Source: https://performantrac.com/audit-issues/page/4/
Timestamp: 2019-04-20 22:48:16+00:00

Document:
Dates Service: Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded.
References: "Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 42 CFR §405.986- Good Cause for Reopening 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 CMS Benefit Policy Manual 100-02, Chapter 9- Coverage of Hospice Services under Hospital Insurance, §10- Requirements, General"
Dates Service: Claims that have a “claim paid date” which is more than 3 years prior to the informational Letter date (automated review).
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.
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).
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).
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.
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.

References: §405
 §405
 §10
 §40
 §50
 §10