 2008 2. 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 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 6. 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 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 11. 42 CFR §424.57(c)- Application Certification Standards 12. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, Effective 10/01/2015; Revised 01/01/2019 13. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52467: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, Effective 10/01/2015; Revised 01/01/2019 14. 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 Spinal Orthoses
_0024
Complex
DME by supplier; DME by physician
Region-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: 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: 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)(4) - Payment for Certain Customized Items 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(h) - Payment for Prosthetic Devices and Orthotics and Prosthetics 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1) – General Rule for Payment 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F) - Special Payment Rules for Certain Prosthetics and Custom Fabricated Orthotics 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F)(ii) - Description of custom–fabricated item. 10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)(F)(iii) - Qualified practitioner defined 11. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 12. 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 13. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(n) - Durable Medical Equipment Definition 14. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 15. 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 16. 42 CFR §405.986- Good Cause for Reopening 17. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 18. 42 CFR §424.57(c)- Application Certification Standards 19. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 20. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 21. 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 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders 24. Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders 25. Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 26. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 27. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 28. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 30. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33790- Spinal Orthosis: TLSO and LSO, Effective 10/01/2015; Revised 01/01/2018 32. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52500- Spinal Orthosis: TLSO and LSO, Effective 10/01/2015; Revised 01/01/2018 33. 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
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 National Coverage Determination Manual, Chapter 1, Part 4, Section 280.1- Durable Medical Equipment Reference List 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) CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33800- Respiratory Assist Device, 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"
Complex Medical Necessity Patient Lifts
_0020
Complex
DME by Supplier, DME by Physician
Region-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: 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 
Ankle-Foot Orthoses / Knee-Ankle-Foot Orthoses: Medical Necessity and Coding Requirements
_0013
Complex
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
07/05/2017

Ankle-Foot Orthoses / Knee-Ankle-Foot Orthoses: Medical Necessity and Coding Requirements

Issue Name: Ankle-Foot Orthoses / Knee-Ankle-Foot Orthoses: Medical Necessity and Coding Requirements
Issue Number: _0013
Review Type Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 07/05/2017
Date Revised:
Dates Service: Less than 3 years
Description: This review will determine if the Ankle-Foot or Knee-Ankle-Foot Orthosis 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. 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: "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(a)- Payment for Durable Medical Equipment, (1)(E)(i)(ii)- Clinical Conditions for Coverage; (4)- Payment for Certain Customized Items; (7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h) (1) (F) (i) (ii)- Payment for Prosthetic Devices and Orthotics and Prosthetics 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 1847(a)(2)- Competitive Acquisition of Certain Items 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(9)- Medical and Other Health Services 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (3)- Face-to-Face Encounter Requirements 11. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions, (g)- Items Requiring a Written Order, (4)- Written Order Issuance Requirements 12. 42 CFR §414.402- Definitions 13. 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) 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 15. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Section 100.2- General Documentation Requirements- Certificates of Medical Necessity, Revision 1, Effective 10/01/2003 16. 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 17. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Physician Orders, §5.2.3- Detailed Written Orders, §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. 19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Effective 10/01/2015; Revised 1/01/2017 20. CGS Administrators, LLC, and Palmetto GBA Local Coverage Determination L11517- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Retired 9/30/2015 21. NGS Services, Inc., Local Coverage Determination L27229- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Retired 9/30/2015 22. NHIC, Corp. and Tricenturion Local Coverage Determination L11527- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Retired 9/30/2015 23. Noridian Healthcare Solutions, LLC, Local Coverage Determination L142- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Retired 9/30/2015 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52457- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Effective 10/01/2015; Revised 1/01/2017 25. CGS Administrators, LLC, Policy Article A19885- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Retired 9/30/2015 26. NGS Services, Inc., Policy Article A47227- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Retired 9/30/2015 27. NHIC, Corp. Policy Article A19806- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Retired 9/30/2015 28. Noridian Healthcare Solutions, LLC, Policy Article A19800- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Retired 9/30/2015 29. 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"
Group 3 Power Wheelchair Options Underpayments
_0053
Automated
DME Supplier and DME by Physician
Region-5
5 - Nationwide
05/17/2017

Group 3 Power Wheelchair Options Underpayments

Issue Name: Group 3 Power Wheelchair Options Underpayments
Issue Number: _0053
Review Type Automated
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/17/2017
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: Section 2 of the Patient Access and Medicare Protection Act (PAMPA) mandates that adjustments to the 2016 Medicare fee schedule amounts for certain DME based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs. Group 3 complex rehabilitative power wheelchair bases are currently described by codes K0848 through K0864. Although this PAMPA change is effective January 1, 2016, Medicare could not implement changes to claims processing systems prior to July 5, 2016. Until then, payment for these items will be based on the adjusted fee schedule amounts. This issue recovers the incorrect reductions owed to suppliers for claims for these items for DOS 1/1/2016 - 6/30/2016. Code list avail in the downloadable excel file, Appendix D tab.
References: Medicare Claims Processing Manual, Internet Only Manual, CMS Pub. 100-04, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 30.9- Payment of DMEPOS Items Based on Modifiers, Revision 3824- effective 7/1/2017
Complex Negative Pressure Wound Therapy Pumps WOPD
_0017
Complex
DME by Supplier
Region-5
5 - Nationwide
04/28/2017

Complex Negative Pressure Wound Therapy Pumps WOPD

Issue Name: Complex Negative Pressure Wound Therapy Pumps WOPD
Issue Number: _0017
Review Type Complex
Provider Type: DME by Supplier
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/28/2017
Date Revised:
Dates Service: Claims having a"Claims paid date" of service prior to 05/25/2017
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 NHIC's Local Coverage. Affected Codes; E2402, A6550, A7000
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, 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 7/1/2016, MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 7/1/2016, Local Coverage Determinations (LCDs) L11500, L5008, L27025, and L11489 – Negative Pressure Wound Therapy Pumps, Effective 10/1/2000; Retired 9/30/2015, MAC Policy Articles A35347, A35363, A47111, and A35425, Effective 10/1/2005; Retired 9/30/2015, CMS Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 6/1/2017.
Complex: Power Mobility Devices Not Subject to PA Demonstration
_0031
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide - (CA, FL, IL, MI, NY, NC, and TX, PA, OH, LA, MO, MD, NJ, IN, KY, GA, TN, WA, AND AZ are excluded)
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: Region-5
State: 5 - Nationwide - (CA, FL, IL, MI, NY, NC, and TX, PA, OH, LA, MO, MD, NJ, IN, KY, GA, TN, WA, AND AZ are excluded)
Date Approved: 06/06/2017
Date Revised:
Dates Service: Claims having a Beneficiary State of CA, FL, IL, MI, NY, NC, and TX will be excluded. Claims having a "claim paid date" which is more than 3 years prior to the ADR letter date and with initial dates of service on or after 10/01/2014 will be excluded for Beneficiary States PA, OH, LA, MO, MD, NJ, IN, KY, GA, TN, WA, AND AZ. Claims having a "claim paid date" which is more than 3 years prior to the ADR letter date will be excluded for all Beneficiary States not mentioned above. All claims having a "paid claim date "on or after September 1, 2018 shall be excluded.
Description: "This review will determine if the Power Mobility 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 codes: POV, PMD or PWC HCPCS codes: K0013, K0800-K0802, K0812, K082-K0829, K0835-K0843, K0848-K0855,K0857-K0860, K0863-K0864, K0890-K0891, K0898 "
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)(1)(E)(iv) – Standard for Power Wheelchairs; 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 §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs); 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (1) – Definitions; 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (2) – Conditions of Payment; 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (3) – Exceptions; 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (4) – Dispensing a power mobility device; 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (5) – Documentation; 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; 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.; 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 5.2.4(A)- Written Orders Prior to Delivery-General; Medicare Program Integrity Manual, Chapter 5, Section 5.2.4(B)- Written Orders Prior to Delivery for Power Operated Vehicles and Power Wheelchairs; 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 Determination (LCD) L33789: Effective 10/1/2015, Revision 01/01/2017.; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Power Mobility Devices- Policy Article A52498: Effective 10/1/2015, Revision 09/01/2018; 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