DCS approved audit issues
Updated as of 08/25/2010
(new issues highlighted)
Issue Name:
National Correct Coding Initiative (CCI) - Part B for Ambulatory Surgical
Centers
Issue
Number
A000102009
Issue
Description:
Application of the Part B National Correct Coding Initiative (Mutually
Exclusive and Non-Mutually Exclusive) to Ambulatory Surgical Centers.
Deny Column II code when billed by the same provider and same date of
service as a Column I code.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Ambulatory Surgical Center
Date Posted: August 24, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter
23 (Fee Schedule Administration and Coding Requirements), Subsection
20.9 (Correct Coding Initiative), revision effective 10/1/2003;; Internet Only
Manual 100-4 Medicare Claims Processing Manual, Chapter 14 (Ambulatory
Surgical Centers), Subsection 20.9 (Rebundling of CPT codes); revision
effective 10/1/2003. Column I/Column II code pairs are date sensitive.;
Issue Name:
Cardiac Defibrillator Implantation (At this time medical necessity is excluded
from review))
Issue
Number
A000552010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 222, 223, 224, 225, 226, 227; principal diagnosis,
secondary diagnoses, and procedures affecting or potentially affecting the
MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted: August 24, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Major Chest Procedures (At this time, medical
necessity is excluded from review).
Issue
Number
A000392009
Issue
Description:
MS-DRG Validation 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 for MSDRG 163, 164, 165, principal diagnosis, secondary diagnosis,
and procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
OIG report “National DRG Validation Study Special Report on Coding
Accuracy”, OAI-12-88-01010, which indicated that 20.8% of claims were
submitted with incorrect DRGs; ICD-9-CM Coding Manual ( for dates of
service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Chapter
6.5.3 Section A - C DRG Validation Review, UHDDS - Reporting of inpatient
Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages
31038-31040.;
Issue Name:
MS-DRG Validation for Extensive OR Procedure (At this time, medical
necessity is excluded from review)
Issue
Number
A000442009
Issue
Description:
MS-DRG Validation 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-DRG 981, 982 and 983 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038-31040;
Issue Name:
MS-DRG Validation for Complications of Cholecystectomy (At this time
medical necessity is excluded from review)
Issue
Number
A000572010
Issue
Description:
MS-DRG Validation 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 411, 412, 413, 414, 415, 416, 417, 418, and 419 for
principal and secondary diagnoses and procedures affecting or potentially
affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Craniotomy and Endovascular Intracranial
procedures (At the time, medical necessity is excluded from review)
Issue
Number
A000592010
Issue
Description:
MS-DRG Validation 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-DRG 025, 026 and 027 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Joint Procedures (At this time, medical necessity is
excluded from review)
Issue
Number
A000602010
Issue
Description:
MS-DRG Validation 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-DRG 462, 466, 467, 468, 469 and 470 for principal and
secondary diagnosis and procedures affecting or potentially affecting the
MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Non-extensive O.R. Procedure Unrelated to Principal
Diagnosis (At this time medical necessity is excluded from review)
Issue
Number
A000632010
Issue
Description:
MS-DRG Validation 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-DRG 987, 988 and 989 for principal and secondary diagnosis
and procedures affecting or potentially affecting the MS-DRG assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Hip and Femur Procedures (At this time medical
necessity is excluded from review)
Issue
Number
A000712010
Issue
Description:
MS-DRG Validation 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 495, 496, 497, 498 and 499 for principal and secondary
diagnosis and procedures affecting or potentially affecting the MS-DRG
assignment.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Pathological Fractures (At this time, medical
necessity is excluded from review)
Issue
Number
A000732010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 542, 543, 544; principal diagnosis, secondary
diagnosis and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 3103831040;
Issue Name:
MS-DRG Validation for Seizures (At this time, medical necessity is excluded
from review)
Issue
Number
A000742010
Issue
Description:
MS-DRG Validation 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 for MS-DRGs 100, 101; principal diagnosis, secondary diagnosis
and procedures that affect or can potentially affect the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: August 12, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Addendums and Coding Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review,
Uniform Hospital Discharge Data Set (UHDDS) Reporting of Inpatient Data
Elements, July 31, 1985, Federal Register (Vol. 50, No. 127), Pages 3103831040;
Issue Name:
Date of Death-DME
Issue Number A009012010
Issue
Description:
Medicare does not typically pay for services or equipment provided after
the beneficiary's date of death.
Type of
Review
Automated
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME by Supplier
Date Posted:
August 11, 2010
Dates of
October 1, 2007 - Present
Service:
Issue
References
IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-4
Chapter 20 Section 30.5.4; IOM Publication 100-02, Chapter 15 , Section
110.1; OIG Report March 2000 – OEI-03-99-00200;
Issue Name:
Date of Death-Inpatient
Issue Number
A009022010
Issue
Description:
Medicare does not typically pay for services or equipment rendered after
the beneficiary's date of death.
Type of Review Complex
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospital
Date Posted:
August 11, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM Publication 100-01 Chapter 2 Section 40.5; IOM Publication 100-04
Chapter 3 Section 40.2.2; OIG Report March 2000 – OEI-03-99-00200;
Issue Name:
Technical Component of Radiology
Issue
Number
A000232009
Issue
Description:
A potential vulnerability may exist when the technical component (TC) of
radiology services are furnished to patients in a Prospective Payment
System (PPS) hospital setting and are billed separately to Part B. Therefore,
an issue may exist when these codes are billed and are reimbursed under
Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04. Chapter 13. Section 20.2.1, OIG Report A-01-04-00528;
Issue Name:
MS-DRG Validation for Severe Sepsis (At this time, medical necessity is
excluded from review)
Issue
Number
A000382009
Issue
DRG Validation requires that diagnostic and procedural information and the
Description:
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 for MS-DRGs 177, 189, 193, 291, 438, 441, 444, 592, 602, 682,
689, 691, and 693, principal diagnosis, secondary diagnosis, and procedures
affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-Cm Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinic, PIM Chapter 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127)
Pages 31038-31040. The Medicare Recovery Audit Contractor (RAC)
Demonstration Table P3 and Table P4, Page 57. OIG Report OEI-03-9800370, March 1999;
Issue Name:
MS-DRG Validation for Cardiac Valve Procedures (At this time, medical
necessity is excluded from review)
Issue
Number
A000562010
Issue
Description:
DRG Validation 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 for MS-DRGs 216, 217, 218, 219, 220, and 221, principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch. 6.5.3 A-C DRG Validation Review, Uniform Hospital
Discharge Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31,
1985, Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Coronary Bypass (At this time, medical necessity is
excluded from review)
Issue
Number
A000582010
Issue
Description:
DRG Validation 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 for MS-DRGs 234 and 236, principal diagnosis, secondary
diagnosis, and procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Lysis of Adhesions (At this time, medical necessity is
excluded from review)
Issue
Number
A000612010
Issue
Description:
DRG Validation 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 for MS-DRGs 335, 336, 337, 350, 351, 352, 353, 354, and 355,
principal diagnosis, secondary diagnosis, and procedures affecting or
potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim). ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics. PIM 6.5.3 A-C DRG Validation Review, Uniform Hospital Discharge
Data Set (UHDDS) Reporting of Inpatient Data Elements, July 31, 1985,
Federal Register (Vol. 50, No. 127), Pages 31038-31040;
Issue Name:
MS-DRG Validation for Excisional Debridement (At this time, medical
necessity is excluded from review)
Issue
Number
A000452009
Issue
Description:
DRG Validation 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 for MS-DRGs 463, 464, 465, 573, 574, 575, 901, 902, and 903,
principal diagnosis, secondary diagnosis, and procedures affecting or
potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Official
Guidelines for Coding and Reporting, ICD-9-CM addendums and Coding
Clinics, PIM 6.5.3 A-C DRG Validation Review, UHDDS Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038-31040). The Medicare Recovery Audit Contractor (RAC)
Demonstration Table G1, Page 44, Table HI, Page 45 and Appendix P1
Page 56;
Issue Name:
Global vs. TC/PC Split Reimbursements
Issue
Number
A000212009
Issue
Description:
A potential vulnerability may exist when providers are reimbursed for global
procedures and then receive additional reimbursement for technical (modifier
TC) and/or professional (modifier 26) components for the same service.
Therefore, an issue may exist when these codes are billed and are
reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted: June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04, Chapter 1, Section 120; IOM 100-04, Chapter 12, Section 20.2;
IOM 100-04, Chapter 13, Section 20.1-20.2.3; IOM 100-04, Chapter 16,
pages 80.2.1;
Issue Name:
IV Hydration
Issue Number A000182009
Issue
Description:
A potential vulnerability may exist if certain IV Hydration Codes are billed for
more than one unit per date of service. Therefore, an issue may exist when
these codes are billed and are reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04, Chapter 12, pages 31-32; IOM 100-20, Transmittal 419, page
7;
Issue Name:
Bronchoscopy Services
Issue Number A000172009
Issue
Description:
A potential vulnerability may exist if certain bronchoscopy services are billed
for more than one unit per date of service. Therefore, an issue may exist
when these codes are billed and are reimbursed under Medicare Part B in
this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Federal Register, Volume 67, No. 251, page 8;
Issue Name:
Blood Transfusions
Issue Number A000162009
Issue
Description:
A potential vulnerability may exist if certain blood transfusion codes are
billed for more than one unit per date of service. Therefore, an issue may
exist when these codes are billed and are reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Physician (Carrier) / Outpatient Hospital
Affected:
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04, Chapter 4, Section 231.8;
Issue Name:
Untimed Codes
Issue Number A000152009
Issue
Description:
A potential vulnerability may exist if certain codes are billed for more than
one unit. Therefore, an issue may exist when these codes are billed and
are reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04, Chapter 5, Section 20.2; IOM 100-04, Transmittal 1019, dated
8.3.06, pages 7-11;
Issue Name:
Neulasta
Issue Number A000142009
Issue
Description:
A potential vulnerability may exist if the code J2505 is billed with more than
1 unit per patient per date of service. Therefore, an issue may exist when
these codes are billed and are reimbursed under Medicare Part B inside of
this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04, Transmittal 949 (dated May 12, 2006), HCPCS Level II 2007,
2008, 2009;
Issue Name:
Once In A Lifetime
Issue Number A000132009
Issue
Description:
Certain codes may only be billed once in a lifetime. Therefore, an issue
may exist when these codes are billed and are reimbursed under Medicare
Part B inside of this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
References IOM 100-08, Chapter 3 Section 3.6.;
Issue Name:
Newborn/Pediatric Codes
Issue Number A000122009
Issue
Description:
Providers should not bill new Newborn/Pediatric Codes for patients which
exceed the age limit defined by the CPT Code. Therefore, an issue may
exist when Newborn/Pediatric Codes and are reimbursed under Medicare
Part B outside of the age limit.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
American Medical Association (AMA), Current Procedural Terminology
2007, 2008, 2009;
Issue Name:
New Patient Visits
Issue Number A000072009
Issue
Description:
Providers should not bill new patient Evaluation and Management services
on the same beneficiary within a 3 year period of time. Therefore, an issue
may exist when multiple new patient E&M services and are reimbursed
under Medicare Part B inside of this time frame.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
October 1, 2007 - Present
Service:
Issue
References
IOM 100-04 Chapter 12, Section 30.6.7;
Issue Name:
Duplicate Claims - Part B
Issue Number
A000462009
Issue
Description:
Providers should not bill duplicate claims. Therefore, an issue may exist
when duplicate services are billed and reimbursed under Medicare Part B.
Type of Review Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04 Chapter 1, Section 120;
Issue Name:
Global Billing of Radiology or Diagnostic Tests in the Facility Setting
Issue Number A000092009
Issue
Description:
Providers should not bill diagnostic tests and radiology services globally in
the facility setting. Therefore, an issue may exist when these services are
billed globally and reimbursed under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
NY
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04 Chapter 13, Section 20.2.1; IOM 100-04 Chapter 23;
Issue Name:
Global Surgery - Pre and Post-Operative Visits
Issue Number A000032009
Issue
Description:
E&M services are not allowed to be billed prior to a major surgical service
without the proper modifiers. Therefore, an issue may exist when these
services are billed and reimbursed under Medicare Part B without these
modifiers.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04 Chapter 12, Section 40.1, 40.3;
Issue Name:
National Correct Coding Initiative - Part B
Issue Number A000022009
Issue
Description:
A provider may not bill a Column II code when billed by the same provider
and same date of service as a Column I code. Therefore, an issue may
exist when Column II codes are billed and reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04 Chapter 12, Section 30; IOM 100-04 Chapter 23, Section 20.9;
Issue Name:
Add On Codes
Issue Number A000012009
Issue
Description:
Claims overpaid for add-on codes when the required primary procedure
either was not billed or was not paid for other reasons. Therefore, an issue
may exist when these codes are billed and reimbursed under Medicare Part
B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MD, NJ, NY, PA
Providers
Affected:
Physician (Carrier) / Outpatient Hospital
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
IOM 100-04 Chapter 12, Section 30;
Issue Name:
Parenteral Nutrition Additives with Premix Solutions
Issue Number A000522010
Issue
Description:
When premix parenteral nutrition solutions are used there may not be
separate billing for the carbohydrates, amino acids or additives. Therefore,
an issue may exist when carbohydrates, amino acids, or additives are billed
and reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, PA
Providers
Affected:
DME Suppliers
Date Posted:
June 17, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Article A37215; LCD L5063;
Issue Name: Manual Wheelchair Accessories Billed With Power Wheelchair Bases
Issue
Number
A000702010
Issue
Description:
A supplier can only supply those manual wheelchair options or accessories
that are defined with the code to be used with a manual wheelchair. When
supplying a power wheelchair, a provider may only supply those options or
accessories that are defined with the code to be used with a power
wheelchair. Therefore, an issue may exist when wheelchair options and
accessories are not billed and reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, MD, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: June 10, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD L11473;
Issue Name:
Initial/Preparatory Knee Disarticulation Prosthesis
Issue
Number
A000692010
Issue
Description:
A potential issue may exist when an above knee initial prosthesis or an
above knee preparatory prosthesis is provided and certain prosthetic
substitutions and/or additions are billed at the same time. Therefore, an
issue may exist when these substitutions and/or additions are billed and
reimbursed under Medicare Part B in this manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: June 10, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD L11464;
Issue Name:
MS-DRG Validation for Liver Transplant (At this time, medical necessity is
excluded from review)
Issue
Number
A000502010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 006; principal diagnosis, secondary diagnoses, and
procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
50, No. 147), Pages 31038- 31040.;
Issue Name:
MS-DRG Validation for Heart Transplant (At this time, medical necessity is
excluded from review)
Issue
Number
A000512010
Issue
Description:
MS-DRG Validation 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 for MS-DRG 002; principal diagnosis, secondary diagnoses, and
procedures affecting or potentially affecting the MS-DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual ( for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Chapter 6.5.3 Section A - C DRG
Validation Review, Uniform Hospital Discharge Data Set (UHDDS) Reporting of inpatient Data Elements, July 31, 1985, Federal Register (Vol.
50, No. 147), Pages 31038- 31040.;
Issue Name:
MS-DRG Validation for HIV (At this time, medical necessity is excluded from
review)
Issue
Number
A000422009
Issue
Description:
MS-DRG Validation 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 claims where diagnosis code 042 Human Immunodeficiency Virus
(HIV) Disease was billed as secondary. Principal diagnosis, secondary
diagnoses, and procedures affecting or potentially affecting the claim will be
reviewed for accuracy.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: May 11, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9 CM Official
Guidelines for Coding and Reporting, ICD-9-CM Addendums and Coding
Clinics, PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS - Reporting of
Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 127),
Pages 31038- 31040.;
Issue Name:
IPPS Hospital to Hospital Transfers
Issue
Number
A000082009
Issue
Description:
Medicare pays full MS-DRG payments to the final discharging hospital, while
payment to the transferring hospital is often based upon a per diem rate
(depending on the length of stay). Therefore, an improperly reported transfer
may result in an overpayment when both hospitals receive full MS-DRG
payments.
Type of
Automated Review for Overpayments
Review
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 31, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
Section 1886(d) of the Social Security Act; Internet-Only Manual (IOM),
Publication100-04, Chapter 3, Sections 20.1.2.4 and 40.2.4,; Code of
Federal Regulations 42 CFR 412.4;
Issue Name:
MS-DRG Validation for Cardiac Procedures (At this time, medical necessity
is excluded from review)
Issue
Number
A000412009
Issue
Description:
DRG Validation 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 for MS-DRGs 228, 231, 233, 235, 237, 248, and 250, principal
diagnosis, secondary diagnosis, and procedures affecting or potentially
affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA;
Issue Name:
MS-DRG Validation for Major Large and Small Bowel Procedures (At this
time, medical necessity is excluded from review)
Issue
Number
A000402009
Issue
Description:
DRG Validation 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 for MS-DRGs 329, 330, and 331, principal diagnosis, secondary
diagnosis, and procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007;
AHIMA.;
Issue Name:
MS-DRG Validation for Intracranial Hemorrhage or Cerebral Infarction (At
this time, medical necessity is excluded from review)
Issue
Number
A000432009
Issue
Description:
DRG Validation 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 for MS-DRGs 061, 062, 063, 064, 065, 066, 067, 068, 069, principal
diagnosis, secondary diagnosis, and procedures affecting or potentially
affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: March 23, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A-C, DRG Validation
Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007;
AHIMA.;
Issue Name:
Oxygen Accessories
Issue
Number
A000332009
Issue
Description:
A potential issue may exist if certain oxygen accessories are billed when an
oxygen system rental has been billed in the month prior to the date of
service or in the subsequent month. Therefore, an issue may exist when
these accessories are billed and reimbursed under Medicare Part B in this
manner.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
NJ, PA
Providers
Affected:
DME Suppliers
Date Posted: February 10, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD L11468; LCD Policy Article A33768;
Issue Name:
MS-DRG Validation for MS-DRG 189 Pulmonary Edema & Respiratory
Failure (At this time, Medical Necessity is excluded from review)
Issue
Number
A000352009
Issue
Description:
DRG Validation 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 for MS-DRG 189, principal diagnosis, secondary diagnosis, and
procedures affecting or potentially affecting the DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
Validation Review, OIG Report DRG 87: Pulmonary Edema and Respiratory
Failure, August 1989;
Issue Name:
MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical
Necessity is excluded from review)
Issue
Number
A000362009
Issue
Description:
DRG Validation 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 for MS DRGs 003, 004, 011, 012, 013; principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review;
UHDDS - Reporting of Inpatient Data Elements, July 31, 1985, Federal
Register (Vol. 50, No. 147), Pages 31038-31040;
Issue Name:
MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At
this time, Medical Necessity is excluded from review)
Issue
Number
A000302009
Issue
Description:
DRG Validation 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 for MS DRGs 003, 004, 207, 870, 927 and 933; principal diagnosis,
secondary diagnosis, and procedures affecting or potentially affecting the
DRG.
Type of
Review
DRG Validation
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Inpatient Hospitals
Date Posted: January 19, 2010
Dates of
Service:
October 1, 2007 - Present
Issue
References
ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM
Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG
Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April
2007; AHIMA;
Issue Name: Ambulance Unbundled Services During an Inpatient Hospital Stay
Issue
Number
A000062009
Issue
Description:
Ambulance services should be billed to the inpatient provider for services for
inpatients. Therefore, an issue may exist when a beneficiary received
ambulance services during an inpatient stay, which have been billed and
reimbursed under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
Ambulance Providers
Date Posted: January 7, 2010
Dates of
October 1, 2007 - Present
Service:
Issue
References
Issue Name:
Internet Only Manual, Medicare Benefit Policy Manual Publication 100-02
Chapter 10, Section 10 and 10.3.3; Internet Only Manual, Medicare
Processing Manual, Publication 100-04, Chapter 3, Sections 10.4 and 10.5.;
Internet Only Manual, Medicare Claims Processing Manual, Publication 10004, Chapter 15, Section 10.2, Summary of Benefit and 30.A, Modifier specific
to Ambulance Services.;
Solid Insert with Seat or Back Wheelchair Cushions
Issue Number A000262009
Issue
Description:
Code E0992 (solid seat insert) is not separately payable when provided with
a seat or a seat back wheelchair cushion. Therefore an issue may exist
when E0992 is billed and reimbursed under Medicare Part B with a seat or
seat back wheelchair cushion.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD Policy Article A17918;
Issue Name:
Lower Limb Suction Valve Prosthesis
Issue
Number
A000252009
Issue
Description:
Codes L5647 and L5652 describe a modification to a prosthetic socket that
incorporates a suction valve in the design. The items described by these
codes are not components of a suspension locking mechanism (L5671).
Therefore, an issue may exist when such a locking mechanism is billed and
reimbursed under Medicare Part B along with a suction valve suspension.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, NH, NJ, NY, PA, RI
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD Policy Article A25310; Region A DMERC PSC Bulletin;
Issue Name: Prosthetic Additions with Initial or Preparatory Knee Prosthesis
Issue
Number
A000282009
Issue
Description:
When an initial below knee prosthesis (L5500) or a preparatory below knee
prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or
additions of procedures and components are covered in accordance with the
functional level assessment, except for certain codes. Therefore, an issue
may exist when these codes are billed and reimbursed under Medicare Part
B with such a prosthesis.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD Policy L11464;
Issue Name:
Multiple DME Rentals within a Month
Issue
Number
A000042009
Issue
Description:
Certain procedure codes may not be billed in conjunction with other
procedure codes for the same date of service and for the same beneficiary.
Therefore an issue may exist when these codes are billed and reimbursed
under Medicare Part B on the same date of service and for the same
beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
CMS Pub.100-4, Ch 20, § 30.1, 30.2, 30.5, 30.7, 13.8; Social Security Act,
Volume I, Title XVIII, Section 1834;
Issue Name:
Headrest with a Power Operated Vehicle or a Power Wheelchair with a
Captain's Chair Seat
Issue
Number
A000272009
Issue
Description:
Headrests (E0955) may not be billed on the same date of service as a Power
Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair
seat. Therefore, an issue may exist when a beneficiary receives a Power
Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair
seat and a headrest, which has been billed and reimbursed under Medicare
Part B, on the same date of service.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
DE, MA, MD, ME, NH, NJ, NY, PA
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD Policy L15845;
Issue Name:
Wheel Attachment with New Non-Wheeled Walker
Issue
Number
A000292009
Issue
Description:
Wheel attachment (E0155) cannot be paid on the same day or within one
month of the initial issue of a nonwheeled walker. Therefore, an issue may
exist when a beneficiary receives this wheel attachment, which has been
billed and reimbursed under Medicare Part B, within a month of an initial
issue of a nonwheeled walker.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted: December 22, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD Policy L11472;
Issue Name: Clinical Social Worker (CSW) Services
Issue
Number
A000222009
Issue
Description:
CSW services rendered during an inpatient acute care or skilled nursing
facility stay are not separately payable under Medicare Part B, instead they
are included in the facility’s Prospective Payment System (PPS) payment.
CSW providers are expected to render services under arrangement with the
facility. Therefore, an issue may exist when a beneficiary received CSW
services during an inpatient stay, which have been billed and reimbursed
under Medicare Part B.
Type of
Review
Automated Review for Overpayments
State(s)
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Affected:
Providers
Affected:
CSW Providers
Date Posted: December 11, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
Medicare Benefit Policy Manual: Pub100-2, Ch15, § 170; CMS MedLearn
Matters Article #: SE0439.;
Issue Name: Pharmacy Supply and Dispensing Fees
Issue
Number
A000052009
Issue
Description:
Pharmacy supply and dispensing fees when billed by a DME supplier are
required to be accompanied with an oral anti-cancer, oral anti-emetic,
immunosuppressive drug or inhalation drug. The absence of one of the
aforementioned drugs billed on the same date of service or a denial of one of
the aforementioned drugs represents a potential issue.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, MA, ME, NH, NJ, NY, VT
Providers
Affected:
DME Suppliers
Date Posted: September 18, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
Internet Only Manual 100-04 (Medicare Claims Processing Manual), Chapter
17 (Drugs and Biologicals), Section 80.7; Transmittal 754, Change Request
3990, Requirement 3990.15.; DME MAC Jurisdiction A Article for Nebulizers
A24944 (LCD L11499); DME MAC Jurisdiction A Article for Oral Anticancer
Drugs A25227 (LCD L5057); DME MAC Jurisdiction A Article for Oral
Antiemetic Drugs A25228 (LCD L5058); DME MAC Jurisdiction A Article for
Immunosuppressive Drugs A23662 (LCD L11531);
Issue Name:
Wheelchair Bundling
Issue Number
A000202009
Issue
Description:
A potential issue may exist if certain procedure codes are billed in
conjunction with other procedure codes for the same date of service and
the same beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC, DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
September 18, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
LCD L11473, CMS Pub.100-3, Ch1, § 280.1 & 280.3;
Issue Name:
Urological Bundling
Issue Number A000192009
Issue
Description:
A potential issue may exist if certain urological procedure codes are billed
in conjunction with other urological procedure codes for the same date of
service and same beneficiary.
Type of
Review
Automated Review for Overpayments
State(s)
Affected:
CT, DC DE, MA, MD, ME, NH, NJ, NY, PA, RI, VT
Providers
Affected:
DME Suppliers
Date Posted:
September 18, 2009
Dates of
Service:
October 1, 2007 - Present
Issue
References
CMS Pub.100-3, Ch1, § 230.17; LCD L5080; LCD Policy Article 25230;