Source: https://performantrac.com/audit-regions/region-5/page/2/
Timestamp: 2019-06-18 17:40:19
Document Index: 778261912

Matched Legal Cases: ['§405', 'arty 8', '§405', '§424', '§424', '§3', '§4', '§110', '§405', 'arty 42', '§405', '§424', '§424', '§3', '§4', '§110', '§405', '§405', '§424', '§424', '§110', 'art 4', '§240', 'art 4', '§280', '§3', '§424']

Region 5 – Page 2 – Performant CMS RAC
Complex Negative Pressure Wound Therapy Pumps-DWO
Issue Name: Complex Negative Pressure Wound Therapy Pumps-DWO
Issue Number: _0081
Date Approved: 02/26/2018
Dates Service: Less than 3 years and on or after 5/25/2017
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 Local Coverage Determination (LCD) L33821 (related MAC Policy Article A52511). 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"
Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
_0080
Issue Name: Complex Group 2 Support Surfaces without Correct Diagnosis of Condition- DWO
Issue Number: _0080
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: "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 - Special Payment Rules Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 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 1861(s) - Medical and Other Health Services Definitions 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 §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 42 CFR §424.57(c)- Application Certification Standards 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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33642: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52490: Pressure Reducing Support Surfaces- Group 2, Effective 10/01/2015; Revised 5/25/2017 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"
Issue Name: Ventilators Subject to DWO Requirements on or after January 1, 2016
Issue Number: _0079
Date Approved: 01/11/2018
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: 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 - Special Payment Rules; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a) - Payment for Durable Medical Equipment; 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; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies; 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 1861(n) - Durable Medical Equipment Definition ; Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions; 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 §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges; 42 CFR §424.57(c)- Application Certification Standards; Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General ; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.5- Intrapulmonary Percussive Ventilator; Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List; 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 5, Section 5.2 - Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.1- Rules Concerning Orders, Physician Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.2 – Verbal and Preliminary Written Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.3- Rules Concerning Orders, Detailed Written Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders; Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record; Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation; Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity; CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33800: Respiratory Assist Device, Effective 10/01/2015; Revised 1/01/2017; 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: 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 1814(a)(2)(C) - Conditions of and Limitations on payment for services 2.	Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services 3.	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 4.	Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services 5.	Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(o) – Home Health Agency 6.	Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(r) - Physician 7.	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 8.	Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(gg)(2) – Certified Nurse-Midwife Services 9.	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 10.	42 CFR 409.41 – Requirement for Payment 11.	42 CFR 409.42 – Beneficiary qualifications for coverage of services 12.	42 CFR 409.43 – Plan of care requirements 13.	42 CFR 409.44 – Skilled services requirements 14.	42 CFR 409.45 – Dependent services requirements 15.	42 CFR 409.46 – Allowable administrative costs 16.	42 CFR 409.47 – Place of service requirements 17.	42 CFR §424.22(a)(1)(i)-(v) – Requirement for home health services 18.	IOM, 100-01 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 19.	IOM, 100-01 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 20.	IOM, 100-02 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 21.	IOM, 100-02 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 22.	IOM, 100-02 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 23.	IOM, 100-02 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