Source: https://performantrac.com/audit-issues/page/2/
Timestamp: 2019-04-20 22:32:12+00:00

Document:
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 Edit Parameters: 1.	Assigned Claims Only 2.	Provider Types: Professional Services (Physician/non-physician practitioner) and Outpatient Hospital 3.	Error Code: 6000 – Unbundling service – included in allowable for another billed service 4.	Exclude claims that have a “paid claim date” which is more than 3 years prior to the Informational Letter Date (automated review). 5.	Algorithm identifies all Paid Part B Professional Claims and Outpatient Hospital Claims (Bill Type 12X, 13X), or Provider Types Outpatient Hospital and Professional Services (Physician/non- physician practitioner) with (Allowed Amt>$0.00) for CPT codes listed as Most Extensive Code billed on the same day as one or both of the corresponding Less Extensive Code(s) in the Appendix D table ""Most Extensive CT Scan Procedure Table"" for the same beneficiary, same group practice (Based on Tax ID and Specialty Code) and admit date and discharge date. •	The CPT code identified as the Most Extensive Code is the valid, anchor claim. •	The CPT code(s) identified as the Less Extensive Code(s), for the identified Most Extensive code, is the finding, overpaid claim. 6.	Algorithm excludes claims that do not have matching 26/TC modifiers, in any position, for each of the code combinations. Both the finding and anchor claim must have the same Modifier, either 26 or TC. 7.	Exclude all Prior Authorization claims identified with a valid Unique Tracking Number (UTN) 8.	Algorithm excludes findings for the following modifiers on either the anchor or findings claim: •	59 – Distinct Procedural Service •	76- Repeat Procedure by Same Physician •	77- Repeat Procedure by Another Physician •	XE - Separate Encounter, Service that is distinct - occurred during separate encounter •	XS - Separate Structure, Service that is distinct - performed on a separate organ/structure •	XP - Separate Practitioner, Service that is distinct - performed by a different practitioner •	XU - Unusual Non-Overlapping service, use of a service that is distinct – does not overlap usual components of the main source •	GA - Waiver of Liability Statement issued as required by payer policy •	GX - Notice of Liability issued, voluntary under payer policy •	Q0 - Investigational clinical service provided in a clinical research study that is in an approved clinical research study •	Q1 - Routine clinical service provided in a clinical research study that is in an approved clinical research study 9.	Algorithm excludes any claims that will have an overpayment adjustment of less than $25. 10.	Exclude all claims identified with a valid Unique Tracking Number (UTN)."
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 (LCD) L33318, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date 10/16/2017 24.	CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52456, Knee Orthoses; Effective Date: 10/01/2015; Revision Effective Date: 01/01/2017 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 08/28/2018"
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.
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).
Dates Service: Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review).
References: "1.	Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10). 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 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 Definitions42 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 6.	42 CFR §405.986- Good Cause for reopening 7.	CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§10 General exclusions from coverage 8.	CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 General exclusion from coverage §§20 Services not reasonable and Necessary 9.	First Coast Service Options (FCSO) Local overage Determination (LCD) Vertebroplasty, Vertebral Augmentation, percutaneous L34976: Effective 10/01/2015; revised 4/17/18. 10.	Novitas LCD L35130 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 05/04/2017. 11.	Palmetto LCD L33473 Vertebroplasty/Kyphoplasty: Effective 10/01/2015; Revised 08/09/2018. 12.	WPS LCD L34592 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015; Revised 2/1/18. 13.	NGS LCD L33569 Vertebroplasty, Vertebral Augmentation, percutaneous: Effective 10/01/2015. 14.	Noridian LCD, Percutaneous Vertebral Augmentation, L34106, Effective 10/01/2015 15.	Noridian LCD, Percutaneous Vertebral Augmentation, L34228, Effective 10/01/2015 16.	CGS LCD, Vertebroplasty and Vertebral Augmentation, L34048, effective 10/01/2015 17.	Annual American Medical Association: CPT Manual."
Dates Service: Include claims that have a “claim paid date” which is less than 3 years prior to the ADR date.
References: "1.	Title XVIII of the Social Security Act (SSA): §§1833(e); 1862(a)(1)(A); 1862(a)(10) 2.	42 CFR §§405.980(b) and (c); 405.986; 411.15(k)(1); 424.5(a)(6) 3.	CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §§10, 20 4.	CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 16 §120 – Cosmetic Surgery 5.	National Correct Coding Initiative Policy Manual, Chapter 6, E, 7 6.	Medicare Claims Processing Manual Chapter 12, §40.6 (A) 7.	Novitas LCD L35090: Effective 10/1/2015; Revised 4/14/2017 8.	WPS L34698: Effective 10/01/2015; Revised 01/01/2018; 02/01/2016; 10/01/2016; 01/01/2017 9.	Palmetto GBA L33428: Effective 10/01/2015; Revised 10/1/18 10.	Noridian LCD L35163: Effective 10/1/2015; Revised 10/10/2017 11.	Noridian LCD L37020: Effective 10/10/2017 12.	Annual American Medical Association: CPT Manual"
Description: Claims for Cryosurgery of the Prostate are not deemed to be medically necessary based on the guidelines outlined in the Centers for Medicare and Medicaid National Coverage Determination Manual (Publication 100-03, Part 4, § 230.9).
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 §405.986 Good Cause for Reopening ; 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; CMS National Coverage Determinations Manual (NCD), Pub 100-03, Part 4, §230.9 Cryosurgery of Prostate (Rev. 1, 10-03-03).; CMS Claims Processing Manual, Pub 100-04, Ch. 32, §180 Cryosurgery of the Prostate Gland (Rev. 1111, Issued: 11-09-06, Effective: 04-01-07, Implementation: 04-02-07).

References: §405
 §405
 §3
 § 20
 §405
 §405
 §424
 §424
 §3
 §4
 §110
 §405
 §405
 §120
 §40
 § 230
 §405
 §405
 §230
 §180