CMS Approved Audit Issues

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This list includes all CMS-approved audit issues.

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Issue Name Issue Number Review Type Provider Type Region State Date Approved Details
Bone Marrow & Stem Cell Transplantation: Medical Necessity and Documentation Requirements _0181 Complex Inpatient Hospital Region-1 1 - All Region 1 states 3/17/2020 details
Procedures that Include Imaging: Unbundling _0179 Automated Professional Services (Physician/non-physician practitioner) Region-1 1 - All Region 1 states 3/1/2020 details
Procedures that Include Ultrasound: Incorrect Coding _0180 Automated Professional Services (Physician/non-physician practitioner) Region-1 1 - All Region 1 states 3/1/2020 details
Hospital Beds: Medical Necessity and Documentation Requirements _0177 Complex DME by Supplier and DME by Physician Region-5 5 - Nationwide 3/1/2020 details
Manual Wheelchairs: Medical Necessity and Documentation Requirements _0178 Complex DME by Supplier and DME by Physician Region-5 5 - Nationwide 3/1/2020 details
Annual Wellness Visits: Incorrect Coding _0176 Complex Physician/Non-physician Practitioner Region-1 1 - All Region 1 states 1/20/2020 details
Emergency Ambulance Services: Medical Necessity and Documentation Requirements _0175 Complex Ambulance Region-1 1 - All Region 1 states 1/20/2020 details
Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements _0171 Complex Physicians and Non-Physician Practitioners, Hospital Outpatient Region-1 1 - All Region 1 states 12/25/2019 details
Ocular Photodynamic Therapy with Verteporfin: Medical Necessity and Documentation Requirements _0172 Complex Physician and non-physician practitioners, hospital outpatient, and ambulatory surgical center Region-1 1 - All Region 1 states 12/22/2019 details
Surgical Dressings: Medical Necessity and Coding Requirements _0173 Complex DME by Supplier/ DME by Physician Region-5 5 - Nationwide 01/01/2020 details
Cervical Orthoses within the Reasonable Useful Lifetime: Excessive Units _0174 Automated DME by Supplier and DME by Physician Region-5 5 - Nationwide 01/01/2020 details
Renal and Peripheral Angiography: Medical Necessity and Documentation Requirements _0170 Complex Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP) Region-1 1 - All Region 1 states 11/19/2019 details
Therapeutic, Prophylactic & Diagnostic Infusions: Incorrect Coding and Documentation Requirements _0161 Complex Outpatient Hospital Region-1 1 - All Region 1 states 11/19/2019 details
Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements _0067 Complex Inpatient Hospital (8), Inpatient Psychiatric Facility (IPF) (15) Region-1 1 - All Region 1 states 11/15/2019 details
Denial of the Professional Component for Previously-Denied Facility Claims for Medically Unnecessary Endomyocardial Biopsies and Right Heart Cauterizations Billed as Separate Procedures _0168 Automated Physician/Non- physician Practitioner (NPP) Region-1 1 - All Region 1 states 9/25/2019 details
Outpatient Services within 3 Days Prior to and Including the Date of a Hospital Admission: Unbundling _0169 Automated Outpatient Facility Region-1 1 - All Region 1 states 11/26/2019 details
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses within the Reasonable Useful Lifetime: Excessive Units _0167 Automated DME by Supplier and DME by Physician Region-5 5 - Nationwide 10/1/2019 details
Transportation component by portable suppliers for electrocardiogram services: Unbundling _0166 Automated Professional Services (Physician/non-physician practitioner) Region-1 1 - All Region 1 states 10/02/2019 details
Positron Emission Tomography for Dementia and Neurodegenerative Diseases: Medical Necessity and Documentation Requirements _0165 Complex Outpatient Hospital, Professional Services Region-1 1 - All Region 1 states 09/24/2019 details
Bilateral Indicator ‘3’: Incorrect Coding _0164 Automated Professional Services (Physician/non-physician practitioner) Region-1 1 - All Region 1 states 09/23/2019 details
Pass-Through Payment Device: Incorrect Coding _0156 Complex Hospital Outpatient; Ambulatory Surgery Center (ASC) Region-1 1 - All Region 1 states 09/23/2019 details
Ambulance Services Billed During Hospice: Unbundling _0163 Automated Ambulance Services Region-1 1 - All Region 1 states 07/22/2019 details
Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements _0162 Complex Outpatient Hospital Region-1 1 - All Region 1 states 07/16/2019 details
Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases: Medical Necessity and Documentation Requirements _0160 Complex Hospital Outpatient; Ambulatory Surgery Center; Professional Services (physician/non-physician practitioner) Region-1 1 - All Region 1 states 08/19/2019 details
Outpatient Therapy Services During Home Health: Unbundling _0158 Automated Hospital Outpatient, SNF Outpatient, Outpatient Rehabilitation Facility, Comprehensive Outpatient Rehabilitation Facility Region-1 1 - All Region 1 states 07/11/2019 details
Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements _0157 Complex Place of Service 24 with Type of Service “F” Region-1 1 - All Region 1 states 06/26/2019 details
Ophthalmic Diagnostic CPT Codes: Excessive Units _0159 Automated Professional Services (Physician/non-physician practitioner) Region-1 1 - All Region 1 states 06/17/2019 details
Ambulatory Surgical Center Coding Validation _0153 Complex ASC Region-1 1 - All Region 1 states 05/26/2019 details
Non-Emergency Ambulance Services- Advanced Life Support and Basic Life Support: Medical Necessity and Documentation Requirements _0154 Complex Ambulance Region-1 1 - All Region 1 states 05/20/2019 details
Mohs Micrographic Surgery: Incorrect Coding and Incorrect Units Billed _0150 Complex Physicians and Non-Physician Practitioners Region-1 1 - All Region 1 states 04/30/2019 details
Physician/Non-Physician Practitioner Coding Validation _0151 Complex Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 04/23/2019 details
Medical Necessity and Coding of Chest X-Rays _0136 Complex Outpatient hospital Region-1 1 - All Region 1 states 04/25/2019 details
Subsequent Hospital Visit and Discharge Day Management on the Same Day: Unbundling _0149 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 04/18/2019 details
Ambulatory Surgical Center Services During a Covered Part A Skilled Nursing Facility Stay: Unbundlingy _0142 Automated "Ambulatory Surgery Center (ASC) SNF" Region-1 1 - All Region 1 states 04/01/2019 details
Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity, Unbundling, and Documentation Requirements _0145 Complex Outpatient Hospital, Professional Services, and Ambulatory Surgical Centers Region-1 1 - All Region 1 states 03/31/2019 details
Pulmonary Rehabilitation: Medical Necessity and Documentation Requirements _0140 Complex Hospital Outpatient and Professional Services Region-1 1 - All Region 1 states 03/27/2019 details
Magnetic Resonance Imaging Procedures: Excessive Units _0147 Automated Professional Services (Physician/Non-Physician Practitioner), Outpatient Hospital Region-1 1 - All Region 1 states 03/27/2019 details
Computed Tomography Scans: Excessive Units _0146 Automated All Provider Specialties Region-1 1 - All Region 1 states 03/26/2019 details
Cardiac Rehabilitation: Medical Necessity and Documentation Requirements _0135 Complex Outpatient Hospital Region-1 1 - All Region 1 states 03/07/2019 details
Skilled Nursing Facility Consolidated Billing for Therapies: Unbundling _0138 Automated Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist Region-1 1 - All Region 1 states 02/19/2019 details
Subsequent Hospital and Nursing Facility Care Services: Excessive Units _0125 Automated Professional Services and CAHs type of bill 85x identified by revenue codes 96x, 97x or 98x Region-1 1 - All Region 1 states 02/21/2019 details
Vertebroplasty or Kyphoplasty: Medical Necessity and Documentation Requirements _0139 Complex Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 02/19/2019 details
Panniculectomy: Medical Necessity and Documentation Requirements _0130 Complex Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner) Region-1 1 - All Region 1 states 02/12/2019 details
Evaluation and Management Same Day as Admission to a Nursing Facility: Unbundling _0132 Automated Physician/ Non-Physician Practitioner Region-1 1 - All Region 1 states 02/14/2019 details
Cryosurgery of the Prostate: Medical Necessity and Documentation Requirements _0134 Complex Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 02/14/2019 details
Positron Emission Tomography Scans Paid without Tracer Codes- Independent Diagnostic Testing Facility: Non-Allowable Service _0133 Automated IDTF (Independent Diagnostic Testing Facility), Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 01/01/2018 details
Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements _0129 Complex Outpatient Hospital Region-1 1 - All Region 1 states 01/29/2019 details
Part B Therapies during Inpatient: Unbundling _0124 Automated Physical Therapist, Occupational Therapist, Speech language Therapist Region-1 1 - All A/B MACs 11/29/2018 details
Destruction of Premalignant Lesions: Excessive Units _0121 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 12/03/2018 details
Technical Component of Diagnostic Procedures during Inpatient: Unbundling _0123 Automated Physician/Non-Physician Practitioner Independent Diagnostic Testing Facility (IDTF) Region-1 1 - All Region 1 states 12/10/2018 details
Endoscopy Procedures: Diagnostic and Surgical Billed Same Day _0126 Automated Outpatient Facility; ASC; Professional Services Region-1 1 - All Region 1 states 11/27/2018 details
Outpatient Hospice Related Services: Unbundling _0122 Automated Part A Outpatient Region-1 1 - All Region 1 states 11/28/2018 details
Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month _0112 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 11/12/2018 details
Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding _0120 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 11/02/2018 details
Arthroscopic Extensive Shoulder Debridement: Incorrect Coding _0118 Automated Physician/Non- physician Practitioner (NPP); Outpatient Hospital (For claims prior to 10/01/2017. After 10/01/2017, denial of 29823 made no change in APC.) Region-1 1 - All Region 1 states 10/19/2018 details
Automated Arthroscopic Limited Debridement _0117 Automated Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered prior to 10/1/2017 due to change from T (multiple surg payment) to J1 (APC payment) Region-1 1 - All Region 1 states 10/19/2018 details
Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered _0115 Automated Physician Claims Region-1 1 - All Region 1 states 10/16/2018 details
Modifiers TC and 26: Incorrect Coding _0116 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 10/12/2018 details
Transthoracic Echocardiography: Medical Necessity and Documentation Requirements _0111 Complex Inpatient Hospital, Outpatient Hospital, SNF Region-1 1 - All Region 1 states 10/12/2018 details
Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements _0073 Complex Inpatient Rehabilitation Facility, Inpatient Region-1 1 - All Region 1 states 10/12/2018 details
Skilled Nursing Facility Consolidated Billing: Part B – Use of Modifier 26, Professional Component _0110 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 09/20/2018 details
Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full _0109 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 09/20/2018 details
Facility vs Non Facility Reimbursement: Incorrect Coding _0108 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 09/14/2018 details
Physician Services during Hospice Period: Unbundling _0105 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 08/16/2018 details
Ambulatory Payment Classification Coding Validation _0101 Complex Outpatient Hospital Region-1 1 - All Region 1 states 07/26/2018 details
Add-on codes paid without Primary Code and/or denied Primary Code – Ambulatory Surgical Center _0104 Automated Ambulatory Surgery Center (ASC) Region-1 1 - All Region 1 states 07/26/2018 details
Add-On Code Paid without Primary Code and/or Denied Primary Code: Clinical Laboratory _0100 Automated Laboratory Region-1 1 - All Region 1 states 06/21/2018 details
Skilled Nursing Facility Consolidated Billing: Outpatient Facility - Not Separately Payable Services _0099 Automated Outpatient Facility Region-1 1 - All Region 1 states 06/20/2018 details
Critical Care Professional Services: Unbundling _0098 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 06/16/2018 details
Implantable Automatic Defibrillators: Medical Necessity, Documentation and Coding Validation _0093 Complex Inpatient Hospital, Outpatient Hospital, ASC, Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 05/15/2018 details
Duplicate Claims- Professional Services _0091 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 05/11/2018 details
Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements _0092 Complex Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP) Region-1 1 - All Region 1 states 05/08/2018 details
Laboratory/Pathology Technical Component for Inpatient or Outpatient Hospitals: Unbundling _0090 Automated Physician/Non-Physician Practitioner; Lab; IDTF (Independent Diagnostic Testing Facility) Region-1 1 - All Region 1 states 04/03/2018 details
Laboratory Services Rendered During an Inpatient Stay: Unbundling _0085 Automated Lab and Outpatient Region-1 1 - All Region 1 states 03/19/2018 details
Cataract Removal Excessive Units - Partial Denial _0083 Automated Professional Services, Outpatient, ASC Region-1 1 - All Region 1 states 03/19/2018 details
Cataract Removal: Duplicate Payment _0084 Automated Physician/Non-Physician Practitioner, Outpatient, ASC Region-1 1 - All Region 1 states 03/19/2018 details
Observation Evaluation and Management Services Billed Same Day as Inpatient: Unbundling _0086 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 03/19/2018 details
Clinical Social Worker during Inpatient: Unbundling _0089 Automated Clinical Social Workers Region-1 1 - All Region 1 states 03/19/2018 details
Ancillary Services Billed Without an Approved Surgical Procedure _0088 Automated Ambulatory Surgery Center (ASC) Region-1 1 - All Region 1 states 03/16/2018 details
Laboratory Services for End-Stage Renal Disease Subject to Part B Consolidated Billing: Unbundling _0087 Automated Professional Services(Physician/Non-Physician Practitioner); Laboratory Region-1 1 - All Region 1 states 03/16/2018 details
Cardiac Pacemakers: Medical Necessity and Documentation Requirements _0078 Complex Outpatient, Ambulatory Surgery Center Region-1 1 - All Region 1 states 02/15/2018 details
Evaluation and Management Services Billed Same Day as Dialysis: Unbundling _0076 Automated Physician/Non-Physician practitioner(NPP) Region-1 1 - All Region 1 states 01/16/2018 details
Initial Hydration, Infusion and Chemotherapy Administration: Incorrect Units Billed _0071 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 10/05/2017 details
Annual Wellness Visit Billed Sooner Than Eleven Whole Months Following the Initial Preventive Physical Examination _0077 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 01/15/2018 details
Drugs and Biologicals: Incorrect Units Billed (Single-Dose Vials) _0074 Complex Outpatient Hospital & Physician Region-1 1 - All Region 1 states 01/11/2018 details
Outpatient Service Overlapping or During an Inpatient Stay: Duplicate Payments _0072 Automated Hospital Outpatient, Hospital Inpatient Part B Region-1 1 - All Region 1 states 10/26/2017 details
Critical Care Billed on the Same Day as Emergency Room Services _0070 Automated Physician/Non-Physician Practitioner Region-1 1 - All Region 1 states 10/19/2017 details
Untimed Therapy: Excessive Units _0060 Automated Outpatient Hospital; Part B Professional Services; Outpatient Non-Hospital Facility; Skilled Nursing Facility (SNF); Outpatient Rehab Facility (ORF); Comprehensive Outpatient Rehab Facility (CORF); Physician and Non-Physician Practitioner/ Provider Specialty; Region-1 1 - All Region 1 states 09/20/2017 details
Arthroscopic Limited Shoulder Debridement: Incorrect Coding _0057 Complex Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non- physician Practitioner (NPP) Region-1 1 - All Region 1 states 09/11/2017 details
Nursing Facility Services: Excessive Units _0061 Automated Professional (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 09/08/2017 details
Facility Duplicate Claims _0064 Automated Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility (SNF) Region-1 1 - All Region 1 states 09/07/2017 details
Critical Care: Excessive Units _0063 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 1 - All Region 1 states 09/07/2017 details
Radiology: Technical Component during Inpatient Stay _0062 Automated Radiologists and other Part B providers performing radiology services Region-1 1 - All Region 1 states 09/07/2017 details
Ambulance Transfer between Skilled Nursing Facilities: Unbundling _0049 Automated Ambulance Providers Region-1 1 - All Region 1 states 08/09/2017 details
Evaluation and Management Services in Skilled Nursing Facilities: Incorrect Coding _0056 Automated Physician/Non-physician Practitioner (NPP) Region-1 1 - All Region 1 states 08/02/2017 details
Panretinal (Scatter) Laser Photocoagulation: Excessive Frequency _0047 Automated Outpatient Hospital (OPH), Physician/Non-physician Practitioner Region-1 J6, JK, J15 04/28/2017 details
Global versus Technical Component/Professional Component Reimbursements: Unbundling _0051 Automated Physician/Non-physician Practitioner (NPP), Lab/Ambulatory services. Region-1 1 - All Region 1 states 05/04/2017 details
Ambulance Billed during Inpatient: Unbundling _0054 Automated Ambulance Providers Region-1 1 - All Region 1 states 05/31/2017 details
SNF Review: Documentation and Medical Necessity of SNF _0004 Complex SNF Region-1 1 - All Region 1 states 06/01/2017 details
Sacral Neurostimulation: Medical Necessity and Documentation Requirements _0003 Complex Inpatient hospital-acute care; physician; outpatient hospital; professional services (physician/non-physician practitioner); ASC Region-1 1 - All Region 1 states 02/17/2017 details
Bariatric Surgery: Medical Necessity and Documentation Requirements _0008 Complex Inpatient Hospital, Outpatient Hospital Region-1 1 - All Region 1 states 02/01/2017 details
Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes During Inpatient _0011 Automated Professional Services (Physician/ non Physician Practitioner) Region-1 1 - All Region 1 states 02/01/2017 details
Inpatient Psychiatric Stay Billed without Source of Admission Equal to “D” _0022 Automated Inpatient Hospital, Inpatient Psychiatric Facility Region-1 1 - All Region 1 states 02/09/2017 details
Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services _0027 Complex Outpatient Hospital (OPH), Physician Region-1 1 - All Region 1 states 04/25/2017 details
Annual Wellness Visits: Excessive Units _0028 Automated Physician/Non- Physician Practitioner Region-1 1 - All Region 1 states 03/30/2017 details
Trastuzumab (Herceptin) Multi-Dose Vial: Incorrect Wastage _0036 Complex Outpatient hospital; Professional services (physician/non-physician practitioner) Region-1 1 - All Region 1 states 02/21/2017 details
Hospital Services: Excessive Units _0037 Automated Professional Services (Physician/Non- Physician Practitioner) Region-1 1 - All Region 1 states 02/23/2017 details
Visits to Patients in Swing Beds: Incorrect Coding _0038 Automated Physician; Professional Services Region-1 1 - All Region 1 states 02/23/2017 details
Ophthalmology Codes for New Patient: Incorrect Coding _0039 Automated Physician; Professional Services Region-1 1 - All Region 1 states 03/09/2017 details
Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect Coding _0042 Automated Professional Services (Physician/Non- Physician Practitioner) Region-1 1 - All Region 1 states 03/09/2017 details
New Patient Visits: Incorrect Coding _0043 Automated Physician/Non- Physician Practitioner Region-1 1 - All Region 1 states 03/09/2017 details
Complex Inpatient Hospital MS-DRG Coding Validation _0001 Complex Inpatient Hospital (IPH) Region-1 1 - All Region 1 states 02/01/2017 details
Cataract Removal: Medical Necessity and Coding Requirements _0002 Complex Ambulatory Surgery Center (ASC); Outpatient Hospital Region-1 - CGS, Cahaba, First Coast, NGS, Noridian, Novitas, Palmetto **please note-WPS is excluded** 1 - Excludes WPS 02/07/2017 details
Blood Glucose Test or Reagent Strips: Medical Necessity and Documentation Requirements _0152 Complex DME by Supplier/DME Physician Region-5 5 - Nationwide 06/14/2019 details
Upper Limb Orthotics within the Reasonable Useful Lifetime: Excessive Units _0155 Automated DME by Supplier and DME by Physician Region-5 5 - Nationwide 05/17/2019 details
Therapeutic Shoes and Inserts for Persons with Diabetes: Medical Necessity and Documentation Requirements _0141 Complex DME by Supplier/ DME by Physician Region-5 5 - Nationwide 04/26/2019 details
Same Knee Orthoses within Reasonable Useful Lifetime: Excessive Units _0148 Automated DME by Supplier and DME by Physician Region-5 5 - Nationwide 05/01/2019 details
Prefabricated Knee Orthoses: Medical Necessity and Documentation Requirements _0144 Complex DME by Supplier/ DME by Physician Region-5 5 - Nationwide 03/15/2019 details
Pneumatic Compression Device: Medical Necessity and Documentation Requirements _0131 Complex DME Supplier and DME by Physician Region-5 5 - Nationwide 01/23/2019 details
Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime: Excessive Units _0128 Automated DME by Supplier and DME by Physician Region-5 5 - Nationwide 01/01/2019 details
Durable Medical Equipment Billed While in Hospice _0114 Automated DME Supplier/DME by Physician Region-5 5 - Nationwide 09/20/2018 details
Custom-Fabricated Knee Orthoses: Medical Necessity and Documentation Requirements _0107 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 09/14/2018 details
Parenteral Nutrition: Medical Necessity and Documentation Requirements _0106 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 09/14/2018 details
Urological Supplies: Medical Necessity and Documentation Requirements _0103 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 07/19/2018 details
Home Use of Oxygen: Medical Necessity and Certification _0102 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 07/12/2018 details
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 details
Negative Pressure Wound Therapy Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements _0081 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 02/26/2018 details
Group 2 Support Surfaces Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements _0080 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 02/20/2018 details
Ventilators Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements _0079 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 01/11/2018 details
Home Health: Medical Necessity and Documentation Requirements _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 details
Respiratory Assist Devices: Medical Necessity and Documentation Requirements _0069 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 12/17/2017 details
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 details
Continuous Positive Airway Pressure Machine without an Obstructive Sleep Apnea Diagnosis _0065 Automated DME Supplier, DME by Physician Region-5 5 - Nationwide 09/08/2017 details
Spinal Orthoses: Medical Necessity and Documentation Requirements _0024 Complex DME by supplier; DME by physician Region-5 5 - Nationwide 08/02/2017 details
Complex Medical Necessity Patient Lifts _0020 Complex DME by Supplier, DME by Physician Region-5 5 - Nationwide 06/01/2017 details
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 details
Negative Pressure Wound Therapy- Medical Necessity and Documentation Requirements _0017 Complex DME by Supplier Region-5 5 - Nationwide 04/28/2017 details
Power Mobility Devices: Medical Necessity and Documentation Requirements _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 details
Enteral Nutrition Therapy: Medical Necessity and Documentation Requirements _0015 Complex DME Supplier and DME by Physician Region-5 5 - Nationwide 05/11/2017 details
Blood Glucose Monitors: Medical Necessity and Documentation Requirements _0012 Complex DME Supplier and DME by Physician Region-5 5 - Nationwide 05/08/2017 details
Glucose Monitor Supplies Billed With Same Dates of Service as Glucose Monitor: Unbundling _0014 Automated DME by Supplier, DME by Physician Region-5 5 - Nationwide 01/05/2017 details
Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision _0016 Automated DME by Supplier, DME by Physician Region-5 5 - Nationwide 02/02/2017 details
Spring-Powered Devices: Excessive Units _0018 Automated DME by Supplier, DME by Physician Region-5 5 - Nationwide 01/05/2017 details
Durable Medical Equipment Billed while Inpatient _0019 Automated DME by Supplier, DME by Physician Region-5 5 - Nationwide 02/16/2017 details
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 details
High Frequency Chest Wall Oscillation Devices: Medical Necessity and Documentation Requirements _0023 Complex DME by Supplier and DME by Physician Region-5 5 - Nationwide 02/08/2017 details
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 details
Nebulizer Drugs: Medical Necessity and Documentation Requirements _0026 Complex DME by Supplier, DME by Provider Region-5 5 - Nationwide 04/14/2017 details
Group 2 Support Surfaces: Medical Necessity and Documentation Requirements _0029 Complex DME by Supplier and DME by Physician Region-5 5 - Nationwide 02/15/2017 details
Osteogenesis Stimulators: Medical Necessity and Documentation Requirements _0030 Complex DME by Supplier and DME by Physician Region-5 5 - Nationwide 02/14/2017 details
Durable Medical Equipment Rentals: Multiple Billing within the Same Month _0046 Automated DME by Supplier, DME by Physician Region-5 5 - Nationwide 03/31/2017 details
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Bone Marrow & Stem Cell Transplantation: Medical Necessity and Documentation Requirements

Issue Name: Bone Marrow & Stem Cell Transplantation: Medical Necessity and Documentation Requirements
Issue Number: _0181
Review Type: Complex
Provider Type: Inpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 3/17/2020
Dates Service: Claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request (complex review).
Description: The medical record will be reviewed to determine if the service was reasonable and necessary and all documentation requirements are present for MS-DRGs: 009 - Bone marrow transplant, 014 - Allogenic bone marrow transplant, 016 - Autologous bone marrow transplant with a complication or comorbidity (CC), 017 - Autologous bone marrow transplant without a CC or major CC. Affected codes: MS-DRGs: 014 - Allogenic bone marrow transplant, 016 - Autologous bone marrow transplant with CC/MCC or T-Cell Immunotherapy, 017 - Autologous bone marrow transplant without a CC or major CC.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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, § 3.6.2.1- Coverage determinations, §3.6.2.2-Reasonable and Necessary Criteria, §3.4.1.3-Diagnosis Code Requirements, §3.3.2.4- Signature Requirements 6. National Coverage Determination Manual, Chapter 1, Part 2- Coverage Determinations, §110.23- Stem Cell Transplantation"

Procedures that Include Imaging: Unbundling

Issue Name: Procedures that Include Imaging: Unbundling
Issue Number: _0179
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 3/1/2020
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review)
Description: The focus of this issue is to target claims where the definition of the procedure code includes imaging and imaging was then unbundled. Affected codes: 70010-79999
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.9- National Correct Coding Initiative (CCI) 7. American Medical Association (AMA), Current Procedural Terminology (CPT) 8. The National Correct Coding Initiative Policy Manual for Medicare Services (also known as the Coding Policy Manual),Chapter III Surgery: Integumentary System CPT Codes 10000-19999; Chapter IV Surgery: Musculoskeletal System CPT Codes 20000-29999; Chapter V Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems CPT Codes 30000-39999; Chapter VI Surgery: Digestive System CPT Codes 40000-49999; Chapter VII Surgery: Urinary, Male Genital, Female Genital, Maternity Care and Delivery Systems CPT Codes 50000-59999 ; Chapter VIII Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems CPT Codes 60000-69999 "

Procedures that Include Ultrasound: Incorrect Coding

Issue Name: Procedures that Include Ultrasound: Incorrect Coding
Issue Number: _0180
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 3/1/2020
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: The focus of this issue is to target claims where there was an additional payment made for imaging due to incorrect coding. If the provider billed a procedure code where the definition of the code does not include ultrasound and then billed ultrasound, the service will be re-coded to the code that includes ultrasound and the ultrasound will then be denied. Affected codes: 10021, 20605, 20610, 32554, 32556, 49082, 76942, 76998
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.9- National Correct Coding Initiative (CCI) 7. American Medical Association (AMA), Current Procedural Terminology (CPT) 8. The National Correct Coding Initiative Policy Manual for Medicare Services (also known as the Coding Policy Manual) "

Hospital Beds: Medical Necessity and Documentation Requirements

Issue Name: Hospital Beds: Medical Necessity and Documentation Requirements
Issue Number: _0177
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 3/1/2020
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020 will be excluded.
Description: Hospital Beds must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined in Local Coverage Determination for Hospital Beds. Medical documentation will be reviewed to determine that services were reasonable and necessary. Affected codes: E0250, E0260
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. Medicare National Coverage Determination Manual, Chapter 1- Coverage Determinations, Part 4, 280.7- Hospital Beds 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33820- Hospital Beds and Accessories, Effective 10/01/2015; Revised 1/01/2017 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Coverage Article A52508- Hospital Beds and Accessories, Effective 10/01/2015; Revised 1/01/2017 22. 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 01/01/2020"

Manual Wheelchairs: Medical Necessity and Documentation Requirements

Issue Name: Manual Wheelchairs: Medical Necessity and Documentation Requirements
Issue Number: _0178
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 3/1/2020
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020 will be excluded.
Description: This review will determine if the Manual Wheelchairs are 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: K0001, K0003
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 Request 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. Medicare National Coverage Determination Manual, Chapter 1- Coverage Determinations, Part 4, 280.3- Mobility Assistive Equipment 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33788- Manual Wheelchair Bases, Effective 10/01/2015; Revised 1/01/2017 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52497- Manual Wheelchair Bases, Effective 10/01/2015; Revised 1/01/2019 22. 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 01/01/2020 "

Annual Wellness Visits: Incorrect Coding

Issue Name: Annual Wellness Visits: Incorrect Coding
Issue Number: _0176
Review Type: Complex
Provider Type: Physician/Non-physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 1/20/2020
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Claims for HCPCS code G0402- Initial Preventative Physical Examination (IPPE), billed more than once in a lifetime, or after the initial 12 months or 12 months after the effective date of the beneficiary’s first part B coverage period will be denied. Claims for HCPCS code G0438- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); initial, billed more than once in a lifetime will be denied. Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, billed more than once within 12 months of G0438 or G0439 will be denied. Affected codes: G0402, G0438, G0439.
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 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 1861 (S)(2)(FF)- Medical and other health services- personalized prevention plan services (as defined in subsection 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (HHH)-Annual Wellness Visit 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 42 CFR §§ 410.15 - Annual Wellness Visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage. 8. 42 CFR §§ 410.16 Initial preventive physical examination: Conditions for and limitations on coverage. 9. 42 CFR § 411.15 - Particular services excluded from coverage, (a) Routine physical checkups such as:(1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening mammography, colorectal cancer screening tests, screening pelvic exams, prostate cancer screening tests, glaucoma screening exams, ultrasound screening for abdominal aortic aneurysms (AAA), cardiovascular disease screening tests, diabetes screening tests, a screening electrocardiogram, Initial Preventive Physical Examinations that meet the criteria specified in paragraphs (k)(6) through (k)(15) (k) Any services that are not reasonable and necessary for one of the following purpose: (15) In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in §410.64 of this chapter. 10. 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 11. Medicare Benefit Policy Manual- Chapter 15- Covered Medical and Other Health Services, §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) 12. Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, Section 30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] 13. Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, Section 100.1.1 Evaluation and Management (E/M) Services -(C) Exception for E/M Services Furnished in Certain Primary Care Centers 14. Medicare Claims Processing Manual- Chapter 18 (Preventive and Screening Services), §140- Annual Wellness Visit "

Emergency Ambulance Services: Medical Necessity and Documentation Requirements

Issue Name: Emergency Ambulance Services: Medical Necessity and Documentation Requirements
Issue Number: _0175
Review Type: Complex
Provider Type: Ambulance
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 1/20/2020
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: Medicare pays for emergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation or levels of service are contraindicated (i.e. would endanger the beneficiary, cause serious impairment to bodily functions or serious dysfunction of any body organ or part). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, and not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment.
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 1861(s)(7)- Definitions of Services, Institutions, Etc. 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (v)(1)(K)(ii) – Reasonable Cost. 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)-(16)- Establishment of Fee Schedule for Ambulance Services. 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information 9. 42 CFR 410.40- Coverage of ambulance services, (b) Levels of service. 10. 42 CFR 410.40- Coverage of ambulance services, (d) Medical necessity requirements (1) General Rule and (3) Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis. 11. 42 CFR 410.41- Requirements for ambulance suppliers, (c) Billing and reporting requirements. 12. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(1) Any Services not Reasonable and Necessary. 13. 42 CFR 424.36- Signature Requirements 14. 42 CFR 414.605 Definitions 15. 42 CFR 414.610 Basis of Payment 16. 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary. 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 18. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services 19. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30- General Billing Guidelines, (A)- Modifiers Specific to Ambulance Service Claims and (B)- HCPCS Codes 20. Novitas LCD L35162, Ambulance Services (Ground Ambulance), Effective Date 10/01/2015, Revised 11/14/2019 21. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015. 22. FCSO, LCD L33383, Non-Emergency Ground Ambulance Services. Effective Date 10/1/2015. Retirement Date 6/28/2018. 23. FCSO, LCD L37697, Emergency and Non-Emergency Ground Ambulance Services, Effective Date 6/28/2018, Revised 11/28/2019"

Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements

Issue Name: Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements
Issue Number: _0171
Review Type: Complex
Provider Type: Physicians and Non-Physician Practitioners, Hospital Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/25/2019
Dates Service: Review claims having a “paid claim date” which is less than 3 years prior to the ADR letter date.
Description: Erythropoiesis stimulating agents (ESAs) stimulate the bone marrow to make more red blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need for blood transfusion in patients with specific clinical indications. Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria. Affected codes: J0881 and J0885 that were billed with modifiers EA and EB 96372, 96374, 96375
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Benefit Policy Manual, Chapter 15, §50 Drugs and Biologicals 7. National Coverage Determinations (NCD) Manual, Chapter 1- Coverage Determinations, §110.21 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions 8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals, §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements; §80.9- Required Modifiers for ESAs Administered to Non-ESRD Patients; and §80.12- Claim Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy 9. CGS Administrators, LLC, LCD L34356- Erythropoiesis Stimulating Agents (ESA), Effective 10/01/2015; Revised 10/03/2019 10. WPS LCD L34633- Erythropoiesis Stimulating Agents; Effective 10/01/2015; Revised 02/09/2020 11. FCSO LCD L36276- Erythropoiesis Stimulating Agents. Effective 01/01/2015; Revised10/29/2019 12. CGS Administrators, LLC, LCA A56462- Billing and Coding: Erythropoiesis Stimulating Agents (ESA), Effective 10/03/2019; Revised 01/23/2020 13. WPS LCA A56795- Billing and Coding: Erythropoiesis Stimulating Agents; Effective 08/01/2019; Revised 02/09/2020 14. WPS LCA A57844- Response to Comments: Erythropoiesis Stimulating Agents; Effective 02/09/2020 15. FCSO LCD L36276 Erythropoiesis Stimulating Agents. Effective 01/01/2015; Revised10/29/2019"

Ocular Photodynamic Therapy with Verteporfin: Medical Necessity and Documentation Requirements

Issue Name: Ocular Photodynamic Therapy with Verteporfin: Medical Necessity and Documentation Requirements
Issue Number: _0172
Review Type: Complex
Provider Type: Physician and non-physician practitioners, hospital outpatient, and ambulatory surgical center
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/22/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Ocular Photodynamic Therapy (OPT) is used in the treatment of ophthalmologic diseases; specifically, for age-related macular degeneration (AMD). It involves the infusion of a photosensitive (light-activated) drug verteporfin. Once introduced to the body, this drug accumulates and is retained in diseased tissue to a greater degree than in normal tissue. Infusion is followed by the targeted irradiation of this tissue with a non-thermal laser. The drug then becomes active and locally treats the diseased tissue. OPT is only covered when used in conjunction with verteporfin. Medical records will be reviewed to determine if the use of verteporfin in the setting of OPT meets Medicare coverage criteria. Affected codes: J3396, 67221, 67225
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §50 Drugs and Biologicals 7. Medicare National Coverage Determinations (NCD) Manual, Chapter 1 Coverage Determinations, §80.2 Photodynamic Therapy, §80.2.1(B) Nationally Covered Indications, §80.3 Photosensitive Drugs 8. Medicare Claims Processing Manual, Chapter 17 Drugs and Biologicals, §10 Payment Rules for Drugs and Biologicals, §40 Discarded Drugs and Biologicals, §70 Claims Processing Requirements, §90.2 - Drugs, Biologicals, and Radiopharmaceuticals, §100.2.9 - Submission of Claims With the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient” 9. Medicare Claims Processing Manual, Chapter 32 Billing Requirements for Special Services, §300 Billing Requirements for Ocular Photodynamic Therapy (OPT) with Verteporfin

Surgical Dressings: Medical Necessity and Coding Requirements

Issue Name:Surgical Dressings: Medical Necessity and Coding Requirements
Issue Number: _0173
Review Type: Complex
Provider Type: DME by Supplier/ DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/01/2020
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded
Description: This review will determine if the Surgical Dressing 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: A6010, A6021, A6197, A6210, A6211, A6212
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(i) - Payment for Surgical Dressings 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)(5)- Medical and Other Health Services, Surgical Dressings 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 §410.36- Medical Supplies, Appliances, and Devices 10. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 13. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements 14. 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 15. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and other Health Services, §100- Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations 16. Medicare Claims Processing Manual, Chapter 7- SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §60- Billing for Durable Medical Equipment (DME), Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings) 17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33831: Surgical Dressings, Effective 10/01/2015; Revised 01/01/2020 18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A54563: Surgical Dressings, Effective 10/01/2015; Revised 01/01/2020 19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020 "

Cervical Orthoses within the Reasonable Useful Lifetime: Excessive Units

Issue Name:Cervical Orthoses within the Reasonable Useful Lifetime: Excessive Units
Issue Number: _0174
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/01/2020
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date.
Description: Claims for cervical orthoses with dates of service within the period of reasonable useful lifetime (RUL), i.e., five years, of a previously paid same cervical orthoses for the same beneficiary, will be denied as the reasonable useful lifetime (RUL) requirement has not been met. Affected codes: L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0700, L0710, L0810, L0820, L0830, L1000, L1001, L1005, L1200, L1300, L1310, L1499
References: "1. Social Security Act, 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, 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(h)- Payment for Prosthetic Devices and Orthotics and Prosthetics. 4. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - The term “medical and other health services” means any of the following items or services (9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient’s physical condition 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i)- Establishment of Reasonable Useful Lifetime and (iii)- Length of Reasonable Useful Lifetime (i) Establishment of reasonable useful lifetime. —In accordance with clause (iii), the Secretary shall determine and establish a reasonable useful lifetime for items of durable medical equipment for which payment may be made under this paragraph. (iii) Length of reasonable useful lifetime. —The reasonable useful lifetime of an item of durable medical equipment under this subparagraph shall be equal to 5 years, except that, if the Secretary determines that, on the basis of prior experience in making payments for such an item under this title, a reasonable useful lifetime of 5 years is not appropriate with respect to a particular item, the Secretary shall establish an alternative reasonable lifetime for such item 8. 42 Code of Federal Regulations §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 Code of Federal Regulations §414.210(f)(1)- Payment for Replacement of Equipment (f) Payment for replacement of equipment. If an item of DME or a prosthetic or orthotic device paid for under this subpart has been in continuous use by the patient for the equipment's reasonable useful lifetime or if the carrier determines that the item is lost, stolen, or irreparably damaged, the patient may elect to obtain a new piece of equipment. (1) The reasonable useful lifetime of DME or prosthetic and orthotic devices is determined through program instructions. In the absence of program instructions, carriers may determine the reasonable useful lifetime of equipment but in no case can it be less than 5 years. Computation is based on when the equipment is delivered to the beneficiary, not the age of the equipment. 10. 42 Code of Federal Regulations §414.210- General Payment Rules 11. 42 Code of Federal Regulations §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 12. 42 Code of Federal Regulations §424.57(c)- Application Certification Standards 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, § §110.2.C- Repairs, Maintenance, Replacement, and Delivery and § 130- Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General, §110.2.C- Repairs, Maintenance, Replacement, and Delivery 15. 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 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 19. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 20. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs, Effective 01/01/2017, Revised 04/06/2020 "

Renal and Peripheral Angiography: Medical Necessity and Documentation Requirements

Issue Name:Renal and Peripheral Angiography: Medical Necessity and Documentation Requirements
Issue Number: _0170
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/19/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: In current practice, invasive renal and peripheral angiography is mainly used to clarify inconclusive or contradictory findings of noninvasive studies; or used in conjunction with therapeutic procedures. Therefore, diagnostic (aka stand-alone) renal and peripheral angiography procedures will be denied without documentation of a prior, inconclusive non-invasive study that supports the medical necessity for invasive angiography. Additionally, renal and peripheral angiography services will be reviewed for application and observance of correct coding guidelines.
References: "1. Social Security Act (SSA) Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 6. 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 Part 7. 42 CFR §405.986- Good Cause for reopening 8. 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 9. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §3.6.2.4 - Coding Determinations 10. Medicare Benefit Policy Manual, Chapter 16 - General exclusion from coverage, §10 - General exclusions from coverage 11. Medicare Benefit Policy Manual, Chapter 16 - General exclusion from coverage, §20 - Services not reasonable and necessary 12. National Correct Coding Initiative Policy Manual, Chapter 1 - General Correct Coding Policies, §E- Modifiers and Modifier Indicators 13. National Correct Coding Initiative Policy Manual, Chapter 5 - Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems 14. National Correct Coding Initiative Policy Manual, Chapter 9 - Radiology Services 15. First Coast LCD L36767 - Aortography and Peripheral Angiography; Effective 10/31/2016; Revised 10/01/2019 16. Novitas LCD L35092 - Diagnostic Abdominal Aortography and Renal Angiography Effective date 10/01/2015; Revised 11/7/2019 17. Annual American Medical Association CPT Manual; Surgery, Cardiovascular; Appendix L Vascular Families "

Therapeutic, Prophylactic & Diagnostic Infusions: Incorrect Coding and Documentation Requirements

Issue Name:Therapeutic, Prophylactic & Diagnostic Infusions: Incorrect Coding and Documentation Requirements
Issue Number: _0161
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/19/2019
Dates Service: Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date.
Description: Documentation will be reviewed to determine if correct billing, coding, and documentation guidelines for Therapeutic, Prophylactic, and Diagnostic Infusions were met.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals 7. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §90.2- Drugs, Biologicals, and Radiopharmaceuticals 8. Annual CPT Manual"

Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements

Issue Name: Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements
Issue Number: _0067
Review Type: Complex
Provider Type: Inpatient Hospital (8), Inpatient Psychiatric Facility (IPF) (15)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/15/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Inpatient hospital services furnished to a patient of an inpatient psychiatric facility will be reviewed to determine that services were medically reasonable and necessary
References: "1. Title XVIII of the Social Security Act (SSA), Section 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. Title XVIII of the Social Security Act (SSA), Section 1814(a)(2)(A) and (4)- Conditions of Limitations on Payment for Services 4. Title XVIII of the Social Security Act (SSA), Section 1835(a)- Procedure for Payment of Claims of Providers of Services 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 42 CFR 409.62- Lifetime Maximum on Inpatient Psychiatric Care 8. 42 CFR 412.404- Conditions for Payment under the Prospective Payment System for Inpatient Hospital Services of Psychiatric Facilities 9. 42 CFR 424.14- Requirements for Inpatient Services of Inpatient Psychiatric Facilities 10. 42 CFR 412.27(c)(3), (4) and (5)- Excluded Psychiatric Units: Additional Requirements 11. 42 CFR 482.61- Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals 12. 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 13. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, section 10.9- Inpatient Psychiatric Facility Services Certification and Recertification 14. Medicare Benefit Policy Manual, Chapter 2- Inpatient Psychiatric Hospital Services, section 20- Admission Requirements; section 30- Medical Records Requirements; section 30.1- Development of Assessment/Diagnostic Data; section 30.2- Psychiatric Evaluation; section 30.2.1- Certification and Recertification Requirements; section 30.2.1.1- Certification; section 30.2.1.2- Recertification; section 30.2.1.3- Delayed/Lapsed Certification and Recertification; section 30.3- Treatment Plan; section 30.3.1- Individualized Treatment or Diagnostic Plan; section 30.3.2- Services Expected to Improve the Condition or for Purpose of Diagnosis; section 30.4 - Recording Progress; section 30.5- Discharge Planning and Discharge Summary 15. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, section 190- Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) 16. American Psychiatric Associations Diagnostic and Statistical Manual, Text Revision, Fourth Edition 17. ICD-10-CM codebook, Chapter 5- Mental Disorders Inpatient Psychiatric Facility PPS FY Addendum A Final PPS Payment Updates "

Denial of the Professional Component for Previously-Denied Facility Claims for Medically Unnecessary Endomyocardial Biopsies and Right Heart Cauterizations Billed as Separate Procedures

Issue Name: Denial of the Professional Component for Previously-Denied Facility Claims for Medically Unnecessary Endomyocardial Biopsies and Right Heart Cauterizations Billed as Separate Procedures
Issue Number: _0168
Review Type: Automated
Provider Type: Physician/Non- physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 9/25/2019
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: When a procedure is performed, there are sometimes two claims submitted for the same code. The facility’s claim for procedure is submitted and the surgeon’s claim for the procedure is also submitted. The documentation for this procedure is the same as is the CPT/ HCPCS code billed. If, after complex review, there is a denial of the procedure code on the facility claim that is upheld, recover the physician claim for that same code automatically.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations §411.15(k)(1), Particular services excluded from coverage (k) Any services that are not reasonable and necessary for one of the following purposes: (1) For the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member 7. 42 Code of Federal Regulations §424.5(a)(6), Basic conditions (a) As a basis for Medicare payment, the following conditions must be met: (6) Sufficient information. The provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 8. CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16 - General Exclusions from Coverage §20- services not reasonable and necessary 9. CMS Pub. 100-08, Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3- Requesting Additional Documentation During Prepayment and Post payment Review"

Outpatient Services within 3 Days Prior to and Including the Date of a Hospital Admission: Unbundling

Issue Name: Outpatient Services within 3 Days Prior to and Including the Date of a Hospital Admission: Unbundling
Issue Number: _0169
Review Type: Automated
Provider Type: Outpatient Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/26/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: All diagnostic (including clinical diagnostic laboratory tests) services and related non-diagnostic services provided to a beneficiary by the admitting hospital within 3 days ( for IPPS Hospitals) prior to or 1 day (NON IPPS Hospitals) prior to including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment. Affected codes: All diagnostic and non-diagnostic CPT/HCSPCS codes ( Diagnostic codes are identified as any CPT/HCPCS code billed with a revenue code listed in Appendix D)
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 3- Outpatient Services Treated as Inpatient Services, §40.3.B- Preadmission Diagnostic Services 7. Medicare Claims Processing Manual, Chapter 3- Outpatient Services Treated as Inpatient Services, §40.3.D- Other Preadmission Services"

Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses within the Reasonable Useful Lifetime: Excessive Units

Issue Name: Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses within the Reasonable Useful Lifetime: Excessive Units
Issue Number: _0167
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 10/1/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Claims for Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses with dates of service within the reasonable useful lifetime of a previously-paid identical Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses (identical HCPCS code), for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met. Affected Codes: L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4631
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, Section 1834(a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment. 3. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 4. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §414.210- General Payment Rules, § (f)(1)- Payment for Replacement of equipment 7. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 110.2 – Repairs, Maintenance, Replacement, and Delivery (C) - Replacement 8. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686: Ankle-Foot/Knee-Ankle-Foot Orthosis; Effective 10/01/2015; Revised 01/01/2020 9. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52457: Ankle-Foot/Knee-Ankle-Foot Orthosis- Policy Article; Effective 10/01/2015; Revised 01/01/2020 10. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020"

Transportation component by portable suppliers for electrocardiogram services: Unbundling

Issue Name: Transportation component by portable suppliers for electrocardiogram services: Unbundling
Issue Number: _0166
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/02/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Carriers do not receive the transportation payment for EKG Services provided by Portable X-ray Suppliers or any other entity. Affected codes: R0070, R0075, 93000, 93005, 93010
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) 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 4) 42 CFR §405.986- Good Cause for Reopening 5) 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 6) Medicare Claims Processing Manual, Chapter 13- Radiological Services and Other Diagnostic Procedures, Section 90.3-Transportation Component (HCPCS Codes R0070 – R0076) "

Positron Emission Tomography for Dementia and Neurodegenerative Diseases: Medical Necessity and Documentation Requirements

Issue Name: Positron Emission Tomography for Dementia and Neurodegenerative Diseases: Medical Necessity and Documentation Requirements
Issue Number: _0165
Review Type: Complex
Provider Type: Outpatient Hospital, Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/24/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date.
Description: Under specific requirements, Medicare covers FDG (fluorodeoxyglucose) Positron Emission Tomography (PET) scans for the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease (AD). Medical records will be reviewed to determine if the utilization of PET scan for the diagnosis or treatment of dementing neurodegenerative diseases is medically necessary according to Medicare coverage indications.
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 Benefit 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 42 CFR §424.5- Basic Conditions, (a)(6)- Sufficient Information 6. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)- Any Services Not Reasonable and Necessary 7. 42 CFR §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 8. National Coverage Determination Manual, Ch. 1, §220.6.13 FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative Diseases 9. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 10. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.1- Billing Instructions, (D)- Post-Payment Review for PET Scans 11. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.12- Coverage for PET Scans for Dementia and Neurodegenerative Diseases 12. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.3.1- Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005 13. Novitas LCA A53134: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions; Effective 10/01/2015; Revised 01/01/2020 14. Noridian LCA A54666: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Revised 01/01/2020 15. Noridian LCA A54668: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Revised 01/01/2020 "

Bilateral Indicator ‘3’: Incorrect Coding

Issue Name: Bilateral Indicator ‘3’: Incorrect Coding
Issue Number: _0164
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region 1
State: 1 - All Region 1 states
Date Approved: 09/23/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: A Bilateral Indicator of "3" indicates the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with either a modifier 50 or modifiers RT and LT, and a ‘2’ in the units field, reimbursement is based on 100% of the Medicare allowed amount for each side less any applicable multiple procedure pricing rules. This query identifies claims with underpayments due to code being submitted with a quantity of "2” when performed bilaterally. Affected codes: Bilateral Indicator ‘3’ codes (indicated in the Medicare Physician Fee Schedule (MPFSDB) – the bilateral indicator field provides the appropriate indicator code for each CPT code)
References: 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 23, Fee Schedule Administration 
and Coding Requirements – Addendum - MPFSDB Record Layouts, File Layout thru 2018
http://www.cms.gov/Regulations-and Guidance/Guidance/Manuals/downloads/clm104c23.pdf 7. Medicare Claims Processing Manual, Chapter 12, §40.7- Claims for Bilateral Surgeries C. 3.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Pass-Through Payment Device: Incorrect Coding

Issue Name: Pass-Through Payment Device: Incorrect Coding
Issue Number: _0156
Review Type: Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/23/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and after December 31, 2017
Description: The outpatient code editor (OCE) has designated specific code pairs for device to procedure edits. The medical record will be reviewed to ensure the device billed on the claim corresponds with the correct procedure and did not bypass an edit inappropriately. In addition, the record will be reviewed to determine the number of units billed are supported in the record for each procedure performed
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.2.3- Comprehensive APCs; §60.1- Categories for Use in Coding Devices Eligible for Transitional Pass-Through Payments Under the Hospital OPPS; §60.4- General Coding and Billing Instructions and Explanations 7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.6.2.4- Coding Determinations 8. American Medical Association (AMA), Current Procedure Terminology, Coding and Payment 9. American Medical Association Healthcare Common Procedure Coding System (HCPCS) 10. APC Payment Book, APC Grouping Logic: Status Indicator H = Pass-Through Devices Separate cost-based pass-through payment; not subject to copayment. 11. ASC Addendum AA Payment Indicator J7 OPPS pass-through device paid separately when provided integral to a surgical procedure on ASC list; payment contractor-priced. 12. Integrated OCE (IOCE) Quarterly Data Files https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/passthrough_payment.html

Ambulance Services Billed During Hospice: Unbundling

Issue Name: Ambulance Services Billed During Hospice: Unbundling
Issue Number: _0163
Review Type: Automated
Provider Type: Ambulance Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/22/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the Informational Letter date.
Description: Ambulance transports of a hospice patient, which are related to the terminal illness and occur after the effective date of election, are the responsibility of the hospice provider. Payment for the ambulance claim will be recouped if the above condition occurs and separate payment was paid to the provider. Affected codes: A0426, A0427, A0428, A0429, A0433, A0434
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. Title XVIII, §1861(dd)(1) of the Social Security Act- Hospice Care; Hospice Program 4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 Code of Federal Regulations (CFR) §418.54(a)- Standard: Initial Assessment 7. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 8. 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 9. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services Under Hospital Insurance, §40.1.9- Other Items and Services 10. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, §50- Billing and Payment for Services Unrelated to Terminal Illness"

Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements

Issue Name: Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements
Issue Number: _0162
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/16/2019
Dates Service: Claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request (complex review).
Description: All diagnostic tests, including Computed Tomography (CT) Coronary Angiography, must be ordered by the physician who is treating the beneficiary, for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician who is treating the beneficiary are not reasonable and necessary. The physician who orders the service must maintain documentation of medical necessity in the beneficiary's medical record. Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, as part of a routine physical checkup are excluded from coverage. Affected codes: CPT 75574 (computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
References: "1. SSA, §1862(a)(1)(A), §1862(a)(7)- Exclusions from Coverage and Medicare as a Secondary Payer 2. SSA, §1833(e) – Payment of benefits 3. 42 CFR §411.15(a)(1) – Particular services excluded from coverage; Routine physical checkups. 4. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations 5. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions. 9. Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations 220- Radiology; 220.1- Computed Tomography (CT) §A- General, and §F- Computed Tomographic Angiography (CTA) 10. 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 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.4.1.3- Diagnosis Code Requirements 12. Current Procedural Terminology (CPT) Manual"

Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases: Medical Necessity and Documentation Requirements

Issue Name: Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases: Medical Necessity and Documentation Requirements
Issue Number: _0160
Review Type: Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center; Professional Services (physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 08/19/2019
Dates Service: Exclude claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Medical documentation will be reviewed to determine if the use of intravenous immune globulin for the treatment of Autoimmune Mucocutaneous Blistering Diseases (AMBDs) meets Medicare coverage criteria and is reasonable and necessary. Affected codes: J1459, J1556, J1557, J1561, J1566, J1568, J1569, J1572
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, Section 13.5.4 Reasonable and Necessary Provisions in LCDs 6. Medicare National Coverage Determinations (NCD) Manual, Part 4- Coverage Determinations, Section 250.3- Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases. Effective upon Implementation of ICD-10 7. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, Section 80.6- Intravenous Immune Globulin 8. CGS Administrators LCD L35891- Intravenous Immune Globulin; Effective 10/01/2015; Revised 09/19/2019 9. First Coast Service Options (FCSO) LCD L34007- Intravenous Immune Globulin; Effective 10/01/2015; Revised 11/28/2019 10. Noridian Healthcare Solutions LCD L34314- Immune Globulin Intravenous (IVIg); Effective 10/01/2015; Revised 02/01/2020 11. Noridian Healthcare Solutions LCD L34074- Immune Globulin Intravenous (IVIg); Effective 10/01/2015; Revised 02/01/2020 12. Novitas LCD L35093- Intravenous Immune Globulin (IVIG); Effective 10/01/2015; Revised 11/14/2019 13. Palmetto GBA L34580- Intravenous Immunoglobulin (IVIG); Effective 10/01/2015; Revised 10/10/2019 14. WPS LCD L34771- Immune Globulins; Effective 10/01/2015; Revised 11/01/2019 15. NGS LCA A52446- Intravenous Immune Globulin IVIG; Effective 10/01/2015; Revised 11/07/2019 16. CGS LCA A56779- Billing and Coding: Intravenous Immune Globulin; Effective 08/01/2019; Revised 09/19/2019 17. FCSO LCA A57778- Billing and Coding: Intravenous Immune Globulin; Effective 10/03/2018 18. Noridian LCA A57187- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 02/01/2020 19. Noridian LCA A54643- Intravenous Immune Globulin: (IVIg) – NCD – 250.3; Effective 11/07/2015; Revised 11/07/2015 20. Noridian LCA A57194- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 02/01/2020 21. Novitas LCA A56786- Billing and Coding: Intravenous Immune Globulin (IVIG); Effective 08/08/2019; Revised 2/13/2020 22. Palmetto LCA A56718- Billing and Coding: Intravenous Immune Globulin (IVIG); Effective 07/25/2019; Revised 01/31/2020 23. WPS LCA A57554- Billing and Coding: Immune Globulins; Effective 11/01/2019 24. 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 "

Outpatient Therapy Services During Home Health: Unbundling

Issue Name: Outpatient Therapy Services During Home Health: Unbundling
Issue Number: _0158
Review Type: Automated
Provider Type: Hospital Outpatient, SNF Outpatient, Outpatient Rehabilitation Facility, Comprehensive Outpatient Rehabilitation Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/11/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x.
References: "1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20- Home Health Prospective Payment System (HH PPS) Consolidated Billing 7. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2.2 - Therapy Editing"

Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements

Issue Name: Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements
Issue Number: _0157
Review Type: Complex
Provider Type: Place of Service 24 with Type of Service “F”
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/26/2019
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date
Description: Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable to both outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifier 73.
References: "1. SSA, Title XVIII – Health Insurance for the Ages and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §414.40 Coding and Ancillary Policies 4. 42 CFR §419.44 Payment Reductions for Procedures 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 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 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions §3.6.2.4- Coding Determinations 9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.5- Discounting; §20.6- Use of Modifiers, §20.6.1- Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4- Use of Modifiers for Discontinued Services 10. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40.4- Payment for Terminated Procedures 11. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §20.3- Use and Acceptance of Healthcare Common Procedural Coding System Codes and Modifiers 12. American Medical Association (AMA), Current Procedural Terminology, Appendix A Modifiers 13. American Hospital Association (AHA) Coding Clinic for Healthcare Common Procedural Coding System 2007, Volume 7, Number 1, Page 1- Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS 14. American Hospital Association (AHA) Coding Clinic for Healthcare Common Procedural Coding System 2008, Volume 8, Number 2, Pages 1-4- Special Issue: Modifiers 52, 73, and 74 15. American Hospital Association (AHA) Coding Clinic for HCPCS 2016, Volume 16, Number 1, Page 12- Appropriate Use of Modifiers for Discontinued Services under the OPPS 16. AMA CPT Assistant, September 2003, Page 3- Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’"

Ophthalmic Diagnostic CPT Codes: Excessive Units

Issue Name: Ophthalmic Diagnostic CPT Codes: Excessive Units
Issue Number: _0159
Review Type: Automated
Provider Type: Professional Services (Physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/17/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Based on CPT Code descriptions, CPT Code 92133 and/or 92134 cannot be reported at the same patient encounter. CPT codes 92133 and/or 92134 will be considered in this edit, if billed together during the same patient encounter, on the same date of service. Only one is allowed per day, therefore the less comprehensive CPT/HCPCS Code - 92134 will be recovered as an overpayment.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 – current (Special Ophthalmological Services) "

Ambulatory Surgical Center Coding Validation

Issue Name: Ambulatory Surgical Center Coding Validation
Issue Number: _0153
Review Type: Complex
Provider Type: ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/26/2019
Dates Service: 3 Years
Description: Ambulatory Surgical Center coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the CPT/HCPCS coding and associated modifiers by reviewing the procedures affecting or potentially affecting payment. Affected codes: Claims with payment indicator A2; G2; J8; P2; R2
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 42 CFR § 414.B Payment for Part B Medical and Other Health Services- Coding and Ancillary Policies 6. 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 7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions §3.6.2.4- Coding Determinations 8. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package 9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; 40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; 40.5- Payment for Multiple Procedures 10. American Medical Association (AMA), Current Procedure Terminology 11. ASC Payment System; Addendum AA; Payment indicators A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight), G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate. ASC Payment rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html 12. National Correct Coding Initiative Policy Manual 13. American Medical Association CPT Assistant 14. American Hospital Association Coding Clinic for HCPCS"

Non-Emergency Ambulance Services- Advanced Life Support and Basic Life Support: Medical Necessity and Documentation Requirements

Issue Name: Non-Emergency Ambulance Services- Advanced Life Support and Basic Life Support: Medical Necessity and Documentation Requirements
Issue Number: _0154
Review Type: Complex
Provider Type: Ambulance
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/20/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: "Medicare pays for nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation are contraindicated (i.e. would endanger the beneficiary). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment. Affected codes: A0426: Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1); A0428: Ambulance service, basic life support, non-emergency transport, (BLS); Secondary code A0425 Ground mileage, per statute mile"
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 1861(s)(7)- Definitions of Services, Institutions, Etc. 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (v)(1)(K)(ii) – Reasonable Cost. 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)- (16)- Establishment of Fee Schedule for Ambulance Services. 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information 9. 42 CFR 410.40- Coverage of ambulance services, (b) Levels of service. 10. 42 CFR 410.40- Coverage of ambulance services, (d) Medical necessity requirements (1) General Rule and (3) Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis. 11. 42 CFR 410.41- Requirements for ambulance suppliers, (c) Billing and reporting requirements. 12. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(1) Any Services not Reasonable and Necessary. 13. 42 CFR 424.36- Signature Requirements 14. 42 CFR 414.605 Definitions 15. 42 CFR 414.610 Basis of Payment 16. 42 CFR 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary. 17. Federal Register 62861; Vol. 84, No. 221; Rules and Regulations Other Provisions of the Proposed Regulations A. Changes to the Ambulance Physician Certification Statement Requirement 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 19. Medicare Program Integrity Manual; Chapter 3 - Verifying Potential Errors and Taking Corrective Actions; §3.3.2.4 - Signature Requirements; G. Additional Signature Requirements for Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) and Ambulance Certification Statements; 2. Ambulance Certification Statement Signature Requirements 20. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services 21. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30- General Billing Guidelines, (A)- Modifiers Specific to Ambulance Service Claims and (B)- HCPCS Codes 22. Novitas LCD L35162, Ambulance Services (Ground Ambulance), Effective Date 10/01/2015, Revised 11/14/2019 23. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015. 24. FCSO, LCD L33383, Non-Emergency Ground Ambulance Services. Effective Date 10/1/2015. Retirement Date 6/28/2018. 25. FCSO, LCD L37697, Emergency and Non-Emergency Ground Ambulance Services, Effective Date 6/28/2018, Revised 02/19/2019"

Mohs Micrographic Surgery: Incorrect Coding and Incorrect Units Billed

Issue Name: Mohs Micrographic Surgery: Incorrect Coding and Incorrect Units Billed
Issue Number: _0150
Review Type: Complex
Provider Type: Physicians and Non-Physician Practitioners
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/30/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Mohs Micrographic Surgery is a two-step process in which: 1) The tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s); and 2) Additional excision and evaluation is performed until all margins are clear. This review will verify that the physician who performing the Mohs surgery is acting as both surgeon and pathologist. Codes 17311 and 17313 are used for the first layer (stage) only and include the work of excision and pathology of up to five tissue blocks. These codes are not targeted as it is assumed all patients will have first stage but may be used to validate that the physician is acting as both surgeon and pathologist. Reviewers will determine if the correct number of units have been billed for additional Mohs micrographic technique staging unit(s) for HCPCS 17312 and 17314.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 6. AHA Coding Clinic for HCPCS, Third Quarter 2013, Volume 13, Number 3, Page 1 Reporting MOHS micrographic surgery (MMS) 7. CPT Assistant, October 2014, Volume 24, Issue 10, Page 14 Frequently Asked Questions, Mohs Surgery, Tissue Block 8. CPT Assistant, November 2006, Volume 16, Issue 11, Pages 1-7 Mohs Micrographic Surgery 9. CPT Assistant, February 2014, Volume 24, Issue 2, Page 10 Coding Clarification: Mohs Surgery"

Physician/Non-Physician Practitioner Coding Validation

Issue Name: Physician/Non-Physician Practitioner Coding Validation
Issue Number: _0151
Review Type: Complex
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/23/2019
Dates Service: "Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date."
Description: The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Documentation will be reviewed to determine if professional services that affecting MPGS payment meet Medicare coverage criteria and applicable coding guidelines. Affected Codes: CMS MPFS status code “A”
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 42 CFR §414- Payment for Part B Medical and other Health Services, Subpart A – General Provisions, Subpart B – Physicians and other Practitioners, Subpart E – Determination of Reasonable Charges under ESRD Program 6. 42 CFR §414.40- Coding and Ancillary Policies 7. 42 CFR §415- Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings 8. 42 CFR §419.44- Payment Reductions for Procedures 9. Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners 10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.6.2.4- Coding Determinations 13. American Medical Association (AMA), Current Procedural Terminology (CPT) 14. American Medical Association, Healthcare Common Procedure Coding System Level II 15. American Medical Association Current Procedural Terminology Assistant 16. National Correct Coding Initiatives (NCCI) Policy Manual 17. 1995 & 1997 Documentation Guidelines for Evaluation & Management Services 18. CMS Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files" 19. American Hospital Association (AMA) Coding Clinic

Medical Necessity and Coding of Chest X-Rays

Issue Name: Medical Necessity and Coding of Chest X-Rays
Issue Number: _0136
Review Type: Complex
Provider Type: Outpatient hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/25/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR.
Description: Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. This review will ensure chest x-rays are paid when billed appropriately and only when medically necessary.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 CFR §411.15(a)(1) – Particular services excluded from coverage, (a) Routine physical checkups (1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening 7. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations 8. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §§80.4-80.4.4- Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions. 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.4.1.3- Diagnosis Code Requirements 13. Current Procedural Terminology Manual "

Subsequent Hospital Visit and Discharge Day Management on the Same Day: Unbundling

Issue Name: Subsequent Hospital Visit and Discharge Day Management on the Same Day: Unbundling
Issue Number: _0149
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/18/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: Per Medicare Claims Processing Manual Chapter 12, Section 30.6.9.2 (C), CMS does not reimburse both a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. CPT codes 99231 – 99233 will be considered overpayments and will be recovered. Affected Codes: 99231, 99232. 99233; anchor codes 99238, 99239
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual; Publication 100-04; Chapter 12, Section 30.6.9.2 (C) Subsequent Hospital Visit and Discharge Management on Same Day"

Ambulatory Surgical Center Services During a Covered Part A Skilled Nursing Facility Stay: Unbundling

Issue Name: Ambulatory Surgical Center Services During a Covered Part A Skilled Nursing Facility Stay: Unbundling
Issue Number: _0142
Review Type: Automated
Provider Type: "Ambulatory Surgery Center (ASC) SNF"
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/01/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description:Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates for the years 2016, 2017, 2018, 2019 and 2020 are overpayments and will be recovered. Affected codes: All eligible codes based on the Annual SNF Consolidated Billing Part A MAC Updates in Appendix D for the years 2016, 2017, 2018, 2019 and 2020.
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- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3) 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 4) 42 CFR §405.986- Good Cause for Reopening 5) 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 6) Medicare Claims Processing Manual, Chapter 6- Inpatient Part A Billing and SNF Consolidated Billing, § 20.1.2- Other Excluded Services Beyond the Scope of a SNF Part A Benefit https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 7) Medicare Claims Processing Manual, Chapter 6- Inpatient Part A Billing and SNF Consolidated Billing, § 110.2.7- Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c06.pdf 8) Office of Inspector General (OIG) Report: Payments for Ambulatory Surgical Center Services Provided to Beneficiaries in Skilled Nursing Facility Stays Covered Under Medicare Part A in Calendar Years 2006 through 2008 (A-01-0900521) December 2010 https://oig.hhs.gov/oas/reports/region1/10900521.pdf 9) SNF Consolidated Billing – Annual Updates for Part A MAC – 2016, 2017, 2018, 2019 and 2020 https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-A-MAC-Update
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2017-Part-A-MAC-Update
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-A-MAC-Update
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2019-Part-A-MAC-Update
https://www.cms.gov/medicare/snf-consolidated-billing/2020-part-mac-update 10) SNF Consolidated Billing – General Explanation of the Major Categories for Skilled Nursing Facility – https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2016-General-Explanations.pdf
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2018-General-Explanation.pdf
https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2019-General-Explanation.pdf
https://www.cms.gov/files/document/general-explanation-major-categories-snf-cb.pdf"

Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity, Unbundling, and Documentation Requirements

Issue Name: Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity, Unbundling, and Documentation Requirements
Issue Number: _0145
Review Type: Complex
Provider Type: Outpatient Hospital, Professional Services, and Ambulatory Surgical Centers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/31/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Exclude claims with a DOS prior to 10/1/2015.
Description:Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity, Unbundling, and Documentation Requirements
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. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. 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 6. CGS LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 09/26/2019 7. First Coast LCD L33762- Treatment of Varicose Veins of the Lower Extremity; Effective 10/1/2015; Revised 11/27/2019 8. NGS LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 11/21/2019 9. Noridian LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 12/1/2019 10. Noridian LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 12/1/2019 11. Novitas LCD L34924- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 10/1/2015, Revised 11/14/2019 12. Palmetto LCD L33454- Varicose Veins of the Lower Extremities; Effective 10/1/2015, Revised 4/22/2019; Retired 3/10/2020 13. WPS LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 11/01/2019 14. First Coast LCA A55963- Treatment of Varicose Veins of the Lower Extremity- revision to the Part A/B LCD; Effective 4/17/2018 15. First Coast LCA A56064- Treatment of Varicose Veins of the Lower Extremity- revision to the Part A/B LCD; Effective 7/10/2018 16. First Coast LCA A57781- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 10/03/2018 17. NGS LCA A52870- Varicose Veins of the Lower Extremity, Treatment of- Supplemental Instructions Article; Effective 10/1/2015; Revised 11/21/2019 18. Novitas A55229- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 8/11/2016; Revised 11/14/2019"

Medical Necessity Pulmonary Rehabilitation

Issue Name: Medical Necessity Pulmonary Rehabilitation
Issue Number: _0140
Review Type: Complex
Provider Type: Hospital Outpatient and Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/27/2019
Dates Service: Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date
Description:Pulmonary rehabilitation is a physician-supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Medical Documentation will be reviewed to determine if pulmonary rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria. Affected code: G0424
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) §§1861 (s)(2)(CC), (fff)- Medical and Other Health Services- Pulmonary Rehabilitation Program 4. 42 Code of Federal Regulations § 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage 5. 42 Code of Federal Regulations §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 6. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 7. 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 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010. 9. Medicare Claim Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4- Pulmonary Rehabilitation Program Services Furnished On or After January 1, 2010. 10. Noridian LCA A52770 Pulmonary Rehabilitation Services; Effective 10/01/2015; Revised 10/08/2018 11. Noridian LCA A56152 Pulmonary Rehabilitation Services; Effective 10/08/2018"

Magnetic Resonance Imaging Procedures: Excessive Units

Issue Name: Magnetic Resonance Imaging Procedures: Excessive Units
Issue Number: _0147
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner), Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/27/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: When a more extensive MRI is performed on the same site as a less extensive MRI, the less extensive MRI is bundled into the more extensive MRI. Affected codes: See 0147 Appendix D
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. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12 -Physicians/Non-physician Practitioners, Sections 30 – Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures (Effective 10/1/03) 7. Medicare Claims Processing Manual; Chapter 23 – Fee Schedule Administration and Coding Requirements, § 20.9.2 Limiting Charge and CCI Edits 8. NCCI Policy Manual for Medicare Services, Chapter 1- General Correct Coding Policies, Section A- Introduction 9. CPT Manual year 2015 to current"

Computed Tomography Scans: Excessive Units

Issue Name: Computed Tomography Scans: Excessive Units
Issue Number: _0146
Review Type: Automated
Provider Type: All Provider Specialties
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/26/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter Date (automated review)
Description: When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan. Affected codes: 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 74176, 74177, 74178, 74261, 74262
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. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12 -Physicians/Non-physician Practitioners, Section 30- Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures (Effective 10/1/03) 7. NCCI Policy Manual for Medicare Services, Chapter 1- General Correct Coding Policies, Section A- Introduction 8. CPT Manual year 2015 to current "

Cardiac Rehabilitation: Medical Necessity and Documentation Requirements

Issue Name: Cardiac Rehabilitation: Medical Necessity and Documentation Requirements
Issue Number: _0135
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/07/2019
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Cardiac rehabilitation (CR) is a physician-supervised program that furnishes physician prescribed exercise, cardiac risk factor modification, psychosocial assessment, and outcome assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meeting federal guidelines and Medicare coverage criteria. Affected codes: 93797, 93798, G0422, G0423
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 1861(s)(2)(CC), (DD)- Cardiac Rehabilitation Program, Intensive Cardiac Rehabilitation Program 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(eee)(1), (4)(A)- Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation Program 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. 42 CFR §410.49 – Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage 8. 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 9. Medicare National Coverage Determinations (NCD), Part 1 - Coverage Determinations, § 20.10.1 - Cardiac Rehabilitation Programs for Chronic Heart Failure; §20.31 - Intensive Cardiac Rehabilitation (ICR) Programs; §20.31.1 - Pritikin Program; §20.31.2 - Ornish Program for Reversing Heart Disease; §20.31.3 – Benson-Henry Institute Cardiac Wellness Program 10. Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, §232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010 11. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §§140- 140.3- Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs 12. Palmetto LCD L34412- Cardiac Rehabilitation, Effective 10/01/2015; Retired 4/5/2019 13. Noridian LCA A54068- Outpatient Cardiac Rehabilitation, Effective 10/01/2015; Revised 10/01/2019 14. Noridian LCA A54070- Outpatient Cardiac Rehabilitation, Effective 10/01/2015; Revised 10/01/2019 15. Palmetto LCA A53775- Billing and Coding: Frequency and Duration for Cardiac Rehabilitation and Intensive Cardiac Rehabilitation, Effective 10/01/2015; Revised 4/5/2019

Skilled Nursing Facility Consolidated Billing for Therapies: Unbundling

Issue Name: Skilled Nursing Facility Consolidated Billing for Therapies: Unbundling
Issue Number: _0138
Review Type: Automated
Provider Type: Physician/non-physician practitioner, Physical Therapist, Occupational Therapist, Speech-language Pathologist
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Physical therapy, speech-language pathology services, and occupational therapy are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement for services furnished to SNF Part B residents. Affected codes: Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing tables (See Appendix D in downloadable file for a detailed list of CPT/HCPCS including descriptions).
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §10.3- Types of Services Subject to the Consolidated Billing Requirement for SNF, §20.5- Therapy Services 7. Medicare Claims Processing Manual, Chapter 7- SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §110- Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay 8. Medicare SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling

Subsequent Hospital and Nursing Facility Care Services: Excessive Units

Issue Name: Subsequent Hospital and Nursing Facility Care Services: Excessive Units
Issue Number: _0125
Review Type: Automated
Provider Type: Professional Services and CAHs type of bill 85x identified by revenue codes 96x, 97x or 98x
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/21/2019
Dates Service: Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review).
Description: Medicare reimbursement for telehealth services include subsequent hospital care services and subsequent nursing facility care services. However, subsequent hospital care visits are limited to one telehealth visit every three days for hospital inpatients and one subsequent nursing facility telehealth visit every 30 days for nursing facility resident/for the same provider based on same Provider Tax Identification Number (TIN) and Provider Specialty Code.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.3.5 – Payment for Subsequent Hospital Care Services and Subsequent Nursing Facility Care Services as Telehealth Services 7. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.3 - List of Medicare Telehealth Services 8. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.2 - Eligibility Criteria 9. Medicare Claims Processing Manual: Publication 100-04; Chapter 12; Section 190.3.1 - Telehealth Consultation Services, Emergency Department or Initial Inpatient versus Inpatient Evaluation and Management (E/M) Visits 10. Medicare Claims Processing Manual Chapter 12- Physician/ Nonphysician Practitioners, §190.6 - Payment Methodology for Physician/Practitioner at the Distant Site "

Vertebroplasty or Kyphoplasty: Medical Necessity and Documentation Requirements

Issue Name: Vertebroplasty or Kyphoplasty: Medical Necessity and Documentation Requirements
Issue Number: _0139
Review Type: Complex
Provider Type: Hospital Outpatient; Ambulatory Surgery Center (ASC); Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/19/2019
Dates Service: Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date and on/or after 10/01/2015
Description: Medical documentation will be reviewed for correct coding and to determine if vertebroplasty was medically necessary. Affected codes: 22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327 see Appendix D in downloadable xls file
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- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules 3. 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 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(10) 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. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage, §10- General Exclusions from Coverage 10. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16- General Exclusions From Coverage, §20- Services Not Reasonable and Necessary 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. First Coast Service Options (FCSO) Local Coverage Determination (LCD) L34976 Vertebroplasty, Vertebral Augmentation; Percutaneous, Effective 10/01/2015; Revised 01/22/2019 13. Novitas LCD L35130 Vertebroplasty, Vertebral Augmentation (Kyphoplasty) Percutaneous, Effective 10/01/2015; Revised 04/25/2019 14. Palmetto LCD L33473 Vertebroplasty/Kyphoplasty, Effective 10/01/2015; Revised 08/08/2019 15. WPS LCD L34592 Vertebroplasty (Percutaneous) and Vertebral Augmentation including cavity creation, Effective 10/01/2015; Revised 11/01/2018. 16. NGS LCD L33569 Vertebroplasty and Vertebral Augmentation (Percutaneous), Effective 10/01/2015 17. Noridian LCD L34106 Percutaneous Vertebral Augmentation, Effective 10/01/2015 18. Noridian LCD L34228, Percutaneous Vertebral Augmentation, Effective 10/01/2015 19. CGS LCD L34048 Vertebroplasty and Vertebral Augmentation (Percutaneous), Effective 10/01/2015, Revised 08/15/2019 20. Palmetto GBA LCA A56819 Billing and Coding: Vertebroplasty/Kyphoplasty, Effective 8/8/2019 21. Annual American Medical Association: CPT Manual. "

Panniculectomy: Medical Necessity and Documentation Requirements

Issue Name: Panniculectomy: Medical Necessity and Documentation Requirements
Issue Number: _0130
Review Type: Complex
Provider Type: Hospital Outpatient; ASC; Professional Services (physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/12/2019
Dates Service: Include claims that have a “claim paid date” which is less than 3 years prior to the ADR date.
Description: Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if is incidental to another procedure, is not separately coded per Coding Guidelines. Affected codes: 15830, 15847
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. Title XVIII of the Social Security Act (SSA): 1862(a)(10) 4. 42 CFR §411.15 Particular services excluded from coverage, (k)(1) 5. 42 CFR §424.5 Basic conditions, (a)(6) Sufficient information 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests 9. Medicare Benefit Policy Manual, Ch. 16- General Exclusion from Coverage, §10- General Exclusions from Coverage, §20- Services Not Reasonable and Necessary 10. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §120 – Cosmetic Surgery 11. Medicare Claims Processing Manual, Ch. 12 Physicians/Nonphysician Practitioners, §40.6 Claims for Multiple Surgeries (A) General 12. National Correct Coding Initiative Policy Manual, Ch. 6 Surgery: Digestive System CPT Codes 40000 - 49999, E Abdominal Procedures, 7, Revised 1/1/2017 13. National Correct Coding Initiative Policy Manual, Ch. 6 Surgery: Digestive System CPT Codes 40000 - 49999, E Abdominal Procedures, 8, Revised 1/1/2018 14. National Correct Coding Initiative Policy Manual, Ch. 6 Surgery: Digestive System CPT Codes 40000 - 49999, E Abdominal Procedures, 8, Revised 1/1/2019 15. National Correct Coding Initiative Policy Manual, Ch. 1 General Correct Coding Policies, E Modifiers and Modifier Indicators, Revised 1/1/2019 16. Noridian (JE) LCD L35163: Plastic Surgery, Effective 10/1/2015; Revised 10/01/2019 17. Noridian (JF) LCD L37020: Plastic Surgery, Effective 10/10/2017; Revised 10/01/2019 18. Novitas LCD L35090: Cosmetic and Reconstructive Surgery, Effective 10/1/2015; Revised 11/07/2019 19. Palmetto GBA L33428: Cosmetic and Reconstructive Surgery, Effective 10/01/2015; Revised 10/24/2019 20. WPS L34698: Cosmetic and Reconstructive Surgery, Effective 10/01/2015; Revised 10/31/2019 21. Noridian (JE) LCA A57221: Billing and Coding: Plastic Surgery, Effective 10/01/2019 22. Noridian (JF) LCA A57222: Billing and Coding: Plastic Surgery, Effective 10/01/2019 23. Novitas LCA A56587: Billing and Coding: Cosmetic and Reconstructive Surgery, Effective 5/30/2019; Revised 01/01/2020 24. Palmetto GBA A56658: Billing and Coding: Cosmetic and Reconstructive Surgery, Effective 07/04/2019; Revised 10/24/2019 25. WPS A57475: Billing and Coding: Cosmetic and Reconstructive Surgery, Effective 10/31/2019; Revised 2/27/2020 26. Annual American Medical Association: CPT Manual "

Evaluation and Management (E/M) Same Day as Admission to a Nursing Facility

Issue Name: Evaluation and Management Same Day as Admission to a Nursing Facility: Unbundling
Issue Number: _0132
Review Type: Automated
Provider Type: Physician/ Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
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: CMS will not pay for an emergency department visit or an office visit E&M service on the same day as a comprehensive nursing facility assessment when both the E&M service and the comprehensive nursing facility assessment are performed by the same physician, at a site other than the nursing facility. The E&M service is bundled into the comprehensive nursing facility assessment code. The E&M service is not separately payable. Affected codes: CPT 99201 -99215, 99281 – 99285 (Please refer to Appendix D for complete CPT code descriptors)
References: 11. 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: Chapter 12 - Physicians/Nonphysician Practitioners, §30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215), (C) Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility Medicare Claims Processing Manual: Publication 100-04; Chapter 12 Physicians/Nonphysician Practitioners, §30.6.11 Emergency Department Visits (Codes 99281 - 99288), (D) Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission 7. Medicare Claims Processing Manual: Chapter 12 -Physicians/Nonphysician Practitioners, §30.6.13 Nursing Facility Services, (A) Visits to Perform the Initial Comprehensive Assessment and Annual Assessments

Cryosurgery of the Prostate Medical Necessity

Issue Name: Cryosurgery of the Prostate: Medical Necessity and Documentation Requirements
Issue Number: _0134
Review Type: Complex
Provider Type: Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/14/2019
Dates Service: Exclude claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Claims for Cryosurgery of the Prostate are deemed to be medically necessary for the indications listed in the Centers for Medicare and Medicaid National Coverage Determination Manual (Publication 100-03, Part 4, §230.9). Documentation will be reviewed to determine whether Cryosurgery of the Prostate Gland services met Medicare coverage criteria and were reasonable and necessary. Affected codes: 55873 - Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)
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. Medicare Claims Processing Manual, Chapter 32 Billing Requirements for Special Services, §180 Cryosurgery of the Prostate Gland 4. 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 5. 42 CFR §405.986 Good Cause for Reopening 6. 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 7. Medicare National Coverage Determinations Manual (NCD), Chapter 1 Coverage Determinations, Part 4 (Sections 200-310.1), §230.9 Cryosurgery of Prostate

Positron Emission Tomography Scans Paid without Tracer Codes- Independent Diagnostic Testing Facility: Non-Allowable Service

Issue Name: Positron Emission Tomography Scans Paid without Tracer Codes- Independent Diagnostic Testing Facility: Non-Allowable Service
Issue Number: _0133
Review Type: Automated
Provider Type: IDTF (Independent Diagnostic Testing Facility), Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/30/2019
Dates Service: Claims that have a “claim paid date” on or after 01/01/18
Description: "All PET Scans require the use of radiopharmaceutical diagnostic imaging agent (tracer). Affected codes: PET SCAN CPT Codes - 78491, 78492, 78459, 78608, 78811, 78812, 78813, 78814, 78815, 78816 and temporary codes effective 1/1/2018 A9587 and A9598 Tracer Codes – A9515, A9526, A9552, A9555, A9580, A9586, A9587, and A9588"
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 13, § 60.3.1 – Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005 7. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 13, § 60.3.2 – Tracer Codes Required for Positron Emission Tomography (PET Scans); effective 01-01-18 8. CMS Manual System – Transmittal 3911; Change Request 10319 – Subject: New Positron Emission Tomography (PET) Radiopharmaceutical/Tracer Unclassified Codes; effective 01-01-18"

Hyperbaric Oxygen Therapy (HBOT) For Diabetic Wounds

Issue Name: Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements
Issue Number: _0129
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/29/2019
Dates Service:Exclude from review claims having a “paid claim date” which is more than 3 years prior to ADR letter date
Description: For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere pressure. The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Medical records will be reviewed to determine if Hyperbaric Oxygen Therapy (HBOT) is medically necessary according to Medicare coverage indications. Affected code: G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations §424.5- Basic Conditions, (a)(6)- Sufficient Information 7. 42 Code of Federal Regulations §411.15- Particular Services Excluded from Coverage, (k)- Any Services not Reasonable and Necessary, (1) 8. CMS National Coverage Determination Manual, Ch.1 Coverage determination, §20.29 Hyperbaric Oxygen Therapy, Effective 4/03/2017; Implemented 12/18/2017 9. Novitas LCD L35021- Hyperbaric Oxygen (HBO) Therapy; Effective 10/01/2015; Revised 01/01/2020 10. Annual American Medical Association CPT Manual, Coding Guidelines

Part B Therapies during Inpatient: Unbundling

Issue Name: Part B Therapies during Inpatient: Unbundling
Issue Number: _0124
Review Type: Automated
Provider Type: Physical Therapist, Occupational Therapist, Speech language Therapist
Region: Region-1
State: 1 - All A/B MACs
Date Approved: 11/29/2018
Dates Service: Claims having a "claim paid date" which is less than 3 years prior to the informational letter date (automated review).
Description: "HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist or speech language therapist in private practice. Affected Codes: HCPCS/CPT Codes with a PC/TC Indicator of ""7"" in the MPFSDB (See Appendix D for complete list of HCPCS/CPT code and descriptions)"
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23, Addendum-MPFSDB File, Layouts, 2001-2018 File Layout "

Destruction of Premalignant Lesions: Excessive Units

Issue Name: Destruction of Premalignant Lesions: Excessive Units
Issue Number: _0121
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/03/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review).
Description: Based on CPT Code descriptions, CPT Code 17000 may only be billed once per date of service; CPT Code 17003 may only be billed thirteen times per date of service and CPT Code 17004 may only be billed once per date of service. Affected codes: 17000, 17003 and/or 17004
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current (Destruction, Benign or Premalignant Lesions)

Technical Component of Diagnostic Procedures during Inpatient: Unbundling

Issue Name: Technical Component of Diagnostic Procedures during Inpatient: Unbundling
Issue Number: _0123
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner Independent Diagnostic Testing Facility (IDTF)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 12/10/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date (automated reivew)
Description: When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay. Affected codes: CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Layouts, 2011-2018 File Layout 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 23 Fee Schedule Administration and Coding Requirements, §30 Services Paid Under the Medicare Physician’s Fee Schedule 7. Medicare Benefit Policy Manual: CMS Publication 100-02; Chapter 15 Covered Medical and Other Health Services, §30.1 Provider-Based Physician Services"

Endoscopy Procedures: Diagnostic and Surgical Billed Same Day

Issue Name: Endoscopy Procedures: Diagnostic and Surgical Billed Same Day
Issue Number: _0126
Review Type: Automated
Provider Type: Outpatient Facility; ASC; Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/27/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported. Affected codes: 45378, 45330 - (See Appendix D for a detail description of affected codes)
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §30- Correct Coding Policy, (E)- Separate Procedures, (G)- Family of Codes, and (H)- Most Extensive Procedures 6. AMA CPT Manual Endoscopy Section; 2015 to current 7. National Correct Coding Initiative Policy Manual for Medicare Services, Chapter VI – Digestive System CPT Codes 4000 - 4999, §C – Endoscopic Services"

Outpatient Hospice Related Services: Unbundling

Issue Name: Outpatient Hospice Related Services: Unbundling
Issue Number: _0122
Review Type: Automated
Provider Type: Part A Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/28/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(dd)(1) Hospice Care; Hospice Program 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. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §418- Hospice Care 7. CMS Claims Processing Manual, Chapter 11- Processing Hospice Claims, §10- Overview, §40.2- Processing Professional Claims for Hospice Beneficiaries, §50- Billing and Payment for Services Unrelated to Terminal Illness 8. CMS Benefit Policy Manual 100-02, Chapter 9- Coverage of Hospice Services under Hospital Insurance, §10- Requirements, General"

Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month

Issue Name: Monthly Capitation Payment for End-Stage Renal Disease: 4 or More Visits per Month
Issue Number: _0112
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/12/2018
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review).
Description: A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. Affected codes: 990957, 90958, 90959, 90960, 90961, 90962
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §140- Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis; §140.1- Payment for ESRD-Related Services Under the Monthly Capitation Payment (Center Based Patients); and §140.4- Controlling Claims Paid Under the Monthly Capitation Payment Method 7. American Medical Association (AMA), Current Procedural Terminology 2015 to current"

Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding

Issue Name: Modifier 57 for Procedure with a 0-Day or 10-Day Global Indicator: Incorrect Coding
Issue Number: _0120
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 11/02/2018
Dates Service: Exclude claims that have a “claim paid date” which is more than 3 years prior to the Informational Findings Letter (IFL) date (automated review)
Description: Carriers may not pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period. E&M Codes Included in the Global Package billed with Modifier 57 will be recovered as overpayments as they are not allowed for surgical procedures with a 0 or 10 global surgical period. Applicable CPT codes within the 92012-99375 range
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physician/ Non Physician Practitioner, § 30.6.6.C- Payment for Evaluation and Management Services Provided During Global Period of Surgery, CPT modifier ‘57’ – Decision for Surgery Made Within Global Surgical Period"

Arthroscopic Extensive Shoulder Debridement: Incorrect Coding

Issue Name: Arthroscopic Extensive Shoulder Debridement: Incorrect Coding
Issue Number: _0118
Review Type: Automated
Provider Type: Physician/Non- physician Practitioner (NPP); Outpatient Hospital (For claims prior to 10/01/2017. After 10/01/2017, denial of 29823 made no change in APC.)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Shoulder arthroscopy procedures include extensive debridement (e.g., CPT code 29823) even if the extensive debridement is performed in a different area of the same shoulder. If another arthroscopy procedure is billed and paid for the same day, on the same shoulder, for the same beneficiary, on the same date of service, the extensive debridement (code 29823) is not separately payable and CPT code 29823 will be denied. Separate reporting of extensive debridement only applies to three CPT codes: 29824, 29827, and 29828. Affected codes: When CPT code 29823 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29822 and/or 29825 for the same date of service, for the same beneficiary, for the same shoulder, if the provider or facility was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29822, and/or 29825, then 29823 will be denied.
References: "1. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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. 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 4. 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 5. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 6. 42 Code of Federal Regulations §§411.15(k)(1)- Particular Services Excluded from Coverage, 424.5(a)(6)- Basic Conditions 7. Internet Only Manual, CMS Pub. 100-02 Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage §20 –Services Not Reasonable and Necessary. 8. National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014- current 9. AMA CPT Codebook "

Automated Arthroscopic Limited Debridement

Issue Name: Automated Arthroscopic Limited Debridement
Issue Number: _0117
Review Type: Automated
Provider Type: Physician/Non- physician Practitioner (NPP); Outpatient (Outpatient for claims prior to 10/01/2017. After 10/01/2017, denial of 29822 made no change in APC). It is for all physician/ nonphysician in the usual time frame but in Outpatient facility, it must be restricted to claims rendered prior to 10/1/2017 due to change from T (multiple surg payment) to J1 (APC payment).
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822). Code 29822, is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same beneficiary at the same encounter. Affected codes: When CPT code 29822 is billed and paid with one or more of the following CPT codes: 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828 for the same date of service, for the same beneficiary, for the same shoulder, at the same encounter, if the provider was paid for CPT codes 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, and/or 29828, then 29822 will be denied.
References: 1. A, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §411.15(k)(1)- Particular services excluded from coverage 7. 42 CFR §424.5(a)(6)- Basic conditions- Sufficient information 8. Medicare Benefit Policy Manual, Chapter 16- General Exclusions from Coverage, §20- Services Not Reasonable and Necessary 9. National Correct Coding Initiative Policy Manual, Chapter 4- Surgery: Musculoskeletal System CPT Codes 20000-29999, E, “Arthroscopy”- Effective January 1, 2014- current

Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered

Issue Name: Physician Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered
Issue Number: _0115
Review Type: Automated
Provider Type: Physician Claims
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/16/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Home Visits for physician services should not overlap an active Inpatient Stay. Physician claims billed with a home-related place of service that overlaps an inpatient hospital stay will be denied. See appendix D
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2(B)- Exact Duplicate Claims, Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers) 7. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, §10.5- Place of Service Codes and Definitions 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30- Physician Services"

Modifiers TC and 26: Incorrect Coding

Issue Name: Modifiers TC and 26: Incorrect Coding
Issue Number: _0116
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review)
Description: HCPCS Codes with a PC/TC Indicator of "1" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed. Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied. Findings will be the difference between the original Provider Paid Amount and the Re-Calculated Provider Paid Amount. Affected codes: HCPCS Codes with a PC/TC Indicator of "1" as identified in the CMS MPFSDB.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 23; Addendum - MPFSDB Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c23.pdf

Transthoracic Echocardiography: Medical Necessity and Documentation Requirements

Issue Name: Transthoracic Echocardiography: Medical Necessity and Documentation Requirements
Issue Number: _0111
Review Type: Complex
Provider Type: Inpatient Hospital, Outpatient Hospital, SNF
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: For Palmetto LCD specific questions- Claims billed on or after 9/18/2017
Description: "Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary. Affected codes: 93303, 93304, 93306, 93307, 93308 C8921, C8922, C8923, C8924"
References: "1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A); (a)(7)- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations §405.980 - Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations §405.986 - Good Cause for Reopening 5. 42 Code of Federal Regulations §410.32(a) - Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions 6. 42 Code of Federal Regulations §411.15(k)(1) - Particular Services Excluded from Coverage 7. 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 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests 9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.4- Cardiovascular System (Codes 92950- 93799) 10. CGS LCD L34338- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 9/26/2019 11. First Coast LCD L33768- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019 12. NGS LCD L33577- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019 13. Palmetto LCD L37379- Echocardiography; Effective 9/18/2017; Revised 10/10/2019 14. CGS LCA A57306- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 9/26/2019; Revised 10/01/2019 15. First Coast LCA A57182- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 10/03/2018; Revised 4/9/2020 16. NGS LCA A56781- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 8/01/2019; Revised 3/19/2020 17. American Medical Association (AMA), Current Procedural Terminology Manual, Coding Guidelines "

Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements

Issue Name: Inpatient Rehabilitation Facility Stays: Medical Necessity and Documentation Requirements
Issue Number: _0073
Review Type: Complex
Provider Type: Inpatient Rehabilitation Facility, Inpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/12/2018
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Informational Letter date will be excluded.
Description: Inpatient hospital services furnished to a patient in an inpatient rehabilitation facility will be reviewed to determine that services were medically reasonable and necessary
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. 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 4. 42 CFR 405.986- Good Cause for Reopening 5. 42 CFR 412.604(c)- Completion of patient assessment instrument 6. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system 7. 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, and (5)- Interdisciplinary Team Approach to Care 8. Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.3- Documentation Requirements for Therapy Services 10. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements"

Skilled Nursing Facility Consolidated Billing: Part B – Use of Modifier 26, Professional Component

Issue Name: Skilled Nursing Facility Consolidated Billing: Part B – Use of Modifier 26, Professional Component
Issue Number: _0110
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. And Informational Letter date after January 1, 2016.
Description: When a Part B CPT/HCPCS code listed on File 2 (Professional Components of Services to be Submitted with a 26 Modifier) is billed during a paid inpatient Part A SNF stay, without modifier 26, the Part B claim will be repriced with modifier 26 to reflect the professional component reduction. The overpayment is identified by the difference between the original paid Part B amount and the re-calculated paid amount based on modifier 26 pricing.CPT/HCPCS codes listed on the CMS File 2 - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier. (https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation.html)
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement 7. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation https://www.cms.gov/medicare/snf-consolidated-billing/2020-part-b-mac-update

Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full

Issue Name: Skilled Nursing Facility (SNF) Consolidated Billing Part B - Full
Issue Number: _0109
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review) and Prior to Claims paid date of January 1, 2020.
Description: Payment for the majority of Skilled Nursing Facility (SNF) services provided to beneficiaries in a Medicare covered Part A stay are included in a bundled prospective payment made through the fiscal intermediary (FI) A/B Medicare Admin. Contractor (MAC) to the SNF. These bundled services are to be billed by the SNF to the FI A/B MAC in a consolidated bill. The consolidated billing requirements confers on the SNF the billing responsibility for the entire package of care that residents receive during a covered Part A SNF stay. Affected Codes: All CPT/HCPCS codes Excluding those service codes listed in 109 Appendix D of the downloadable Excel file.
References: "1. Title XVIII, §§1833(d) and (e) of the Social Security Act- Payment of Benefits 2. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 6. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement 7. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-B-MAC-Update.html"

Facility vs Non Facility Reimbursement: Incorrect Coding

Issue Name: Facility vs Non Facility Reimbursement: Incorrect Coding
Issue Number: _0108
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/14/2018
Dates Service: Time Period Being Reviewed (look-back period) Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
Description: Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings. The rate, facility or nonfacility, which a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or nonfacility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. Download Excel file for affected POS code list in _0108 Appendix D
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual Chapter 12- Physician/Non-Physician Practitioners, §20.4.2- - Site of Service Payment Differential

Physician Services during Hospice Period: Unbundling

Issue Name:Physician Services during Hospice Period: Unbundling
Issue Number: _0105
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: Region 1 - All States
Date Approved: 08/16/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
Description:Physician services billed during an active hospice period should be paid by the Hospice provider if services are related to the hospice beneficiary's terminal condition or if a physician is employed or paid under arrangement by the beneficiary's hospice provider. Medicare should not be billed for either of the aforementioned scenarios. Affected codes: Any codes except codes in Appendix D
References: "1. Title XVIII, §1833(e) of the Social Security Act- Payment of Benefits 2. Title XVIII, §1861 (dd) of the Social Security Act, Hospice Care; Hospice Program 3. Title XVIII, §1862(a)(1)(A) of the Social Security Act- Exclusions from Coverage and Medicare as a Secondary Payer 4. 42 Code of Federal Regulations §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 5. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 6. 42 Code of Federal Regulations §418.400- Individual Liability for Coinsurance for Hospice Care 7. 42 Code of Federal Regulations §418.402- Individual Liability for Services That are Not Considered Hospice Care 8. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services, Section 10- Requirements 9. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services, Section 40.1.3 - Physician Services 10. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, Section 10- Overview 11. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, Sections 20.1 and 30.3 12. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, Section 40.2- Processing Professional Claims for Hospice Beneficiaries 13. Medicare Claims Processing Manual, Chapter 11 - Processing Hospice Claims, Section 50- Billing and Payment for Services Unrelated to Terminal Illness 14. 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"

Ambulatory Payment Classification Coding Validation

Issue Name: Ambulatory Payment Classification Coding Validation
Issue Number: _0101
Review Type: Complex
Provider Type: Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the procedures affecting or potentially affecting the APC assignment. Affected codes: Claims with status indicators (SI) = J1, T, S, and K
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. 42 CFR §414- Payment for Part B Medical and Other Health Services 4. 42 CFR §419- Prospective Payment System for Hospital Outpatient Department Services 5. 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 6. 42 CFR §405.986- Good Cause for Reopening 7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.6.2.4- Coding Determinations 8. 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 9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§10.1- 10.5, 20, 40-61, 100, 120, 150-240, 270, and 300. 10. American Medical Association (AMA), Current Procedure Terminology, Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1) ,APCs for Hospital Part B services paid through a comprehensive APC (SI = J1),Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies(SI = T), and Nonpass-Through Drugs and Biologicals (SI=K) 11. AMA CPT Assistant 12. National Correct Coding Initiative Policy Manual 13. Integrated Outpatient Code Editor (I/OCE) CMS Specifications Appendix L: Comprehensive APC Assignment Logic (OPPS Only, V16.0, Effective 01/01/2015 through V20.0 Effective 01/01/2019), Appendix D: Computation of Discounting Fraction (OPPS only), and Appendix P: Pass-Through Drugs and Biologicals Processing (OPPS Only, V17.2). 14. CMS Hospital Outpatient PPS, Addendum B Updates, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html"

Add-on codes paid without Primary Code and/or denied Primary Code – Ambulatory Surgical Center

Issue Name: Add-on codes paid without Primary Code and/or denied Primary Code – Ambulatory Surgical Center
Issue Number: _0104
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 07/26/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
Description: CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also paid. ASC providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Affected codes see Appendix D.
References: "1.Social Security Act, Section 1833. Payment of Benefits [42 U.S.C. 1395l] (e) 2.Social Security Act, Section 1862. Exclusions from Coverage and Medicare as a Secondary Payer [42 U.S.C. 1395y] (a)(1)(A) 3. 42 Code of Federal Regulations §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30- Correct Coding Policy 6. Medicare Claims Processing Manual, Chapter 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims 7. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 8. Medicare Claims Processing Manual, Chapter 29- Appeals of Claims Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals (Rev. 4278, Effective 4/12/2019) 9. 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 10. AMA CPT Code book"

Add-On Code Paid without Primary Code and/or Denied Primary Code: Clinical Laboratory

Issue Name: Add-On Code Paid without Primary Code and/or Denied Primary Code: Clinical Laboratory
Issue Number: _0100
Review Type: Automated
Provider Type: Laboratory
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/21/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date
Description: CMS has designated certain codes as "add-on procedures". These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. Clinical Laboratory providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Affected codes: 81266, 81265, 81416, 81415, 81426, 81425, 81536, 81535, 82952, 82951, 86826, 86825, 87187, 87186, 87188, 87503, 87502, 87904, 87903, 88155, 88142-88154, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88174, 88175, 88177, 88172, 88185, 88184, 88314, 17311-17315, 88302-88309, 88329-88334, 88341, 88342, 88350, 88346, 88364, 88365, 88369, 88368, 88373, 88367, 88388
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30 D. Coding Services Supplemental to Principal Procedure (Add-On Codes) Code 7. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70 Time Limitations for Filing Part A and Part B Claims 8. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8 Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 9. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals 10. National Correct Coding Initiative, Add-on Code Edits "

Skilled Nursing Facility Consolidated Billing: Outpatient Facility - Not Separately Payable Services

Issue Name:Skilled Nursing Facility Consolidated Billing: Outpatient Facility - Not Separately Payable Services
Issue Number: _0099
Review Type: Automated
Provider Type: Outpatient Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/20/2018
Dates Service:Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review)
Description:Payment for the Skilled Nursing Facility (SNF) services listed in appendix D provided to beneficiaries by the outpatient facility, in a Medicare covered Part A SNF stay, are included in a bundled prospective payment and are not separately payable. Payment for those services will be recouped as identified overpayments.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing; §§10-10.4- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview; §§20- 20.6- Services Included in Part A PPS Payment Not Billable Separately by the SNF "

Critical Care Professional Services: Unbundling

Issue Name: Critical Care Professional Services: Unbundling
Issue Number: _0098
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/16/2018
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: Claims for Part B Professional services for the same Beneficiary, same Date of Service, and Same Provider will be recovered as overpayments as they are not payable when performed on the same day a physician bills for critical care. These services are included in the critical care service and should not be reported separately. Affected codes: 36000, 36410, 36415, 36591, 36600, 43752, 71010, 71015, 71020, 71045, 71046, 91105, 92953, 93561, 93562, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762, 99090 (see appendix D for long descriptors).
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. 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 4. 42 CFR §405.986- Good Cause for Reopening   5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, § 30.6.12 (J) – Critical Care Services and Other Procedures Provided on the Same Day by the Same Physician as Critical Care Codes 99291-99292"

Implantable Automatic Defibrillators: Medical Necessity, Documentation and Coding Validation

Issue Name: Implantable Automatic Defibrillators: Medical Necessity, Documentation and Coding Validation
Issue Number: _0093
Review Type: Complex
Provider Type: Inpatient Hospital, Outpatient Hospital, ASC, Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/15/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and prior to 2/15/2018
Description: The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications as published in the CMS National Coverage Determinations (NCD) Manual, Publication 100-03, Section 20.4 and CMS IOM 100-04, Ch. 32 §§270,270.1,270.2. Affected Codes: 33240, 33241, 33243, 33244, 33249 0JH608Z, 0JH609Z, 0JH638Z, 0JH639Z, 0JH63FZ, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determinations (NCD) Manual: Chapter 1 – Coverage Determinations, Part 1- Sections 10- 80.12, Section 20.4- Implantable Automatic Defibrillators (ICDs), Effective 2/15/2018 7. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270- Claims Processing for Implantable Automatic Defibrillators 8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270.1- Coding Requirements for Implantable Automatic Defibrillators 9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 270.2- Billing Requirements for Patients Enrolled in a Data Collection System 10. First Coast Local Coverage Article A56341- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 10/01/2019 11. NGS Local Coverage Article A56326- Implantable Automatic Defibrillators- Coding and Billing; Effective 3/26/2019; Revised 10/01/2019 12. Noridian Local Coverage Article A56340- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/19; Revised 10/1/2019 13. Noridian Local Coverage Article A56342- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/19; Revised 10/1/2019 14. Novitas Local Coverage Article A56355- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 4/9/2020 15. Palmetto Local Coverage Article: A56343- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 10/01/2019 16. WPS Local Coverage Article A56391- Billing and Coding: Implantable Automatic Defibrillators; Effective 5/13/2019; Revised 3/26/2020 "

Duplicate Claims- Professional Services

Issue Name:Duplicate Claims- Professional Services
Issue Number: _0091
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/11/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Duplicate claims are any claims paid across more than one claim number for the same Beneficiary, CPT/HCPCS code and service date by the same provider. Affected Codes: All CPT, HCPCS Codes
References: "1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments 7. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2(B)- Exact Duplicates, Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers) 8. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.2- Site of Service Payment Differential 9. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, §10.5- Place of Service Codes (POS) and Definitions"

Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements

Issue Name:Percutaneous Implantation of Neurostimulator Electrode Array: Documentation Requirements
Issue Number: _0092
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non-physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/08/2018
Dates Service: Claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: The review shall identify claims billed incorrectly as percutaneous implantation of neurostimulator electrode when the record demonstrates either transcutaneous placement of a device or percutaneous placement without identification of the selected (peripheral or cranial) nerve. Affected codoes: 64553- Percutaneous implantation of neurostimulator electrode array; cranial nerve 64555- Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §30.3- Acupuncture 7. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.7.1- Assessing Patients Suitability for Electrical Nerve Stimulation Therapy 8. American Medical Association Current Procedural Terminology Manual Healthcare Common Procedure Coding System, 2014 to current"

Laboratory/Pathology Technical Component for Inpatient or Outpatient Hospitals: Unbundling

Issue Name:Laboratory/Pathology Technical Component for Inpatient or Outpatient Hospitals: Unbundling
Issue Number: _0090
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner; Lab; IDTF (Independent Diagnostic Testing Facility)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/03/2018
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: The technical component (TC) of lab/pathology services furnished to patients in an inpatient or outpatient hospital setting are not separately payable. All Lab/Pathology CPT/HCPCS codes with TC/PC Indicator 1 or 3. See Appendix D for complete list of codes.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12 Physician/Non-Physician Practitioners, § 60 (B) Payment for Technical Component (TC) Services 7. Medicare Claims Processing Manual; Chapter 23 – Fee Schedule Administration and Coding Requirements; Addendum – MPFSDB File Record Layout and Field Descriptions"

Laboratory Services Rendered During an Inpatient Stay: Unbundling

Issue Name:Laboratory Services Rendered During an Inpatient Stay: Unbundling
Issue Number: _0085
Review Type: Automated
Provider Type: Lab and Outpatient
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Laboratory services are covered under Part A, excluding anatomic pathology services and certain clinical pathology services, therefore if billed separately should be denied as unbundled services. See 0085 Appendix D for affected codes.
References: "1. Social Security Act, Title XVIII - Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act, Title XVIII - Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients 8. Current Procedural Terminology Coding Book"

Cataract Removal Excessive Units - Partial Denial

Issue Name:Cataract Removal Excessive Units - Partial Denial
Issue Number: _0083
Review Type: Automated
Provider Type: Professional Services, Outpatient, ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Less than 3 years.
Description: Cataract removal cannot be performed more than once on the same eye on the same date of service. Providers billing for more than one unit of cataract removal for the same eye, on the same claim line, will be denied. The New Issue indicates the finding is billed on the same claim line with units greater than 1 (for the same eye). Provider is entitled to payment for one eye and only a partial payment will be recovered. Affected codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D Ophthalmology)

Cataract Removal: Duplicate Payment

Issue Name: Cataract Removal: Duplicate Payment
Issue Number: _0084
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner, Outpatient, ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review).
Description: Cataract removal cannot be performed more than once on the same eye on the same date of service. Providers billing for more than one unit of cataract removal for the same eye will be denied. This new issue indicates that findings are across claims, for the same eye, and the finding claim line is a Full recovery.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter 8- Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems CPT Codes 60000 – 69999, Section D - Ophthalmology"

Observation Evaluation and Management Services Billed Same Day as Inpatient: Unbundling

Issue Name: Observation Evaluation and Management Services Billed Same Day as Inpatient: Unbundling
Issue Number: _0086
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
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: Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill observation care codes (initial, subsequent and/or discharge management) for services on the date that he or she admits the patient to inpatient status. Affected Codes: 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 7. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 8. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 9. Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 12 (Physicians/Nonphysician Practitioners), §30.6.8(D)- Admission to Inpatient Status Following Observation Care "

Clinical Social Worker during Inpatient: Unbundling

Issue Name: Clinical Social Worker during Inpatient: Unbundling
Issue Number: _0089
Review Type: Automated
Provider Type: Clinical Social Workers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/19/2018
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the Informational Letter date will be excluded.
Description: Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facilities PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility. Affected Codes: Psychiatry CPT Codes 90785 - 90899 (See attached table - Appendix D)
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 §1861(hh)- Clinical Social Worker, (hh)(2)- Clinical Social Worker Services 4. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 42 CFR §409.10(a)(4)- Included Services- Medical Social Services 7. 42 CFR §410.73- Clinical Social Worker Services 8. 42 CF §412.50(b)- Furnishing of Inpatient Hospital Services Directly or Under Arrangements 9. 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 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §170- Clinical Social Worker (CSW) Services 11. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients "

Ancillary Services Billed Without an Approved Surgical Procedure

Issue Name: Ancillary Services Billed Without an Approved Surgical Procedure
Issue Number: _0088
Review Type: Automated
Provider Type: Ambulatory Surgery Center (ASC)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/16/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: Covered ancillary items and services identified in Appendix D are not payable if there is no approved ASC surgical procedure on the same claim or in history for the same date of service and same provider. Affected codes: All ancillary services
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §260- Ambulatory Surgical Center Services 7. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgery Centers, §40- Payment for Ambulatory Surgery 8. CMS Ambulatory Surgery Center Approved HCPCS Code and Payment Rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates "

Laboratory Services for End-Stage Renal Disease Subject to Part B Consolidated Billing: Unbundling

Issue Name: Laboratory Services for End-Stage Renal Disease Subject to Part B Consolidated Billing: Unbundling
Issue Number: _0087
Review Type: Automated
Provider Type: Professional Services(Physician/Non-Physician Practitioner); Laboratory
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/16/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: The ESRD PPS includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and will no longer be separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Should these laboratory services, and limited drugs be provided to a beneficiary, but are not related to the treatment for ESRD, the claim lines must be submitted with the new AY modifier to allow for separate payment outside of ESRD prospective payment system. Affected codes: Labs subject to ESRD Consolidated Billing" for CY 2014-2018 found on www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Benefit Policy Manual, Chapter 11- End Stage Renal Disease, §20.2- Laboratory Services 7. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §60.1- Lab Services
ESRD PPS Consolidated Billing (files for 2014 – 2019) www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html"

Cardiac Pacemakers: Medical Necessity and Documentation Requirements

Issue Name:Cardiac Pacemakers: Medical Necessity and Documentation Requirements
Issue Number: _0078
Review Type: Complex
Provider Type: Outpatient, Ambulatory Surgery Center
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/15/2018
Dates Service:Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date and billed prior to 01/13/2017.
Description: Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. Affected Codes: 33206, 33207, 33208.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determinations (NCD), Ch. 1, Part 1, §20.8.3- Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers 7. CGS Local Coverage Article A54961- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 05/01/2016 8. Cahaba Local Coverage Article A54949- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 4/15/2016; Retired 01/29/2018 9. First Coast Local Coverage Article A54926- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 5/1/2016 10. NGS Local Coverage Article A54909- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 4/15/2016; Revised 05/01/2016 11. Noridian Local Coverage Article A54929- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 4/15/2016; Revised 9/5/2018 12. Noridian Local Coverage Article A54931- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 4/15/2016, Revised 9/5/2018 13. Novitas Local Coverage Article A54982- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 5/1/2016; Revised 11/8/2018 14. Palmetto Local Coverage Article A54831- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 01/13/2016; Revised 10/01/2019 15. WPS Local Coverage Article A54958- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers – Coding and Billing; Effective 5/15/2016; Revised 4/01/2018 16. Annual American Medical Association CPT Manual, Coding Guidelines"

Evaluation and Management (E/M)Same Day as Dialysis

Issue Name:Evaluation and Management Services Billed Same Day as Dialysis: Unbundling
Issue Number: _0076
Review Type: Automated
Provider Type: Physician/Non-Physician practitioner(NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/16/2018
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:CPT codes 90935 and 90937 are used to report inpatient ESRD hemodialysis and outpatient hemodialysis performed on non-ESRD patients (e.g., patients in acute renal failure requiring a brief period of dialysis prior to recovery). CPT codes 90945 and 90947 are used to report all non-hemodialysis procedures. These four (4) codes include payment for any evaluation and management services related to the patient’s renal disease that are provided on the same date as the dialysis service. Payment for all evaluation and management services is bundled into the payment for 90935, 90937, 90945, and 90947, except for the evaluation and management services which may be reported on the same date as a dialysis service with the use of the –25 modifier and they are significant and separately identifiable and met any medical necessity requirements. The Evaluation and Management CPT codes 99201-99205, 99211-99215, 99221-99223, 99238-99239, and 99291-99292 billed for the same date of service and same provider as dialysis CPT codes are not separately payable without modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service).
Affected Codes: Appendix D Added
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- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §170(B) Inpatient and Outpatient Dialysis Services On Same Date As An Evaluation and Management Service 6. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.10 Consultation Services 7. 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"

Initial Hydration, Infusion and Chemotherapy Administration: Incorrect Units Billed

Issue Name: Initial Hydration, Infusion and Chemotherapy Administration: Incorrect Units Billed
Issue Number: _0071
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/05/2017
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: Claims for Initial CPT/HCPCS code: 96360 – Intravenous infusion, hydration, initial, 31 minutes to 1 hour, 96365 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (Specify substance or drug); initial, up to 1 hour, 96369 – Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s), 96374 – Intravenous push, single or initial substance/drug, 96409 – Intravenous, push technique, single or initial substance/drug or 96413 - Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug billed in excess of 1 per date of service, by the same provider, for the same Beneficiary will be denied. When administering multiple infusions, injections or combinations, the physician should only report one "initial" service code unless protocol requires that two separate IV sites must be used. For these separate identifiable services, physicians need to report with using modifier 76, 59, XE, XS, XP or XU.
References: 1. SA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12-Physicians/Nonphysician Practitioners, §30.5 – Payment for Codes for Chemotherapy Administration and Nonchemotherapy Injections and Infusions, effective 6/26/2006 7. Noridian – Chemotherapy Administration Billing – updated Sept. 18, 2018 (https://med.noridianmedicare.com/web/jea/topics/drugs-biologicals-injections/chemotherapy-administration-billing)

Annual Wellness Visit Billed Sooner Than Eleven Whole Months Following the Initial Preventive Physical Examination

Issue Name: Annual Wellness Visit Billed Sooner Than Eleven Whole Months Following the Initial Preventive Physical Examination
Issue Number: _0077
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/15/2018
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded.
Description: The Annual Wellness Visit (AWV) is not payable if an Initial Preventive Physical Examination (IPPE) has been paid within the previous 11 whole months.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 CFR §411.15- Particular Services Excluded from Coverage, (a)(1)- Routine Checkups 7. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(15), (16)- Any Services that are not Reasonable and Necessary, (15)-additional preventive services; (16) Annual Wellness Visit with PPE 8. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit (AWV) "

Drugs and Biologicals: Incorrect Units Billed (Single-Dose Vials)

Issue Name: Drugs and Biologicals: Incorrect Units Billed (Single-Dose Vials)
Issue Number: _0074
Review Type: Complex
Provider Type: Outpatient Hospital & Physician
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 01/11/2018
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Drugs and Biologicals should be billed in multiples of the dosage specified in the CPT/HCPCS code long descriptor. The number of units billed should be assigned based on the dosage increment specified in that CPT/HCPCS long descriptor, and correspond to the actual amount of the drug administered to the patient, including any appropriate discarded drug waste. If the drug dose used in the care of a patient is less than a multiple of the CPT/HCPCS code dosage descriptor, the provider rounds to the next highest unit. Claims billed with excessive or insufficient units will be reviewed by a nurse, pharmacist, certified pharmacy technician, or certified coder to determine the actual amount administered and the correct number of billable/payable units. Affected codes: C9025, C9132, J0129, J0178, J0180, J0202, J0221, J0256, J0475, J0485, J0490, J0583, J0585, J0588, J0775, J0881, J0894, J0897, J1300, J1439, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1602, J1745, J1786, J1930, J2182, J2323, J2326, J2350, J2353, J2357, J2505, J2507, J2562, J2778, J2796, J2997, J3101, J3262, J3357, J3380, J3385, J3489, J7312, J7325, J7326, J7327, J9022, J9023, J9033, J9035, J9041, J9042, J9043, J9047, J9055, J9145, J9171, J9173, J9176, J9179, J9205, J9217, J9228, J9263, J9264, J9271, J9280, J9285, J9299, J9301, J9303, J9305, J9306, J9307, J9308, J9310, J9311, J9312, J9315, J9351, J9354, J9395, Q2043, Q2050 20610, 20611, 67028, 96360, 96361, 96365, 96366, 96367, 96368, 96369, 96370, 96371, 96372, 96373, 96374, 96375, 96376, 96377, 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415, 96416, 96417, 96420, 96422, 96423, 96425, 96440, 96446, 96450, 96452 J0220, J0480, J0584, J0586, J0587, J0598, J1301, J1442, J1610, J1640, J2278, J3111, J3370, J7170, J7179, J7198, J7201, J7205, J7207, J9025, J9032, J9153, P9045, P9047
Affected Codes: Appendix D Added
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, 10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals 7. Medicare Alpha-Numeric HCPCS File 8. Annual American Medical Association: CPT Manual 9. Annual HCPCS Level II Manual 10. Medicare Part B Drug Average Sales Price; ASP Pricing File 11. U.S. National Library of Medicine DailyMed"

Outpatient Service Overlapping or During an Inpatient Stay: Duplicate Payments

Issue Name: Outpatient Service Overlapping or During an Inpatient Stay: Duplicate Payments
Issue Number: _0072
Review Type: Automated
Provider Type: Hospital Outpatient, Hospital Inpatient Part B
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/26/2017
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: Outpatient service dates that fall totally within inpatient admission and discharge dates at the same or another provider or outpatient bill that overlaps an inpatient admission are considered exact duplicates and should be rejected.
References: "1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2 (A)- Exact Duplicates- Submission of Institutional Claims 7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3 (B)- Outpatient Services Treated as Inpatient Services- Preadmission Diagnostic Services 8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling 9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §200.2- Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD) 10. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4- CWF Editing of Ambulance Claims for Inpatients 11. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §10.2- Billing Requirements 12. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments 13. Medical Benefit Policy Manual, Chapter 6- Hospital Services Covered under Part B, §10.2- Other Circumstances in Which Payment Cannot Be Made Under Part A 14. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service and §20- Coverage Guidelines for Ambulance Service Claims 15. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §20- Coverage Guidelines for Ambulance Service Claims"

Critical Care Billed on the Same Day as Emergency Room Services

Issue Name: Critical Care Billed on the Same Day as Emergency Room Services
Issue Number: _0070
Review Type: Automated
Provider Type: Physician/Non-Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 10/19/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review)
Description: Hospital emergency department services are not payable for the same calendar date as critical care services when provided by the same physician or physician group with the same specialty to the same patient. Affected codes: 99281,99282, 99283, 99284, 99285, 99291, and 99292.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.12 (H) & (I)"

Untimed Therapy: Excessive Units

Issue Name: Untimed Therapy: Excessive Units
Issue Number: _0060
Review Type: Automated
Provider Type: Outpatient Hospital; Part B Professional Services; Outpatient Non-Hospital Facility; Skilled Nursing Facility (SNF); Outpatient Rehab Facility (ORF); Comprehensive Outpatient Rehab Facility (CORF); Physician and Non-Physician Practitioner/ Provider Specialty;
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/20/2017
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: When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider should enter a 1 in the units billed column per date of service. Affected codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 97012, 97016, 97018, 97022, 97024, 97028, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, G0281, G0283, G0329
References: 1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. American Medical Association (AMA), Current Procedure Terminology 2014 to current 7. Medicare Benefit Policy Manual: Chapter 15 – Covered Medical and Other Health Services, Sections 220 – Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services Under Medical Insurance, and 230 – Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology 8. Medicare Claims Processing Manual, Chapter 5 (Part B Outpatient Rehabilitation and CORF/OPT Services), §§10.3.2 (Exceptions Process), 10.6 (Functional Reporting), and 20.2 (Reporting of Service Units with HCPCS) (Revised March 9, 2018)

Arthroscopic Limited Shoulder Debridement: Incorrect Coding

Issue Name: Arthroscopic Limited Shoulder Debridement: Incorrect Coding
Issue Number: _0057
Review Type: Complex
Provider Type: Outpatient Hospital, (OPH); Ambulatory Surgery Center (ASC); Physician/Non- physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/11/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the Additional Documentation Request Letter date will be excluded.
Description: Shoulder arthroscopy procedures include a limited debridement (e.g., CPT code 29822). Code 29822, is not separately payable when another shoulder arthroscopy procedure is billed and paid on the same shoulder for the same day for the same beneficiary at the same encounter. Affected codes: 29822, 29805, 29806, 29807, 29819, 29820, 29821, 29823, 29824, 29825, 29827, 29828
References: 1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Benefit Policy Manual, Chapter 16- General Exclusions From Coverage, §20- Services Not Reasonable and Necessary 7. National Correct Coding Initiative Policy Manual, Chapter 4, E, “Arthroscopy”- Effective January 1, 2014; Revised January 1, 2020

Nursing Facility Services: Excessive Units

Issue Name: Nursing Facility Services: Excessive Units
Issue Number: _0061
Review Type: Automated
Provider Type: Professional (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/08/2017
Dates Service: Exclude claims having a paid claim date which is more than 3 years prior to the Informational letter date.
Description: The Nursing Facility Services codes represent a “per day” service. As such, these codes may only be reported once per day, per Beneficiary, Provider and date of service. Affected Codes: 99304, 99305, 99306, 99307, 99308, 99309, 99310.
References: "1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations §424.5(a)(6)- Sufficient Information 4. 42 Code of Federal Regulations §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 5. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 6. Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners, § 30.6.13 Nursing Facility Services, (B) Visits to Comply With Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF and NF 7. Medicare Program Integrity Manual, Chapter 3, §3.2.3.8 No Response or Insufficient Response to Additional Documentation Requests 8. Medicare Program Integrity Manual, Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), §3.5.1 Re-opening Claims, §3.6 Determinations Made During Review 9. American Medical Association (AMA), Current Procedure Terminology Manual, 2014 to current 10. Local Coverage Article: Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility (A56712), Revised 11/21/2019
Local Coverage Article: Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility (A56712), Revised 11/21/2019"

Facility Duplicate Claims

Issue Name: Facility Duplicate Claims
Issue Number: _0064
Review Type: Automated
Provider Type: Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility (SNF)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/07/2017
Dates Service: Less than 3 years.
Description: Duplicate claims or line date of service items will be denied. Affected codes: All CPT and All HCPCS
References: "1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A) Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) Payment of Benefits 3. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 6. Medicare Claims Processing Manual, Chapter 1 – General Billing Requirements, §120.2(A)- Submission of Institutional Claims 7. 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"

Critical Care: Excessive Units

Issue Name: Critical Care: Excessive Units
Issue Number: _0063
Review Type: Automated
Provider Type: Professional Services (Physician/Non-Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/07/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date.
Description: CPT Code 99291 is used to report the first 30 - 74 minutes of Critical Care on a given calendar date of service. It should only be used once per calendar date per beneficiary by the same physician or physician group of the same specialty. Affected Codes: 99291.
References: "1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physicians/ Nonphysician Practitioners, §30.6.12- Critical Care Visits and Neonatal Intensive Care (Codes 99291 and 99292), Section (F)- Hours and Days of Critical Care that may be Billed, Section (G)- Counting of Units of Critical Care Services, and Section (I)- Critical Care Services Provided by Physicians in Group Practice(s)"

Radiology: Technical Component during Inpatient Stay

Issue Name: Radiology: Technical Component during Inpatient Stay
Issue Number: _0062
Review Type: Automated
Provider Type: Radiologists and other Part B providers performing radiology services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 09/07/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date.
Description: Carriers may not pay for the technical component (TC) of radiology services furnished to patients in hospital settings. Query identifies TC portion of radiology paid to entities other than the inpatient facility. Findings are limited to claim lines billed with modifier TC and claim lines for service codes with TC/PC Indicator "1" and/or “3” for TC component only. Code list avail in the downloadable excel file, Appendix D tab.
References: 1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 13 Radiology Services and Other Diagnostic Procedures, § 20.2.1Hospital and Skilled Nursing Facility (SNF) Patients 7. Change Request 5675 8. Medicare Claims Processing Manual, Chapter 26 Completing and Processing Form CMS-1500 Data Set, § 10.7 – Type of Service

Ambulance Transfer between Skilled Nursing Facilities: Unbundling

Issue Name: Ambulance Transfer between Skilled Nursing Facilities: Unbundling
Issue Number: _0049
Review Type: Automated
Provider Type: Ambulance Providers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 08/09/2017
Dates Service: Claims that have a claim paid date which is less than 3 years prior to the informational letter date.
Description: Algorithm identifies all paid Ambulance Claims billed with any HCPCS codes listed in Appendix D with modifier NN on the same line, for SNF claims. Under the prospective payment system, some ambulance transportation provided by outside suppliers to SNF residents is included in the SNFs’ Medicare Part A payments and is subject to consolidated billing. Therefore, Medicare Part B payments that suppliers receive for the ambulance transportation are overpayments. Affected codes: A0021, A0080, A0090 , A0100,A0110 , A0120, A0130, A0160, A0170, A0180, A0190, A0200, A0210 , A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0425, A0426, A0427, A0428, A0429,A0432, A0433, A0434, A0888, A0998, A0999.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual; Chapter 6- Inpatient Part A Billing and SNF Consolidated Billing, §20.3.1- Ambulance Services, 7. Medicare Claims Processing Manual, Chapter 15- Ambulance, § 30.2.2- SNF Billing 8. American Medical Association (AMA), Professional HCPCS Level II Manual 2014 to current 9. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10.3.3- Separately Payable Ambulance Transport Under Part B Versus Patient Transportation That is Covered Under a Packaged Institutional Service "

Evaluation and Management Services in Skilled Nursing Facilities: Incorrect Coding

Issue Name: Evaluation and Management Services in Skilled Nursing Facilities: Incorrect Coding
Issue Number: _0056
Review Type: Automated
Provider Type: Physician/Non-physician Practitioner (NPP)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 08/02/2017
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: When evaluation and management (E/M) services are provided to patients in a Skilled Nursing Facility (SNF), CPT codes (99306,99309, 99310) should be reported. It is inappropriate to report hospital inpatient care codes (99223, 99232,99233) for SNF E/M services. Affected Codes: 99223, 99232, 99233,
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physician/ Non Physician Practitioners, §30.6.13- Nursing Facility services 7. American Medical Association (AMA) Current Terminology Manual (CPT), Evaluation and Management section, Nursing Facility Services Guidelines"

Panretinal (Scatter) Laser Photocoagulation - Excess Frequency

Issue Name: Panretinal (Scatter) Laser Photocoagulation: Excessive Frequency
Issue Number: _0047
Review Type: Automated
Provider Type: Outpatient Hospital (OPH), Physician/Non-physician Practitioner
Region: Region-1
State: J6, JK, J15
Date Approved: 04/28/2017
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded
Description: Claims for CPT code 67228 (Treatment of extensive or progressive retinopathy), billed more frequently than once per eye within the global surgery period will be denied. Affected codes: 67228
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. 42 Code of Federal Regulations (CFR) §424.5(a)(6)- Sufficient Information 4. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 5. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 6. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions), §3.5.1- Reopening Claims and §3.6- Determinations Made During Review 7. 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 8. CGS Administrators, Local Coverage Determination (LCD) L34064- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 10/03/2019 9. NGS, Local Coverage Determination (LCD) L33628- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 9/19/2019 10. CGS Administrators, Local Coverage Article A56594- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 10/03/2019; Revised 01/02/2020 11. NGS, Local Coverage Article A52822- Panretinal (Scatter) Laser Photocoagulation- Supplemental Instructions Article; Effective 10/01/2015; Retired 5/01/2016 12. NGS, Local Coverage Article A56550- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 8/1/2019; Revised 9/19/2019 "

Global versus Technical Component/Professional Component Reimbursements: Unbundling

Issue Name:Global versus Technical Component/Professional Component Reimbursements: Unbundling
Issue Number: _0051
Review Type: Automated
Provider Type: Physician/Non-physician Practitioner (NPP), Lab/Ambulatory services.
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/04/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Claims for CPT/HCPCS codes that are billed with a TC and/or PC modifier in addition to the global procedure by the same provider, will be denied. Affected codes: 76519, 92136, 51725, 51726, 51727, 51728, 51729, 51736, 51741, 51784,51785,51792, 88300, 88302, 88304, 88305, 88307, 88309, 88311, 88312, 88313, 88314, 88319, 88329, 88331, 88332, 88333
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare Fee-for-Service Payment/Physician Fee Schedule PFS Relative Value Files 6. Medicare Claims Processing Manual, Chapter 1 (General Billing Requirements), §120 (Detection of Duplicate Claims) 7. Medicare Claims Processing Manual, Chapter 12 (Physician/Non-physician Practitioners), §20.2 (Relative Value Units) 8. Medicare Claims Processing Manual, Chapter 13 (Radiology Services and Other Diagnostic Procedures), §20.1 (Professional Component [PC]), 20.2 (Technical Component [TC]), and 20.2.3 (Services Furnished in Leased Departments) 9. Medicare Claims Processing Manual, Chapter 16 (Laboratory Services), §80.2.1 (Technical Component [TC] of Physician Pathology Services to Hospital Patients) 10. 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 11. Facility Outpatient Hospital Services and Practitioner Services MUE Tables "

Ambulance Billed during Inpatient: Unbundling

Issue Name: Ambulance Billed during Inpatient: Unbundling
Issue Number: _0054
Review Type: Automated
Provider Type: Ambulance Providers
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 05/31/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Ambulance services during an Inpatient stay are included in the facility’s PPS payment and are not separately payable under Part B, excluding the date of admission, date of discharge and any leave of absence days. Ambulance providers are expected to seek reimbursement from the inpatient facility. The edits will capture improper payment of ambulance services during an inpatient hospital stay. Affected codes: HCPCS codes A0021 through A0999 (Ambulance Services) Modifiers DD through SX (Ambulance Destination Modifiers) See attached Appendix D for complete list and descriptions
References: "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- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling 7. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4 CWF Editing of Ambulance Claims for Inpatients "

Skilled Nursing Facility: Medical Necessity and Documentation Requirements

Issue Name: Skilled Nursing Facility: Medical Necessity and Documentation Requirements
Issue Number: _0004
Review Type: Complex
Provider Type: SNF
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 06/01/2017
Dates Service: Exclude claims having a “claim paid date” greater than 3 years prior to the ADR date. Exclude claims with dates of service on or after October 1, 2019
Description: Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
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. 42 Code of Federal Regulations 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 4. 42 Code of Federal Regulations 405.986- Good Cause for Reopening 5. 42 Code of Federal Regulations 409.30-409.36 Basic Requirements 6. 42 Code of Federal Regulations 424.20 Requirements for posthospital SNF care 7. 42 Code of Federal Regulations 483.20 Resident assessment 8. 42 Code of Federal Regulations 411.15(k)(1) 9. 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 10. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40.4- Timing of Recertifications for Extended Care Services, §40.5- Delayed Certifications and Recertifications for Extended Care Services 11. Medicare Program Integrity Manual, Chapter 6 Medicare Contractor Medical Review Guidelines for Specific Services, §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills, §6.1.4- Bill Review Process, §6.3- Medical Review of Certification and Recertification of Residents in SNFs 12. Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3- Certification and Recertification of Need for Treatment and Therapy Plans of Care "

Sacral Neurostimulation: Medical Necessity and Documentation Requirements

Issue Name: Sacral Neurostimulation: Medical Necessity and Documentation Requirements
Issue Number: _0003
Review Type: Complex
Provider Type: Inpatient hospital-acute care; physician; outpatient hospital; professional services (physician/non-physician practitioner); ASC
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/17/2017
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: Claims for sacral nerve stimulation for urinary or fecal incontinence not deemed to be medically necessary will be denied. Affected Codes: HCPCS: 64561, 64581, 64590, A4290, C1767, C1778, C1883, C1897
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. National Coverage Determination 230.18- Sacral Nerve Stimulation for Urinary Incontinence, Effective 1/1/2002 6. Medicare Claims Processing, Chapter 32- Billing Requirements for Special Services, Section 40- Sacral Nerve Stimulation 7. First Coast Service Options, Inc., LCD L36296- Sacral Neuromodulation, Effective 10/1/2015; Revised 08/06/2019 8. Novitas Solutions, Inc., LCD L34707- Sacral Nerve Stimulation, Effective 07/24/2014; Retired 09/30/2015 9. Novitas Solutions, Inc., LCD L35449- Sacral Nerve Stimulation, Effective 10/1/2015; Revised 04/18/2019 10. Noridian Healthcare Solutions, LLC, LCA A51767 Article for Sacral Nerve Stimulation for Urinary and Fecal Incontinence R3, Effective 04/20/2012; Retired 9/30/2015 11. Noridian Healthcare Solutions, LLC, LCA A53017- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 02/28/2019 12. Noridian Healthcare Solutions, LLC, LCA A53359- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 02/28/2019 13. CGS Administrators, LLC, LCA A55835- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 02/01/2018 14. CPT Assistant, December 2012, Volume 22, Issue 12, page 14- Surgery: Nervous System, Placement Permanent Neurostimulator Electrode Array with Implant of Pulse Generator "

Bariatric Surgery: Medical Necessity and Documentation Requirements

Issue Name: Bariatric Surgery: Medical Necessity and Documentation Requirements
Issue Number: _0008
Review Type: Complex
Provider Type: Inpatient Hospital, Outpatient Hospital
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/01/2017
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: The surgical management for the treatment of morbid obesity is considered reasonable and necessary for Medicare beneficiaries who have a BMI > 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. Claims reporting surgical services for beneficiaries that do not meet all the Medicare coverage guidelines will be denied as not medically necessary. Affected Codes: 43770, 43644, 43645, 43845, 43846, 43846, 43847, 43775, 278.01 V85.35-V85.39, V85.41 - V85.45, E66.01, Z68.35-Z68.39, Z68.41-Z68.45. Code list avail in Appendix D of the 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. National Coverage Determinations Manual, Chapter 1, Part 2, Section 100.1- Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, Effective 9/24/2013 7. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity 8. First Coast LCD L33411- Surgical Management of Morbid Obesity; Effective 10/1/2015; Revised 10/01/2019 9. Palmetto GBA LCD L34576- Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 10/1/2015; Revised 10/10/2019 10. Novitas LCD L35022- Bariatric Surgical Management of Morbid Obesity; Effective 10/1/2015; Revised 10/17/2019 11. NGS LCA A52447- Laparoscopic Sleeve Gastrectomy (LSG)- Medical Policy Article; Effective 10/1/2015; Revision 10/1/2019 12. Noridian LCA A53026- Bariatric Surgery Coverage; Effective 10/1/2015; Revised 10/01/2018 13. Noridian LCA A53028- Bariatric Surgery Coverage; Effective 10/1/2015; Revised 10/01/2018 14. Novitas LCA A56422- Billing and Coding: Bariatric Surgical Management of Morbid Obesity: Effective 03/28/2019; Revised 10/01/2019 15. WPS LCA A54923- Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity; Effective 3/1/2016; Revised:11/01/2019 16. Palmetto GBA LCA A56852- Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 08/15/2019; Revised 10/10/2019 17. First Coast LCA A57145- Billing and Coding: Surgical Management of Morbid Obesity; Effective 10/03/2018 18. First Coast LCA A55930- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 3/15/2018 19. First Coast LCA A56182- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 11/06/2018 "

Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes During Inpatient

Issue Name: Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes During Inpatient
Issue Number: _0011
Review Type: Automated
Provider Type: Professional Services (Physician/ non Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/01/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date.
Description: Home Services Billed for Hospital Inpatients - Home Services CPT Codes may not be used for billing services provided in settings other than in the private residence of a beneficiary. Affected codes: CPT Code 97535 (Self Care/Home management training direct one-on-one contact, each additional 15 minutes)CPT Codes 99341-99345 (Home visit for evaluation and management of a new patient)CPT Codes 99347-99350 (Home visit for evaluation and management of an established patient)
References: 1.Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3.42 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 4.42 CFR §405.986- Good Cause for Reopening 5.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 6.Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioners, § 30.6.14- Home Care and Domiciliary Care Visits 7.CPT Manual 2013-present

Inpatient Psychiatric Stay Billed without Source of Admission Equal to “D”

Issue Name: Inpatient Psychiatric Stay Billed without Source of Admission Equal to “D”
Issue Number: _0022
Review Type: Automated
Provider Type: Inpatient Hospital, Inpatient Psychiatric Facility
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/09/2017
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: Under the Medicare PPS for inpatient psychiatric facilities (IPF), CMS makes an additional payment to an IPF or a distinct part unit (DPU) for the first day of a beneficiary's stay to account for emergency department costs if the IPF has a qualifying emergency department. However, CMS does not make this payment if the beneficiary was discharged from the acute care section of a hospital to its own hospital based IPF. In that case, the costs of emergency department services are covered by the Medicare payment that the acute hospital received for the beneficiary's inpatient acute stay.Source of admission code 'D' has been designated for usage when a patient is discharged from an acute hospital to their own psychiatric DPU. This code will prevent the additional payment for the beneficiary's first day of coverage at the DPU. An overpayment occurs when source of admission code 'D' is not billed for these transfer claims.
References: "1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.6.4- Emergency Department (ED) Adjustment 7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.6.4.1- Source of Admission for IPF PPS Claims for Payment of ED Adjustment 8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.10.1- General Rules"

Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services

Issue Name: Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Services
Issue Number: _0027
Review Type: Complex
Provider Type: Outpatient Hospital (OPH), Physician
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 04/25/2017
Dates Service: Review claims having a “paid claim date” which is less than 3 years prior to the ADR letter date.
Description: To identify claims where modifier -59 has been inappropriately appended when Endomyocardial Biopsies and Right Heart Catheterizations are billed together. Affected Codes: 93451.
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. 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 4. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 23 (Fee Scheduled Administration and Coding Requirements), §20.9.1.1(B)- Instructions for Codes with Modifiers- Modifier "-59" 7. NCCI Manuals, 2015, 2016, 2017, 2018, 2019, and 2020 Chapter 1 – General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare 8. NCCI Manuals, 2015, 2016, 2017, 2018, 2019, and 2020 Chapter 11 – Medicine & E/M CPT Codes 90000-99999 for National Correct Coding Initiative Policy Manual for Medicare 9. CPT Manual"

Annual Wellness Visits: Excessive Units

Issue Name: Annual Wellness Visits: Excessive Units
Issue Number: _0028
Review Type: Automated
Provider Type: Physician/Non- Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/30/2017
Dates Service: Exclude from the automated review claims having a paid claim date more than 3 years prior to the Informational letter date.
Description: Claims for HCPCS code G0438 billed more than once in a lifetime will be denied. HCPCS code G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit) is a "one time" allowed Medicare benefit per beneficiary. Affected codes: G04838.
References: 1. cial 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations (CFR) §410.15-Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage 7. 42 Code of Federal Regulations (CFR) § 411.15- Particular services excluded from coverage (a) -Routine physical checkups such as Particular services excluded from coverage (1)- Examinations performed for a purpose 8. 42 Code of Federal Regulations (CFR)§411.15- Particular services excluded from coverage (k)- Any services that are not reasonable and necessary (15)- In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter. 9. Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) 10. Medicare Benefit Policy Manual, CMS Publication 100-02, Chapter 12 (Physicians/Nonphysician Practitioners), §30.6.1.1- Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) 11. Internet Only Manual, Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] (Effective 1/27/2014) 12. Medicare Claims Processing Manual, Chapter 18 (Preventive and Screening Services), §140- Annual Wellness Visit

Trastuzumab (Herceptin) Multi-Dose Vial: Incorrect Wastage

Issue Name: Trastuzumab (Herceptin) Multi-Dose Vial: Incorrect Wastage
Issue Number: _0036
Review Type: Complex
Provider Type: Outpatient hospital; Professional services (physician/non-physician practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/21/2017
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date.
Description: Claims for trastuzumab (Herceptin) multi-dose vials billed with medication wastage will be denied based on Medicare guidelines outlined by CMS Medicare Claims Processing Manual, 100-04, Chapter 17, Section 40 “Note: Multi-use vials are not subject to payment for discarded amounts of drug or biological." Affected code: J9355- Injection, trastuzumab, excludes biosimilar, 10 mg
References: 1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) Payment of Benefits 2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A) Exclusions from Coverage and Medicare as a Secondary Payer 3. 42 Code of Federal Regulations §424.5(a)(6)- Sufficient Information 4. 42 Code of Federal Regulations §405.980 (b)(c)- Reopening of Initial Determinations, Redeterminations, Reconsiderations, and Reviews 5. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 6. Medicare Claims Processing Manual, Chapter 17 (Drugs and Biologicals), §40- Discarded Drugs and Biologicals 7. Medicare Claims Processing Manual, Chapter 23 (Fee Schedule Administration and Coding Requirements), §20.3- Use and Acceptance of HCPCS Codes and Modifiers 8. Medicare Program Integrity Manual, Chapter 3 (Verifying Potential Error and Taking Corrective Actions), §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests

Hospital Services: Excessive Units

Issue Name: Hospital Services: Excessive Units
Issue Number: _0037
Review Type: Automated
Provider Type: Professional Services (Physician/Non- Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/23/2017
Dates Service: Exclude claims having a paid claim date which is more than 3 years prior to the Informational letter date.
Description: Both Initial Hospital Care codes (CPT codes 99221–99223) and Subsequent Hospital Care codes (CPT Codes 99231 99233) are “per diem” services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. Affected Codes: 99221-99223, 99231-99233.
References: "1. Social Security Act, 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. 42 Code of Federal Regulations §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 4. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 5. 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 6. 42 Code of Federal Regulations §424.5(a)(6)- Basic conditions; Sufficient information 7. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.1- Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services), Effective: 01-01-11 8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.2- Subsequent Hospital Visit and Hospital Discharge Day Management (Codes 99231 - 99239), Effective: 04-01-08 9. American Medical Association (AMA), Current Procedure Terminology 2007 to 2019"

Visits to Patients in Swing Beds: Incorrect Coding

Issue Name: Visits to Patients in Swing Beds: Incorrect Coding
Issue Number: _0038
Review Type: Automated
Provider Type: Physician; Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/23/2017
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: If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply. Affected codes: 99221-99223, 99231-99233, 99238-99239.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.D- Visits to Patients in Swing Beds"

Ophthalmology Codes for New Patient: Incorrect Coding

Issue Name: Ophthalmology Codes for New Patient: Incorrect Coding
Issue Number: _0039
Review Type: Automated
Provider Type: Physician; Professional Services
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any face-to-face service from the physician or physician group practice (limited to physicians of the same specialty) within the previous 3 years. This query identifies claims for patients who have been seen by the same provider in the last 3 years but for which the provider is billing a new (instead of established) visit code. Findings are limited to line with overpayments only. Affected Codes: 92002, 92004
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- 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 1861 (S)(2)(FF)- Medical and other health services- personalized prevention plan services (as defined in subsection 4. 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 5. 42 CFR §405.986- Good Cause for Reopening 6. 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 and §3.5.1 (Re-opening Claims) and §3.6 (Determinations Made During Review) 7. Medicare Claims Processing Manual, Chapter 12 Physicians/Non-physician Practitioners, § 30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215), (A) Definition of New Patient for Selection of E/M Visit Code. "

Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect Coding

Issue Name: Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect Coding
Issue Number: _0042
Review Type: Automated
Provider Type: Professional Services (Physician/Non- Physician Practitioner)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
Dates Service: Claims that have a “claim paid date” less than 6 months prior to the informational Letter date (automated review).
Description: Office or other outpatient visits for evaluation and management services may not be billed for patients while admitted to a hospital setting. Affected codes: CPT Codes 99201-99215,
Evaluation and Management codes when services are provided in the physician's office, in an outpatient or other ambulatory facility
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6- - Evaluation and Management Service Codes - General (Codes 99201 - 99499), §30.6.9.1- Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Services), §30.6.10- Consultation Services 7. CPT Coding Manual"

New Patient Visits: Incorrect Coding

Issue Name: New Patient Visits: Incorrect Coding
Issue Number: _0043
Review Type: Automated
Provider Type: Physician/Non- Physician Practitioner
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 03/09/2017
Dates Service: Claims that have a “claim paid date” which is less than 6 months prior to the Informational Letter date (automated review).
Description: The subsequently billed new patient visit will be denied if another E/M procedure has been billed within the past 3 years. Affected codes: 92002, 92004, 92012, 92014, 99201-99205, 99212-99215, 99241-99245, 99324-99328, 99334-99337, 99341-99345, 99347-99350, 99354, 99355, 99366, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99450, 99455, 99456, G0245, G0246, G0402, G0438, G0439, S0610, S0620.
References: "1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, Section 30.6.1.1 - Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV], Effective 1/27/2014 7. Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, Section 30.6.7.A (Definition of New Patient for Selection of E/M Visit Code, Effective 1/1/2016 8. Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, Section 30.6.9 - Payment for Inpatient Hospital Visits – General, Effective 1/1/2011 9. AMA CPT Manual, Evaluation and Management Services Guidelines (1999 through present) "

Complex Inpatient Hospital MS-DRG Coding Validation

Issue Name: Complex Inpatient Hospital MS-DRG Coding Validation
Issue Number: _0001
Review Type: Complex
Provider Type: Inpatient Hospital (IPH)
Region: Region-1
State: 1 - All Region 1 states
Date Approved: 02/01/2017
Dates Service: Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date
Description: MS-DRG Coding requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Clinical Validation is not permitted. The RAC may review All MS-DRG's (001-999)
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review 7. CMS QIO Manual Section 4130 8. ICD-10 CM Coding Manual 9. ICD-10 CM Addendums 10. ICD-10 CM Official Guidelines for Coding and Reporting, and Addendums 11. ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums 12. Coding Clinic for ICD-10-CM and ICD-10-PCS"

Cataract Removal: Medical Necessity and Coding Requirements

Issue Name: Cataract Removal: Medical Necessity and Coding Requirements
Issue Number: _0002
Review Type: Complex
Provider Type: Ambulatory Surgery Center (ASC); Outpatient Hospital
Region: Region-1 - CGS, Cahaba, First Coast, NGS, Noridian, Novitas, Palmetto **please note-WPS is excluded**
State: 1 - Excludes WPS
Date Approved: 02/07/2017
Dates Service: Less than 3 years, and with a date of service on or after 10/01/2015.
Description: Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected Codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984
References: "1. 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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10- Anesthesia and Pain Management, §10.1- Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery; Effective 10/03/2003 7. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction Effective 10/03/2003 8. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.12- Intraocular Lenses (IOLs), Effective 10/03/2003 9. CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 10/01/2016 10. NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 08/1/2019 11. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 10/10/2017 12. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017 13. Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 06/13/2019 14. Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 02/26/2018 15. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery), Effective 10/01/2015; Revised 06/13/2019 16. First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015 17. Cahaba LCD L34287- Cataract Extraction; Effective 10/01/2015, PART B ONLY; Retired 02/25/2018 18. NGS LCA A56544- Cataract Extraction; Effective 08/01/2019 "

Blood Glucose Test or Reagent Strips: Medical Necessity and Documentation Requirements

Issue Name: Blood Glucose Test or Reagent Strips: Medical Necessity and Documentation Requirements
Issue Number: _0152
Review Type: Complex
Provider Type: DME by Supplier/DME Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 06/14/2019
Dates Service: Claims that have a ‘claim paid date’ which is less than 3 years prior to the Additional Documentation Request.
Description: "The quantity of glucose test strips (A4353) that are covered depends upon the usual medical needs of the diabetic patient. Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips (A4253) were met."
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §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- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 15. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Rules Concerning Orders, Physician Orders 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 17. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 20. 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] 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 24. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §40.2 Home Blood Glucose Monitors 25. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §190.20- Blood Glucose Testing 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822-Glucose Monitors, Effective Date: 10/1/2015; Revised 01/01/2020 27. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464 Glucose Monitor - Policy Article, Effective Date: 10/01/2015; Revised: 01/01/2020 28. 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 04/06/2020"

Upper Limb Orthotics within the Reasonable Useful Lifetime: Excessive Units

Issue Name: Upper Limb Orthotics within the Reasonable Useful Lifetime: Excessive Units
Issue Number: _0155
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/17/2019
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review)
Description: Claims for upper limb orthoses with dates of service within 5 years of the date of service of a previously paid upper limb orthoses for the same beneficiary, for HCPCS codes identified as same, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met. Affected codes: L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984 and L3995
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(h)- Payment for Prosthetic Devices and Orthotics and Prosthetics 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 1861(s)(9)- Medical and Other Health Services: (s) The term “medical and other health services” means any of the following items or services: (9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements if required because of a change in the patient’s physical condition 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. 42 CFR §414.210- General Payment Rules 9. 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 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110.2.C- Durable Medical Equipment- Replacement 11. 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 04/06/2020 "

Therapeutic Shoes and Inserts for Persons with Diabetes: Medical Necessity and Documentation Requirements

Issue Name: Therapeutic Shoes and Inserts for Persons with Diabetes: Medical Necessity and Documentation Requirements
Issue Number: _0141
Review Type: Complex
Provider Type: DME by Supplier/ DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/26/2019
Dates Service: Claims having a “claim paid date” less than 3 years prior to the ADR date will be included. Claims with dates of service on or after January 1, 2020, will be excluded
Description: This review will determine if the documentation submitted for review meets Medicare’s coverage requirements for Diabetic Shoes and Inserts. Claims where the documentation submitted does not support the coverage requirements will be denied. Affected codes A5500, A5501, A5512, A5513
References:" 1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA) 1861(s)(12)- Definitions of Services, Institutions, Etc.; Medical and Other Health Services 3. Social Security Act (SSA) 1861(qq)(1)- Definitions of Services, Institutions, Etc.; Diabetes Outpatient Self-Management Training Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 5. SSA 1833(o)- Payment Of Benefits 6. 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 7. 42 CFR §405.986- Good Cause for Reopening 8. 42 CFR §410.38(g)(3)- Durable Medical Equipment: Scope and Conditions; Items Requiring a Written Order, Face-to-face Encounter Requirements 9. 42 CFR §410.38(g)(4)- Durable Medical Equipment: Scope and Conditions, Items Requiring a Written Order; Written Order Issuance Requirements 10. 42 CFR §424.57 (12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment – General 12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §140, Therapeutic Shoes for Individuals with Diabetes 13. 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 14. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26, Supplier Proof of Delivery Documentation Requirements 15. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2- Rules Concerning Orders 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Rules Concerning Orders, Physician Orders 17. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient's Medical Record 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination L33369: Therapeutic Shoes for Persons with Diabetes; Effective 10/1/2015; Revised 01/01/2020 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52501: Therapeutic Shoes for Persons with Diabetes; Effective 10/1/2015, Revised 01/01/2020 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME; Effective 01/01/2017; Revised 04/06/2020 "

Same Knee Orthoses within Reasonable Useful Lifetime: Excessive Units

Issue Name: Same Knee Orthoses within Reasonable Useful Lifetime: Excessive Units
Issue Number: _0148
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 05/01/2019
Dates Service: Claims for knee orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously-paid identical knee orthosis (identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met. Affected codes: L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860, L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, K0672
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- 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, Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment. 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. 42 Code of Federal Regulations §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 6. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 7. 42 Code of Federal Regulations §414.210- General Payment Rules 8. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 110.2.C – Repairs, Maintenance, Replacement, and Delivery 9. 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 10. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- LCD L33318, Knee Orthoses, Effective 10/01/2015; Revised 1/01/2020 11. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- Local Coverage Article A52465 Knee Orthoses, Effective 10/01/2015; Revised 1/01/2020 12. 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 4/06/2020"

Prefabricated Knee Orthoses: Medical Necessity and Documentation Requirements

Issue Name: Prefabricated Knee Orthoses: Medical Necessity and Documentation Requirements
Issue Number: _0144
Review Type: Complex
Provider Type: DME by Supplier/ DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/15/2019
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020, will be excluded.
Description: Knee Orthoses may have been provided to beneficiaries where all Medicare coverage requirements were not met. This review will determine if the orthoses is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity requirements will be denied. Affected codes: L1812, L1820, L1830, L1831, L1832, L1833, L1836, L1848, L1850, L1851 and L1852
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(a)(1)(M)- Payment for Prosthetic Devices and Orthotics and Prosthetics 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)(1)(E)- Clinical Conditions for Coverage 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)- Replacement of Items 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)-Payment for Prosthetic Devices and Orthotics and Prosthetics 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 8. 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 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1847(a)(2)(C)- Off-The-Shelf Orthotics 10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 11. 42 Code of Federal Regulations §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening 12. Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 13. 42 Code of Federal Regulations §405.986- Good Cause for Reopening 14. 42 Code of Federal Regulations § 410.38- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): Scope and Conditions 15. 42 Code of Federal Regulations § 414.402-Definitions 16. 42 Code of Federal Regulations §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 17. 42 Code of Federal Regulations §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 20. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2 - Rules Concerning Orders, Physician Orders 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.1- Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.2 – Verbal and Preliminary Written Orders 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.7 - Requirements of New Orders 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record 28. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L33318, Knee Orthoses; Effective Date: 10/01/2015; Revised 1/01/2020CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52465, Knee Orthoses; Effective Date: 10/01/2015; Revised 1/01/2020 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 4/06/2020 "

Pneumatic Compression Device: Medical Necessity and Documentation Requirements

Issue Name: Pneumatic Compression Device: Medical Necessity and Documentation Requirements
Issue Number: _0131
Review Type: Complex
Provider Type: DME Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/23/2019
Dates Service: Claims with dates of service on or after January 1, 2020, will be excluded to Time Period Being Reviewed
Description: Pneumatic Compression Devices, HCPCS Codes E0651 and E0652, may have been provided to patients where all Medicare coverage criteria were not met. This review will determine if the pneumatic compression device is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. Affected codes: E0651, E0652, E0656, E0657, E0667, E0668, E0669 and E0670
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) - Part E – Miscellaneous Provisions – Definitions of Services, Institutions, Etc. (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 10. 42 CFR §414.210 (f)– General Payment Rules 11. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 12. 42 CFR §424.57(c)- Application Certification Standards 13. 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 14. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 15. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 16. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders, Section 5.2.1- Physician Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirement of New Orders 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 19. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 20. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 21. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 22. Medicare National Coverage Determination Manual, Chapter 1, Part 4 (Sections 200-310.1) Coverage Determinations, §280.6- Pneumatic Compression Devices Medicare Claims Processing Manual, Chapter 30 Section 50.13.4, Supplier’s Right to Recovery Resalable Items for Which Refund Has Been Made 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, LCD L33829 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2020 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52488 – Pneumatic Compression Devices; Effective 10/01/2015; Revised 01/01/2020 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 01/01/2020

Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime: Excessive Units

Issue Name: Spinal Orthosis (TLSO/ LSO) within the Reasonable Useful Lifetime: Excessive Units
Issue Number: _0128
Review Type: Automated
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 01/01/2019
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review)
Description: Claims for more than one spinal orthosis (identical HCPCS code) within the reasonable useful lifetime will be denied Affected codes: L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651
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 §414.210- General Payment Rules 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. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 13. 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 14. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 15. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 17.Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 21. 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 01/01/2020

Durable Medical Equipment Billed While in Hospice

Issue Name: Durable Medical Equipment Billed While in Hospice
Issue Number: _0114
Review Type: Automated
Provider Type: DME Supplier/DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/20/2018
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review).
Description: All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services or any claims billed after the admit date of a patient to Hospice services and null discharge date (when patient status code is 30), will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D.
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- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 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. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, 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. 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 9. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 10. Code of Federal Regulations 42, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals 11. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 12. 42 CFR §424.57(c)- Application Certification Standards 13. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services Under Hospital Insurance, Section 10- Requirements- General 14. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, Section 10- Overview, Section 30.3- Data Required on the Institutional Claim to A/B MAC (HHH), Section 40.2- Processing Professional Claims for Hospice Beneficiaries 15. Medicare Claims Processing Manual- Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), Section 10.2- Coverage Tables for DME Claims"

Custom-Fabricated Knee Orthoses: Medical Necessity and Documentation Requirements

Issue Name: Custom-Fabricated Knee Orthoses: Medical Necessity and Documentation Requirements
Issue Number: _0107
Review Type: Complex
Provider Type: DME by supplier; DME by physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 09/14/2018
Dates Service: Exclude claims with an initial determination date more than 3 years prior to ADR date. Claims with dates of service on or after January 1, 2020, will be excluded.
Description: Claims for Custom Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied. Affected codes L1844 - KNEE ORTHOSIS, SINGLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED; L1846 - KNEE ORTHOSIS, DOUBLE UPRIGHT, THIGH AND CALF, WITH ADJUSTABLE FLEXION AND EXTENSION JOINT (UNICENTRIC OR POLYCENTRIC), MEDIAL-LATERAL AND ROTATION CONTROL, WITH OR WITHOUT VARUS/VALGUS ADJUSTMENT, CUSTOM FABRICATED
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(4) - Payment for Certain Customized Items 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1834(h) - Payment for Prosthetic Devices and Orthotics and Prosthetics 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(h)(1) - General Rule for Payment 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1834(h)(1)(F)(ii) - Description of custom-fabricated item. 10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(h)(1)(F)(iii) - Qualified practitioner defined 11. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 12. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1861(n) - Durable Medical Equipment Definition 14. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Rules Concerning Orders, Physician Orders 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 28. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33318: Knee Orthoses: Effective 10/01/2015; Revised 1/01/2020 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52465: Knee Orthoses - Policy Article; Effective 10/1/2015, Revision 01/01/2020 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2020"

Parenteral Nutrition: Medical Necessity and Documentation Requirements

Issue Name: Parenteral Nutrition: Medical Necessity and Documentation Requirements
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
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date (complex review)
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 CF §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 Code of Federal Regulations §424.57 - Special payment rules for items furnished by Durable Medical Equipment, Prosthetics/Orthotics & Supplies (DMEPOS) suppliers and issuance of DMEPOS supplier billing privileges 13. 42 CF §424.57(c) - Application Certification Standards 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120 Prosthetic Devices 15. CMS National Coverage Determinations (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- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.2 - Rules Concerning Orders, Physician Orders 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.2.1- Rules Concerning Orders, Physician Orders 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME)E Considerations, Section 5.2.2 – Verbal and Preliminary Written Orders 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.2.7 - Requirements of New Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.3 - Certificates of Medical Necessity (CMNs) and DME Information Forms 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.7- Documentation in the Patient’s Medical Record 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, Section 5.8- Supplier Documentation 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special Durable Medical Equipment/(DME) Considerations, 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 10/01/2015, Revision 1/01/2020 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 1/01/2017; Revised 04/06/2020 "

Urological Supplies: Medical Necessity and Documentation Requirements

Issue Name: Urological Supplies: Medical Necessity and Documentation Requirements
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
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020, will be excluded.
Description: Documentation will be reviewed to determine if Urological Supplies meet coverage criteria and/or are medically reasonable and necessary. Affected codes: See Appendix D.
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)(2) - Payment for Inexpensive and Other Routinely Purchased Durable Medical Equipment 6. 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 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 8. 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 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 10. Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit 11. 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 12. 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 13. 42 CFR §405.986- Good Cause for Reopening 14. 42 CFR §410.38 – Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and Conditions 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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §120 Prosthetic Devices 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 3- Verifying Potential Errors and Taking Corrective Actions, §3.3.2.4- Signature Requirements 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Rules Concerning Orders, Physician Orders 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 28. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 29. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33803: Urological Supplies, Effective 10/01/2015; Revised 1/01/2019 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52521: Urological Supplies, Effective 10/01/2015; Revised 1/01/2019 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 01/01/2020 "

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
Dates Service: Less than 3 years and on or after October 1, 2015
Description: Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonablDocumentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary. Affected code E1390, E0431
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)(6) - 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. Medicare Claims Processing Manual Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); Section 100.2.3- Evidence of Medical Necessity for Oxygen 24. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2- Home Use of Oxygen; Effective 10/27/1993 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination L33797: Oxygen and Oxygen Equipment; Effective 10/01/2015; Revised 01/01/2019 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52514: Oxygen and Oxygen Equipment; Effective 10/01/2015; Revised 01/01/2019 27. 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 04/06/2020"

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
Dates Service: Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date. The look-back period is closed on or after 01/01/2020
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 01/01/2020"

Negative Pressure Wound Therapy Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements

Issue Name: Negative Pressure Wound Therapy Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements
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
Dates Service: Less than 3 years and on or after 5/25/2017
Description: This review will determine if Negative Pressure Wound Therapy 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: 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"

Group 2 Support Surfaces Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements

Issue Name: Group 2 Support Surfaces Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements
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
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: 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-Items and Services Having Special DME Review Considerations, Section 5.2 - Rules Concerning Orders, Physician Orders; 15. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.1- Rules Concerning Orders, Physician Orders; 16. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.2 – Verbal and Preliminary Written Orders; 17. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders; 18. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.7 - Requirements of New Orders; 19. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis; 20. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record; 21. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation; 22. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity; 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33642: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 01/01/2019; 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52490: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 01/01/2019; 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;

Ventilators Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements

Issue Name: Ventilators Subject to Detailed Written Order Requirements: Medical Necessity and Documentation Requirements
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
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020, 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: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 §410.38 – Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and Conditions 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 National Coverage Determination Manual, Chapter 1, Part 4, §240.5- Intrapulmonary Percussive Ventilator 17. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List 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 5- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Rules Concerning Orders, Physician Orders 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 27. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33800: Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2017 28. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52517: Respiratory Assist Devices- Policy Article, Effective 10/01/2015; Revised 1/01/2020 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 01/01/2020

Home Health: Medical Necessity and Documentation Requirements

Issue Name: Home Health: Medical Necessity and Documentation Requirements
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
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 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 1814(a)(2)(C) - Conditions of and Limitations on payment for services; 4. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services; 5. 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; 6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services; 7. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(o) – Home Health Agency; 8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(r) - Physician; 9. 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; 10. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(gg)(2) – Certified Nurse-Midwife Services; 11. 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; 12. 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; 13. 42 CFR §405.986- Good Cause for Reopening; 14. 42 CFR 409.41 – Requirement for Payment; 15. 42 CFR 409.42 – Beneficiary qualifications for coverage of services; 16. 42 CFR 409.43 – Plan of care requirements; 17. 42 CFR 409.44 – Skilled services requirements; 18. 42 CFR 409.45 – Dependent services requirements; 19. 42 CFR 409.46 – Allowable administrative costs; 20. 42 CFR 409.47 – Place of service requirements; 21. 42 CFR §424.22(a)(1)(i)-(v) – Requirement for home health services; 22. 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; 23. 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; 24. 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; 25. Medicare Program Integrity Manual, Chapter 6- - Medicare Contractor Medical Review Guidelines for Specific Services, §3.2.1.1- Certification Requirements; 26. 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; 27. 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; 28. 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; 29. 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; 30. Medicare Benefit Policy Manual, Chapter 7- Home Health Services, Section 30- Conditions Patient Must Meet to Qualify for Coverage of Home Health Services, Subsection- 30.5.2 Physician Recertification;"

Respiratory Assist Devices: Medical Necessity and Documentation Requirements

Issue Name: Respiratory Assist Devices: Medical Necessity and Documentation Requirements
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
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020, 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, E0471
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- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §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- Items and Services Having Special DME Review Considerations, §5.2.5- Face-to-Face Encounter Requirements 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.6- Date and Timing Requirements 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient's Medical Record 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 28. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 29. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination (LCD) L33800: Effective 10/1/2015; Revised 01/01/2017 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Respiratory Assist Device- Policy Article A52517: Effective 10/1/2015; Revised 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 01/01/2020"

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
Dates Service: less than 3 years and on or after October 1, 2015.
Description: This review will determine if a Positive Airway Pressure 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: E0601 - CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICE; 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
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 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery 24. 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 25. Medicare Program Integrity Manual, Chapter 5, Section 5.2.5- Face-to-Face Encounter Requirements 26. Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements 27. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 28. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 29. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 30. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 31. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 32. CGS and Noridian Healthcare Solutions LCD L33718- Positive Airway Pressure (PAP) for the Treatment of Obstructive Sleep Apnea: Effective 10/01/2015; Revised 01/01/2019 33. CGS and Noridian Healthcare Solutions LCA A52467- Positive Airway Pressure (PAP) for the Treatment of Obstructive Sleep Apnea: Effective 10/01/2015; Revised 01/01/2019 34. CGS and Noridian Healthcare Solutions LCA A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017; Revised 01/01/2020"

Continuous Positive Airway Pressure Machine without an Obstructive Sleep Apnea Diagnosis

Issue Name: Continuous Positive Airway Pressure Machine without an 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
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: 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: 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 01/01/2020 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 01/01/2020 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 04/06/2020"

Spinal Orthoses: Medical Necessity and Documentation Requirements

Issue Name: Spinal Orthoses: Medical Necessity and Documentation Requirements
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
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: This review will determine if a Spinal Orthoses is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied Affected codes: L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270, L0456, L0457, L0625, L0627, L0637, L0642
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)(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- Items and Services Having Special DME Review Considerations, Section 5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.1- Rules Concerning Orders, Physician Orders 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.2 – Verbal and Preliminary Written Orders 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders 26. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.2.7 - Requirements of New Orders 27. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record 28. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33790- Spinal Orthosis: TLSO and LSO, Effective 10/01/2015; Revised 01/01/2020 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52500- Spinal Orthosis: TLSO and LSO, Effective 10/01/2015; Revised 01/01/2020 32. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs - Effective 01/01/2017; Revised 04/06/2020

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
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: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(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 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 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 1847(a)(2)- Competitive Acquisition of Certain Items Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(9)- Medical and Other Health Services 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, Prosthetics, Orthotics and Supplies (DMEPOS): Scope and Conditions 42 CFR §414.210(f)- Payment for replacement of equipment 42 CFR §414.402- Definitions 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 15. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Section 100.2- General Documentation Requirements- Certificates of Medical Necessity Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements Medicare Program Integrity Manual, Chapter 5- 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. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Effective 10/01/2015; Revised 1/01/2020 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52457- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Effective 10/01/2015; Revised 1/01/2019 21. 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 01/01/2020

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
Dates Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020, will be excluded.
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. Affected codes: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4360, L4361, L4386, L4387, 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, Prosthetics, Orthotics and Supplies (DMEPOS): Scope and Conditions 11. 42 CFR §414.210(f)- Payment for replacement of equipment 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 16. 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 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 1/01/2020 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52457- Ankle-Foot/ Knee-Ankle-Foot Orthoses, Effective 10/01/2015; Revised 1/01/2019 21. 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 01/01/2020

Negative Pressure Wound Therapy- Medical Necessity and Documentation Requirements

Issue Name: Negative Pressure Wound Therapy- Medical Necessity and Documentation Requirements
Issue Number: _0017
Review Type: Complex
Provider Type: DME by Supplier
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/28/2017
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: "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 5.2.3- Rules Concerning Orders, Detailed Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4(C) - Rules Concerning Orders, Written Orders Prior to Delivery 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements 20. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 21. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 22. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 23. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 24. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 25. 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 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52511: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 27. 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"

Negative Pressure Wound Therapy- Medical Necessity and Documentation Requirements

Issue Name: Negative Pressure Wound Therapy- Medical Necessity and Documentation Requirements
Issue Number: _0017
Review Type: Complex
Provider Type: DME by Supplie
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/28/2017
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: "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 5.2.3- Rules Concerning Orders, Detailed Written Orders 17. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4-Rules Concerning Orders, Written Orders Prior to Delivery 18. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4(C) - Rules Concerning Orders, Written Orders Prior to Delivery 19. Medicare Program Integrity Manual, Chapter 5, Section 5.2.6- Date and Timing Requirements 20. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 21. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 22. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record 23. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation 24. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity 25. 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 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52511: Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017 27. 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"

Power Mobility Devices: Medical Necessity and Documentation Requirements

Issue Name: Power Mobility Devices: Medical Necessity and Documentation Requirements
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
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: 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)(1)(E)(iv) – Standard for Power Wheelchairs 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 §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs) 11. 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (1) – Definitions 12. 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (2) – Conditions of Payment 13. 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (3) - Exceptions 14. 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (4) – Dispensing a power mobility device 15. 42 CFR §410.38 - Durable Medical Equipment: Scope and Conditions, (c) - Power mobility devices (PMDs), (5) – Documentation 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. 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). 19. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §110, Durable Medical Equipment – General, Rev. 10/1/2003. 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 Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 22. Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders 23. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4(A)- Written Orders Prior to Delivery-General 24. Medicare Program Integrity Manual, Chapter 5, Section 5.2.4(B)- Written Orders Prior to Delivery for Power Operated Vehicles and Power Wheelchairs 25. Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders 26. Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 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. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination (LCD) L33789: Effective 10/1/2015; Revised 01/01/2019 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Power Mobility Devices- Policy Article A52498: Effective 10/1/2015; Revised 01/01/2019 32. 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

Enteral Nutrition Therapy: Medical Necessity and Documentation Requirements

Issue Name: Enteral Nutrition Therapy: Medical Necessity and Documentation Requirements
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
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date (complex review).
Description: Enteral nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. Affected codes: B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9000, B9002.
References: ". 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(d)(12)- Special Payment Rules for Items Furnished by DMEPOS Suppliers and Issuance of DMEPOS Supplier Billing Privileges; Evidence of DMEPOS Supplier's Compliance 8. Medicare National Coverage Determination Manual, NCD Section 180.2- Enteral and Parenteral Nutrition Therapy, Rev. 173, Issued 9/04/2014, Effective Upon Implementation of ICD-10. 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 110- Durable Medical Equipment – General 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, Section 120- Prosthetic Devices 11. 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 12. 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 13. Medicare Program Integrity Manual, Chapter 4- Program Integrity, Section 4.26- Supplier Proof of Delivery Documentation Requirements 14. Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.2.3- Detailed Written Orders 15. 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 16. 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 17. 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 18. 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 19. 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 20. 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) 21. Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record 22. Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.8- Supplier Documentation 23. Medicare Program Integrity Manual, Chapter 5- Items and Services having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity 24. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, LCD L33783- Enteral Nutrition, Effective 10/01/2015; Revised 01/01/2020 25. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A52493- Enteral Nutrition- Policy Article, Effective 10/01/2015; Revised 4/30/2020 26. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/06/2020 "

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
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded.
Description: When the indications of coverage and/or medical necessity are not met and/or when the item delivered has not been correctly coded according to the Pricing, Data Analysis and Coding (PDAC) contractor, the blood glucose monitor with integrated voice synthesizer (HCPCS code E2100) will be denied.
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. 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 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions,§3.3, Policies and Guidelines Applied During Review 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services,§110, Durable Medical Equipment – General 15. Medicare National Coverage Determinations Manual, Chapter 1,§40.2, Home Blood Glucose Monitors 16. CGS and Noridian Healthcare Solutions LCD L33822- Glucose Monitors, Effective 10/01/2015; Revised 1/01/2019 17. CGS and Noridian LCA A52464- Glucose Monitor, Effective 10/012015; Revised: 01/01/19 18. CGS and Noridian Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 – Effective 01/01/2017; Revised 01/01/2020"

Glucose Monitor Supplies Billed With Same Dates of Service as Glucose Monitor: Unbundling

Issue Name: Glucose Monitor Supplies Billed With Same Dates of Service as Glucose Monitor: 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
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: When a glucose monitor is provided, the glucose monitor supplies are included in the allowance for the glucose monitor and are not separately payable. These items will be denied when unbundled. Affected codes: A4233, A4234, A4235, A4236.
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §40.2- Home Blood Glucose Monitors 7. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 01/01/2020 8. 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 01/01/2020

Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision

Issue Name: Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision
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
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: Continuous Passive Motion billed for patients who have not received a total knee replacement or total knee revision will be recouped. Affected Codes: E0935 CONTINUOUS PASSIVE MOTION EXERCISE, DEVICE FOR USE ON KNEE ONLY
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual Chapter 20, 30.2.1 - Daily Payment for Continuous Passive Motion (CPM) Devices 7. National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List

Spring-Powered Devices: Excessive Units

Issue Name: Spring-Powered Devices: Excessive Units
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
Dates Service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review).
Description: More than one spring powered device (code A4258) per 6 months is not reasonable and necessary. Units billed in excess on one will be recouped. Affected code: A4258
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §40.2- Home Blood Glucose Monitors 7. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 01/01/2020 8. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464- Glucose Monitor- Policy Article; Effective 10/01/2015; Revised 01/01/2020 9. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs - Effective 01/01/2017; Revised 01/01/2020

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
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. Affected Codes: E0100 -E8002; K0001 -K0899; L0112 -L4631; V2020 -V2786; A4206 -A9999; B4034 -B9999; and J and Q codes (see Appendix D1)
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), §110.3.2- 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

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
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 Devices: Medical Necessity and Documentation Requirements

Issue Name: High Frequency Chest Wall Oscillation Devices: 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
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, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §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, §5.2 - Rules Concerning Orders, Physician Orders 21. Medicare Program Integrity Manual, Chapter 5, §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, §5.2.5- Face-to-Face Encounter Requirements 23. Medicare Program Integrity Manual, Chapter 5, §5.2.6- Date and Timing Requirements 24. Medicare Program Integrity Manual, Chapter 5, §5.2.7 - Requirements of New Orders 25. Medicare Program Integrity Manual, Chapter 5, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 26. Medicare Program Integrity Manual, Chapter 5, §5.7- Documentation in the Patient's Medical Record 27. Medicare Program Integrity Manual, Chapter 5, §5.8- Supplier Documentation 28. Medicare Program Integrity Manual, Chapter 5, §5.9- Evidence of Medical Necessity 29. CGS and Noridian LCD L33785- High Frequency Chest Wall Oscillation Devices; Effective 10/1/2015; Revised 01/01/2019 30. CGS and Noridian Policy Article A52494- High Frequency Chest Wall Oscillation Devices; Effective 10/1/2015; Revised 01/01/2019 31. CGS and Noridian LCA A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2019"

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
Dates Service: Review automated review claims having a paid claim date less than 3 years prior to the Informational Letter date.
Description:To identify improper payments for nebulizers billed not in accordance with billing requirements, for provider types: DME supplier and DME by Physician, using error code 2500 (not medical necessary), and including all places of services for DME claims. Affected codes: 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, J7677(effective for DOS on or after 7/01/2019), J7682, J7686, K0730, Q4074
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, (a)- Payment for Durable Medical Equipment, (1)- General Rule for Payment, (E)- Clinical Conditions for Coverage 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 National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 280.1- Durable Medical Equipment Reference List 12. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33370: Nebulizers, Effective 10/01/2015; Revised 05/17/2020 13. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52466: Nebulizers- Policy Article; Effective 10/01/2015; Revised 05/07/2020 14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020 "

Nebulizer Drugs: Medical Necessity and Documentation Requirements

Issue Name: Nebulizer Drugs: Medical Necessity and Documentation Requirements
Issue Number: _0026
Review Type: Complex
Provider Type: DME by Supplier, DME by Provider
Region: Region-5
State: 5 - Nationwide
Date Approved: 04/14/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date (complex review). The look-back period is closed on or after 01/01/2020
Description: This review will determine if the submitted documentation supports Medicare’s coverage criteria and reasonable and necessary requirements. Affected codes: J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7626, J7631, J7639, J7644, J7669, J7682, J7686, Q0474, J7620
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §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 National Coverage Determinations Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List 12. Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics and Supplies, §100- General Documentation Requirements 13. 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 14. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements 15. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 16. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2 - Rules Concerning Orders, Physician Orders 17. Medicare Program Integrity Manual, Chapter 5, §5.2.1- Rules Concerning Orders, Physician Orders 18. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.2 – Verbal and Preliminary Written Orders 19. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.3- Rules Concerning Orders, Detailed Written Orders 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.7 - Requirements of New Orders 21. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 22. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.7- Documentation in the Patient’s Medical Record 23. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.8- Supplier Documentation 24. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.9- Evidence of Medical Necessity 25. Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §200.2- Nebulized Beta Adrenergic Agonist Therapy for Lung Diseases 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33370: Nebulizers, Effective 10/01/2015; Revised 01/01/2019 27. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52466: Nebulizers, Effective 10/01/2015; Revised 01/01/2019 28. 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 01/01/2020"

Group 2 Support Surfaces: Medical Necessity and Documentation Requirements

Issue Name: Group 2 Support Surfaces: Medical Necessity and Documentation Requirements
Issue Number: _0029
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/15/2017
Dates Service: Claims having a “claim paid date” which is more than 3 years prior to the ADR date will be excluded and claims with dates of service prior to January 01, 2016
Description: Documentation will be reviewed to determine if Group 2 Support Surfaces meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: E0277, E0371, E0372, E0373.
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, §3.3.2.4- Signature Requirements; 12. 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; 13. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements; 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General; 15. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2 - Rules Concerning Orders, Physician Orders; 16. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.7 - Requirements of New Orders; 17. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis; 18. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.7- Documentation in the Patient’s Medical Record; 19. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.8- Supplier Documentation; 20. Medicare Program Integrity Manual, Chapter 5-Items and Services Having Special DME Review Considerations, Section 5.9- Evidence of Medical Necessity; 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33642 – Pressure Reducing Support Surfaces Effective 10/01/2015; Revised 01/01/2019; 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52490 – Pressure Reducing Support Surfaces; Effective 10/01/2015; Revised 01/01/2019; 23. 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 ;"

Osteogenesis Stimulators: Medical Necessity and Documentation Requirements

Issue Name: Osteogenesis Stimulators: Medical Necessity and Documentation Requirements
Issue Number: _0030
Review Type: Complex
Provider Type: DME by Supplier and DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 02/14/2017
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the ADR Letter date.
Description: This review will determine if an Osteogenesis Stimulator 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 E0747, E0748, E0760.
References: "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1833(e) - Payment of Benefits 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 - Special Payment Rules 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §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, §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, §5.2 - Rules Concerning Orders, Physician Orders 21. Medicare Program Integrity Manual, Chapter 5, §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, §5.2.5- Face-to-Face Encounter Requirements 23. Medicare Program Integrity Manual, Chapter 5, §5.2.6- Date and Timing Requirements 24. Medicare Program Integrity Manual, Chapter 5, §5.2.7 - Requirements of New Orders 25. Medicare Program Integrity Manual, Chapter 5, §5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis 26. Medicare Program Integrity Manual, Chapter 5, §5.3 - Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) 27. Medicare Program Integrity Manual, Chapter 5, §5.7- Documentation in the Patient's Medical Record 28. Medicare Program Integrity Manual, Chapter 5, §5.8- Supplier Documentation 29. Medicare Program Integrity Manual, Chapter 5, §5.9- Evidence of Medical Necessity 30. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination L33796 Osteogenesis Stimulators: Effective 10/1/2015, Revision 01/01/2017. 31. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article: Osteogenesis Stimulators - Policy Article A52513: Effective 10/1/2015, Revision 01/01/2017 32. 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"

Durable Medical Equipment Rentals: Multiple Billing within the Same Month

Issue Name: Durable Medical Equipment Rentals: Multiple Billing within the Same Month
Issue Number: _0046
Review Type: Automated
Provider Type: DME by Supplier, DME by Physician
Region: Region-5
State: 5 - Nationwide
Date Approved: 03/31/2017
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:Overpayments associated to DMEPOS suppliers billing multiple rentals for the same equipment within the same month (27 days) will be recovered. Affected codes: E0165, E0170, E0171, E0181, E0182, E0186, E0187, E0193, E0194, E0196, E0235, E0236, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302, E0303, E0304, E0305, E0316, E0371, E0372, E0373, E0424, E0431, E0433, E0434, E0439, E0462, E0470, E0471, E0472, E0480, E0482, E0483, E0500, E0550, E0565, E0570, E0572, E0574, E0575, E0585, E0600, E0601, E0606, E0617, E0618, E0619, E0630, E0635, E0636, E0675, E0744, E0745, E0749, E0779, E0781, E0784, E0791, E0849, E0910, E0911, E0912, E0920, E0930, E0940, E0941, E0946, E0958, E0968, E0983, E0988, E1031, E1035, E1036, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1087, E1088, E1092, E1093, E1100, E1110, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1221, E1222, E1223, E1224, E1225, E1228, E1240, E1270, E1280, E1295, E1390, E1391, E1392, E1405, E1406, E1801, E1802, E1805, E1806, E1811, E1812, E1815, E1816, E1818, E1840, E1841, E2000, E2120, E2374, E2378, E2402, K0001, K0002, K0003, K0004, K0006, K0007, K0009, K0010, K0011, K0012, K0195, K0455, K0606, K0730, K0738, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, B9000, B9002, B9004, B9006, E0776
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. 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 4. 42 CFR §405.986- Good Cause for Reopening 5. 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 6. Medicare Claims Processing Manual Chapter 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), 30.2- Items Requiring Frequent and Substantial Servicing; 30.5- Capped Rental Items; 30.7- Payment for Parenteral and Enteral Nutrition (PEN) Items and Services; 130.8- Installment Payments 7.National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List