Source: https://performantrac.com/audit-issues/
Timestamp: 2019-04-20 22:24:01+00:00

Document:
This list includes all CMS-approved audit issues.
Dates Service: Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review).
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. IOM, 100-08, 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 "
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.	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 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 7.	CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.C 8.	CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- LCD L33318, Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 10/16/2017 9.	CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- Local Coverage Article A52465 Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 01/01/2017 10.	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"
Dates Service: "Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date. "
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 Code of Federal Regulations (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.	IOM, 100-04, Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners 10.	IOM, 100-04, Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements 11.	IOM, 100-08, Medicare Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions §3.6.2.4 Coding Determinations 12.	American Medical Association (AMA), Current Procedural Terminology (CPT) 13.	AMA, HCPCS Level II 14.	AMA CPT Assistant 15.	National Correct Coding Initiatives (NCCI) Policy Manual 16.	1995 & 1997 Documentation Guidelines for Evaluation & Management Services 17.	CMS Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html"
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.	SSA, §1862(a)(1)(A), §1862(a)(7) – Exclusions from coverage 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.	CMS Manual System, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§80.4-80.4.4, Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician 9.	CMS Manual System, Pub, 100-02, Medicare Benefit Policy Manual, Chapter 15, §80.6.1, Definitions. 10.	CMS Manual System, Pub. 100-04, Program Integrity Manual, Chapter 3 §3.2.3.8 - No Response or Insufficient Response to Additional Documentation Requests 11.	CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, §3.4.1.3, Diagnoses Code Requirement. 12.	CPT Manual"
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; Publication 100-04; Chapter 12, Section 30.6.9.2 (C) Subsequent Hospital Visit and Discharge Management on Same Day"
"Ambulatory Surgery Center (ASC) SNF"
Provider Type: "Ambulatory Surgery Center (ASC) SNF"
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)	Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF 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 4)	Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 6 SNF 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 5)	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 6)	SNF Consolidated Billing – Annual Updates for Part A MAC – 2015, 2016, 2017 and 2018 https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2015-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2016-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2017-Part-A-MAC-Update.html https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/2018-Part-A-MAC-Update.html 7)	SNF Consolidated Billing – General Explanation of the Major Categories for Skilled Nursing Facility – https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2018-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2017-General-Explanation.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2016-General-Explanations.pdf https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/Downloads/2015-General-Explanation.pdf "
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.
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.	CGS LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 1/1/2018 7.	First Coast LCD L33762- Treatment of Varicose Veins of the Lower Extremity; Effective 10/1/2015; Revised 01/22/2019 8.	NGS LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/1/2015; Revised 1/1/2018 9.	Noridian LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 1/1/2018 10.	Noridian LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 1/1/2018 11.	Novitas LCD L34924- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 10/1/2015, Revised 5/17/2018 12.	12.	Palmetto LCD L33454- Varicose Veins of the Lower Extremities; Effective 10/1/2015, Revised 4/22/2019 13.	WPS LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/1/2015; Revised 10/01/2018 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.	NGS LCA A52870- Varicose Veins of the Lower Extremity, Treatment of- Supplemental Instructions Article; Effective 10/1/2015; Revised 1/1/2018 17.	Novitas A55229- Treatment of Varicose Veins and Venous Stasis Disease of the Lower Extremities; Effective 8/11/2016; Revised 5/17/2018"
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."
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)- Part E- Miscellaneous Provisions- Definitions of Services, Institutions, ETC.- Pulmonary Rehabilitation Program 4.	42 C.F.R. §§ 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage 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.	CMS Benefit Policy Manual, Pub. 100-02, Chapter 15, Section 231 9.	CMS Claim Processing Manual, Pub. 100-04, Chapter 32, Section 140 10.	CMS Transmittal R1966CP- Pulmonary Rehabilitation (PR) Services; Issued Date 5/7/2010, Implementation Date 10/4/2010 11.	Noridian LCA A52770 Pulmonary Rehabilitation; original effective date: 10/01/2015; Revision Date: 10/08/2018 12.	Noridian LCA A56152 Pulmonary Rehabilitation; original effective date: 10/08/2018"
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.	CMS Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30 (H) (Most Extensive Procedures) and J. With/Without Procedures (Effective 10/1/03) 7.	CMS Publication 100-04; Chapter 23, § 20.9.2 Fee Schedule Administration and Coding Requirements 8.	NCCI Policy Manual for Medicare Services Chapter 1 A 9.	CPT Manual year 2015 to current"

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