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CMS Approved Audit Issues

This list includes all CMS-approved audit issues.

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Complex Medical Necessity Enteral Nutrition Therapy
_0015
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide
05/11/2017

Complex Medical Necessity Enteral Nutrition Therapy

Issue Name: Complex Medical Necessity Enteral Nutrition Therapy
Issue Number: _0015
Review Type Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/11/2017
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 the use of enteral nutrition therapy meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected Codes; A5200, A9270, B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162.
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 National Coverage Determination Manual, NCD Section 180.2- Enteral and Parenteral Nutrition Therapy, Effective date 7/11/84;Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 110- Durable Medical Equipment – General; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 120- Prosthetic Devices; 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; Medicare Program Integrity Manual, Chapter 4- Program Integrity, Section 4.26- Supplier Proof of Delivery Documentation Requirements; Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.2.3- Detailed Written Orders ;Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs);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; 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; 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; 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; 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; Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity; CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, LCD L33783- Enteral Nutrition, Effective 10/01/2015; Revised 1/01/2017;CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A52493- Enteral Nutrition- Policy Article, Effective 10/01/2015; Revised 1/01/2017
Blood Glucose Monitors: Medical Necessity and Documentation Requirements
_0012
Complex
DME Supplier and DME by Physician
Region-5
5 - Nationwide
05/08/2017

Blood Glucose Monitors: Medical Necessity and Documentation Requirements

Issue Name: Blood Glucose Monitors: Medical Necessity and Documentation Requirements
Issue Number: _0012
Review Type Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/08/2017
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: Blood Glucose Monitors with Integrated Voice Synthesizer - Medical documentation will be reviewed to determine if claims for voice synthesized blood glucose monitors were billed without an indication supporting medical necessity. Affected Code; E2100.
References: "1. Title XVIII, Social Security, §1833(e)- Payment of Benefits 2. Title XVIII of the Social Security Act (SSA): §1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer 3. Code of Federal Regulations, 42 CFR §405.980 (b) & (c)- Reopening of Initial Determinations, Redeterminations, and Reconsiderations, Hearings and Reviews 4. Code of Federal Regulations, 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements 6. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 7. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8- Rules Concerning Orders, Refills of DMEPOS Items Provided on a Recurring Basis 8. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) 9. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 10. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 11. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.3, Policies and Guidelines Applied During Review 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110, Durable Medical Equipment – General 14. Medicare National Coverage Determinations Manual, Chapter 1, §40.2, Home Blood Glucose Monitors 15. CGS and Noridian Healthcare Solutions LCD L33822- Glucose Monitors, Effective 10/01/2015; Revised 1/01/2019 16. CGS and Palmetto GBA LCD L11520- Glucose Monitors, Retired 9/30/2015 17. NHIC and Tricenturion LCD L11530- Glucose Monitors, Retired 9/30/2015 18. NGS LCD L23231- Glucose Monitors, Retired 9/30/2015 19. Noridian and Cigna LCD L196- Glucose Monitors, Retired 9/30/2015 20. CGS and Noridian Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 01/01/19 21. CGS and Noridian LCA A52464- Glucose Monitor, Effective 10/012015; Revised: 01/01/19"
Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)
_0014
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
01/05/2017

Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)

Issue Name: Automated Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling)
Issue Number: _0014
Review Type Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/05/2017
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: Glucose Monitors Unbundling - HCPCS codes A4233, A4234, A4235, and A4236, which describe glucose monitor supplies, will be denied when billed with the same date of service as glucose monitor HCPCS codes E0607, E2100 or E2101.
References: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A), Title XVIII of the Social Security Act (SSA): Section 1833(e), Title XVIII of the Social Security Act (SSA): Section 1833(e), LCD #s: L11520, L27231, L11530, L196, LCD #: L33822, LCD #s: L11520, L27231, L11530, L196 for services performed on or after 10/1/15, LCD #: L33822 for services performed on or after 7/1/16 
Automated CPM Billed without Total Knee Replacement
_0016
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
02/02/2017

Automated CPM Billed without Total Knee Replacement

Issue Name: Automated CPM Billed without Total Knee Replacement
Issue Number: _0016
Review Type Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/02/2017
Date Revised: 1/1/17
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: Automated CPM Billed without Total Knee Replacement. Affected Codes: E0935
References: Medicare Claims Processing Manual Chapter 20, 30.2.1 - Daily Payment for Continuous Passive Motion (CPM) Devices (Rev. 1, 10-01-03); National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1) effective 5/5/2005.  
Automated Excessive Units of Spring Powered Devices Billed for >1 in a 6 Month Period
_0018
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
01/05/2017

Automated Excessive Units of Spring Powered Devices Billed for >1 in a 6 Month Period

Issue Name: Automated Excessive Units of Spring Powered Devices Billed for >1 in a 6 Month Period
Issue Number: _0018
Review Type Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/05/2017
Date Revised: 1/5/17
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: Excessive Units of Spring Powered Devices: More than one spring powered device (A4258) per 6 months is not reasonable and necessary. Affected Codes: A4258
References: CMS Pub. 100-3, (Medicare National Coverage Determinations Manual), Chapter 1, Section 40.2, LCD: Glucose Monitors L33822 (Current Nationwide LCD). Retired LCDs: (L196), L11520, L27231, L11530, MAC Policy Article: Glucose Monitors A52464 (Current Nationwide Article). Retired Articles: A33745, A47238, A33614, A33673 
Durable Medical Equipment Billed while Inpatient
_0019
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
02/16/2017

Durable Medical Equipment Billed while Inpatient

Issue Name: Durable Medical Equipment Billed while Inpatient
Issue Number: _0019
Review Type Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/16/2017
Date Revised:
Dates Service: Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational Letter date
Description: A supplier (includes physician furnishing DME) may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two(2) days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility. To see Affected Codes, download the .xls file and reference the 0019 Appendix D tab
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII, §1861(dd)(1) of the Social Security Act- Hospice Care; Hospice Program 3. Social Security Act (SSA), Title XVIII, §1861(n)- Durable Medical Equipment 4. 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 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 6. Social Security Act, Volume 1, Title XVIII (Health Insurance for the Aged and Disabled), Section 1834 (Special Payment Rules for Particular Items and Services), Subsections (2)(B); (3)(A); (5)(A); (7)(A)(i)(1); (7)(C)(ii)(1) 7. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 8. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B 9. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 10. 42 CF §405.986- Good Cause for Reopening 11. 42 CFR §410.38(a)- Durable medical equipment: Scope and conditions 12. 42CFR §418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals 13. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 14. 42 CFR §424.57(c)- Application Certification Standards 15. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 16. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §10.2- Coverage Table for DME Claims, Rev. 4001, effective 6/19/2018 17. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §110.310.2- Date of Service for Pre-Discharge Delivery of DMEPOS 18. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §211- SNF Consolidated Billing and DME Provided by DMEPOS Suppliers 19. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §212- Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers 20. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26.2- Supplier Proof of Delivery Documentation Requirements- Exceptions, Rev. 783, effective 4/1/2016 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.13- Incurred Expenses for DME and Orthotic and Prosthetic Devices"
Complex Medical Necessity Tracheotomy Suction Pumps and Suction Catheters
_0021
Complex
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
02/08/2017

Complex Medical Necessity Tracheotomy Suction Pumps and Suction Catheters

Issue Name: Complex Medical Necessity Tracheotomy Suction Pumps and Suction Catheters
Issue Number: _0021
Review Type Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/08/2017
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: Overpayments were identified where claims for suction pumps and suctions catheters were not in accordance with billing requirements outlined in Local Coverage determinations. Affected Codes: A4605, A4624, A4628, E0600.
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. 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 16. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements 17. 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 18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33612: Suction Pumps, Effective 10/01/2015; Revised date 01/01/2019 19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52519: Suction Pumps, Effective 10/01/2015; Revised date 01/01/2019 20. 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
High Frequency Chest Wall Oscillation Device: Medical Necessity and Documentation Requirements
_0023
Complex
DME by Supplier and DME by Physician
Region-5
5 - Nationwide
02/08/2017

High Frequency Chest Wall Oscillation Device: Medical Necessity and Documentation Requirements

Issue Name: High Frequency Chest Wall Oscillation Device: Medical Necessity and Documentation Requirements
Issue Number: _0023
Review Type Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/08/2017
Date Revised:
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Additional Document Request (ADR) date.
Description: This review will determine if a High Frequency Chest Wall Oscillation 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: E0483, A7025, A7026
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)( (7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment 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 §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 §405.986- Good Cause for Reopening 16. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 17. 42 CFR §424.57(c)- Application Certification Standards 18. 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 19. 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 20. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 21. 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 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Face-to-Face Encounter Requirements 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements 24. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 25. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 26. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient's Medical Record 27. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 28. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 29. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination (LCD) High Frequency Chest Wall Oscillation Devices L33785: Effective 10/1/2015, Revision 01/01/2019. 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: High Frequency Chest Wall Oscillation Devices - Policy Article A52494: Effective 10/1/2015, Revision 01/01/2019 31. 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"
Nebulizers Billed With Diagnosis Codes Other Than Those Listed in Local Coverage Determination
_0025
Automated
DME by Supplier, DME by Physician
Region-5
5 - Nationwide
02/02/2017

Nebulizers Billed With Diagnosis Codes Other Than Those Listed in Local Coverage Determination

Issue Name: Nebulizers Billed With Diagnosis Codes Other Than Those Listed in Local Coverage Determination
Issue Number: _0025
Review Type Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/02/2017
Date Revised: 1/1/17
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: Overpayments were identified where diagnosis codes were not in accordance with billing requirements outlines in Local Coverage Determinations for Nebulizers, Related Drugs, and Accessories. Affected Codes; A4216, A4217, A4619, A7003, A7004, A7005, A7006, A7007, A7010, A7011 (deleted effective 07/01/2016), A7012, A7013, A7014, A7015, A7016, A7017, A7018, A7525, E0565, E0570, E0572, E0574, E0585, E1372, J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7620, J7626, J7631, J7639, J7644, J7669, J7682, J7686, K0730, Q0474. (See 0025 Appendix D in downloadable excel file)
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 §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 9. 42 CFR §424.57(c)- Application Certification Standards 10. CGS and Noridian LCD L33370: Nebulizers, Effective 10/01/2015; Revised 01/01/2019 11. CGS and Policy Article A52466: Nebulizers, Effective 10/01/2015; Revised 01/01/2019 12. CGS and Noridian LCA: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 01/01/2019"