Why Performant?
CMS RAC
About Us
For Investors
Contact Us

CMS Approved Audit Issues

Download .XLS File
Issue Name ▲▼ Issue Number ▲▼ Review Type ▲▼ Provider Type ▲▼ Region ▲▼ State ▲▼ Date Approved ▲▼ Details Dates of Service Description References
Transitional Care Management: Unbundling _0224 Automated Professional Services (Physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 01/14/2025 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review) with dates of service on or before 12/31/2024. A physician or other qualified health care professional who reports Transitional Care Management CPT code 99495 or 99496 may not report telephone Service CPT codes (99441-99443) for the same beneficiary during the timeframe covered by the transitional care management service CPT codes. This is the Unbundling of services, and payments will be recouped. Affected codes: 99441, 99442, 99443
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12 – §30.A – Correct Coding Policy, Coding Based on Standards of Medical/Surgical Practice
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1176
  10. AMA CPT Codebook
Transitional Care Management: Excessive Units _0225 Automated Professional Services (Physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 01/13/2025 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review) Medicare may cover transitional care services during the 30-day period that begins when a physician discharges a Medicare patient from a healthcare facility and continues for the next 29 days. Only one of the Transitional Care Management (TCM) service CPT codes (99495 or 99496) may be billed once during the transitional care period, and TCM services may be reported by only one physician or non-physician practitioner (NPP). Affected codes: 99495, 99496
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1175
  9. AMA CPT Codebook
Drugs and Biologicals in Multi-Dose Vials: Billed with JW Modifier _0223 Automated Outpatient Hospital, Professional Services Region-1, Region-2, All Region 1 and Region 2 states 12/01/2024 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review). The JW modifier is a Healthcare Common Procedure Coding System (HCPCS) Level II modifier required to be reported on a claim to report the amount of drug that is discarded and eligible for payment under the CMS discarded drug policy. The modifier should only be used for claims that bill single-dose container drugs. The use of the JW modifier is not appropriate for drugs that are from multiple-dose containers. Claims billed incorrectly will result in an overpayment. Affected codes: J0702, J9034, J9036, J9056, J9058, J9059, J9267
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §414.904(a)(3)- Average sales price as the basis for payment; Method of payment
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient”
  10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1- Incident to Physician’s Professional Services
  11. Medicare Alpha-Numeric HCPCS File- Alpha-Numeric HCPCS | CMS
  12. HCPCS Level II Codebook
  13. Medicare Part B Drug Average Sales Price; ASP Pricing File- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice
  14. U.S. National Library of Medicine DailyMed
Panniculectomy: Medical Necessity and Documentation Requirements _0130 Complex Ambulatory Surgical Center (ASC); Professional Services Region-1, Region-2 All A/B MACs 08/01/2024 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date. Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if it is incidental to another procedure, is not separately coded per Coding Guidelines. Affected codes: 15830 & 15847
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §411.15 (h)- Particular services excluded from coverage
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §120- Cosmetic Surgery
  10. CGS Administrators, LLC, LDA L39506- Cosmetic and Reconstructive Surgery; Effective 5/28/2023
  11. First Coast Service Option, Inc., LCD L38914- Cosmetic and Reconstructive Surgery; Effective 7/11/2021
  12. Noridian Healthcare Solutions, LLC, LCD L35163- Plastic Surgery; Effective 10/01/2015; Revised 10/01/2019
  13. Noridian Healthcare Solutions, LLC, LCD L37020- Plastic Surgery; Effective 10/10/2017; Revised 10/01/2019
  14. Novitas Solutions, Inc., LCD L35090- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/11/2021
  15. Palmetto GBA L33428- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/29/2021
  16. Wisconsin Physician Service Corporation LCD L39051- Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 10/13/2024
  17. CGS Administrators, LLC, LCA A59299- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 5/28/2023; Revised 11/16/2023
  18. First Coast Service Option, Inc., LCA A58573- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 10/01/2024
  19. Noridian Healthcare Solutions, LLC, LCA A57221- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 01/01/2025
  20. Noridian Healthcare Solutions, LLC, LCA A57222- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 01/01/2025
  21. Novitas Solutions, Inc., LCA A56587- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 5/30/2019; Revised 10/01/2024
  22. Palmetto GBA A56658- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 7/04/2019; Revised 01/01/2025
  23. Wisconsin Physician Service Corporation LCA A58774- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 10/01/2024
  24. AMA CPT Codebook
Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity and Documentation Requirements _0145 Complex Ambulatory Surgical Centers (ASC), Professional Services Region-1, Region-2, All A/B MACs 08/01/2024 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Documentation will be reviewed to determine if claims for Endovenous Radiofrequency Ablation (ERFA) and Endovenous Laser Treatment (EVLT) for Lower Extremity Varicose Veins meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: 36475, 36476, 36478, 36479, 76937
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Ch 12, §40.6 Claims for Multiple Surgeries
  9. CGS Administrators, LLC, LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 10/03/2024
  10. First Coast Service Options, Inc., LCD L38720- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 12/27/2020
  11. National Government Services, Inc., LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 11/21/2019
  12. Noridian Healthcare Solutions, LLC, LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
  13. Noridian Healthcare Solutions, LLC, LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019
  14. Novitas Solutions, Inc., LCD L34924- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 10/01/2015; Revised 12/27/2020
  15. Palmetto GBA LCD L39121- Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 11/16/2023
  16. Wisconsin Physicians Service Insurance Corp., LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 8/31/2023
  17. CGS Administrators, LLC, LCA A57305- Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of; Effective 9/26/2019; Revised 10/03/2024
  18. First Coast Service Options, Inc., LCA A58250- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremity; Effective 12/27/2020; Revised 01/01/2025
  19. National Government Services, Inc., LCA A52870- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 10/01/2015; Revised 01/01/2025
  20. Noridian Healthcare Solutions, LLC, LCA A57706- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2025
  21. Noridian Healthcare Solutions, LLC, LCA A57707- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2025
  22. Novitas Solutions, Inc., LCA A55229- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 8/11/2016; Revised 01/01/2025
  23. Palmetto GBA LCA A58876- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 01/01/2025
  24. Wisconsin Physicians Service Insurance Corp., LCA A56914- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 8/29/2019; Revised 01/01/2025
  25. AMA CPT Codebook
Non-Physician Billed Without Correct Assistant at Surgery Modifier: Incorrect Coding _0222 Automated Part B Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 07/15/2024 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date. Assistant at surgery services by non-physician providers (PA, NP, or CNS), are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the Medicare Physician Fee Schedule Data Base amount. Modifier “AS” is used for assistant at surgery services provided by a physician’s assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). Assistant at surgery claims billed by non-physician practitioners without modifier AS, will be corrected, adding modifier AS, repricing the claim. Affected codes: Include only CPT code range 10021 through 69990 with assistant at surgery indicator of “0” or “2.”
  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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  3. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(a)(1)(O)- Payment of Benefits
  4. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review
  5. 42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request
  6. 42 Code of Federal Regulations (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 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening
  8. 42 Code of Federal Regulations (CFR) §414.4- Payment for Part B Medical and Other Health Services
  9. 42 Code of Federal Regulations (CFR) §414.40- Coding and Ancillary Policies
  10. Medicare Benefit Policy Manual Chapter 15 §190- Physician Assistant (PA) Services
  11. Medicare Benefit Policy Manual Chapter 15 §200 – Nurse Practitioner (NP) Services
  12. Medicare Benefit Policy Manual Chapter 15 §210- Clinical Nurse Specialist (CNS) Services
  13. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.3
  14. Medicare Claims Processing Manual Chapter 12- Physician Practitioner Billing, § 100.1.7.B.
  15. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §110.2 – Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants
  16. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §120 – Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services
  17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  18. Medicare Physician Fee Schedule (MPFS) Physician Fee Schedule | CMS
  19. AMA CPT Codebook
Facet Joint Interventions: Medical Necessity and Documentation Requirements _0095 Complex Hospital Inpatient (Part B) 12x Outpatient 13x Outpatient Surgery 83x Region-1, Region-2, All Region 1 and Region 2 states 09/15/2023 Details Exclude claims that have a “claim paid date” which is more than 3 years prior to the ADR letter date (complex review). Facet joint are joints in the spine that aid stability and allow the spine to bend and twist. Facet joint injections are a type of interventional pain management technique used to diagnose or treat back pain. Intraarticular blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. The review will identify whether the treatment meets indications for coverage and whether it exceeds the limitations of coverage. Affected codes: 64490-64495
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 4 – Part B Hospital, §20.4 – Reporting of Service Units
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38801: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 07/07/2024
  10. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 07/07/2024
  11. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58403 – Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 07/07/2024
  12. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58405 – Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 07/07/2024
  13. CGS Administrators, LLC, Local Coverage Determination (LCD) L38773 – Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 07/07/2024
  14. CGS Administrators, LLC, Local Coverage Article (LCA) A58364 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 07/07/2024
  15. First Coast Service Options (FCSO), Inc. Local Coverage Determination (LCD) L33930 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 08/11/2024
  16. First Coast Service Options (FCSO), Inc. Local Coverage Article (LCA) A57787 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 10/03/18, Revised 08/11/2024
  17. National Government Services (NGS), Inc. Local Coverage Determination (LCD) L35936 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 08/01/2024
  18. National Government Services (NGS), Inc. Local Coverage Article (LCS) A57826 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 12/05/19; Revised 08/01/2024
  19. Novitas Solutions, Inc. Local Coverage Determination (LCD) L34892 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 08/11/2024
  20. Novitas Solutions, Inc. Local Coverage Article (LCA) A56670 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 07/11/19; Revised 08/11/2024
  21. Palmetto GBA Local Coverage Determination (LCD) L38765 – Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 07/07/2024
  22. Palmetto GBA Local Coverage Article (LCA) A58350 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 07/07/2024
  23. WPS Insurance Corporation Local Coverage Determination (LCD) L38841 – Facet Joint Interventions for Pain Management; Effective 04/25/21, Revised 07/14/2024
  24. WPS Insurance Corporation Local Coverage Article (LCA) A58477–– Billing and Coding: Facet Joint Injections for Pain Management; Effective 04/25/21; Revised 07/14/2024
  25. AMA CPT Codebook, 50 – Bilateral Procedures, 59 – Distinct Procedural Service, Appendix D Summary of CPT Add-on Code
Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac Joint: Medical Necessity and Documentation Requirements _0219 Complex Outpatient Hospital ; Ambulatory Surgery Center (ASC); Professional Services Region-1, Region-2, All Region 1 and Region 2 states 06/12/2023 Details Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date. JJ and JM are limited to DOS on/after 7/17/2022. Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary. Affected codes: 27279
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. CGS Administrators, LLC, Local Coverage Determination (LCD) L36494- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 2/01/2016; Retired 4/16/2025.
  9. CGS Administrators, LLC, Local Coverage Article (LCA) A56535- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 2/01/2016; Retired 4/16/2025
  10. CGS Administrators, LLC, Local Coverage Determination (LCD) L39802-Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025
  11. CGS Administrators, LLC, Local Coverage Article (LCA) A59682-Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025
  12. CGS Administrators, LLC, Local Coverage Determination (LCD) L39383-Sacroiliac Joint Injections and Procedures; Effective 03/19/2023; Revised 03/27/2025
  13. CGS, Administrators, LLC, Local Coverage Article (LCA) A59154-Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective 03/19/2023; Revised 03/27/2025
  14. National Government Services, Inc., LCD L36406- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 4/01/2016; Revised 10/10/2019
  15. National Government Services, Inc., LCA A57431- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 10/10/2019; Revised 01/01/2025
  16. Palmetto GBA LCD L39025 – Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022; Revised 05/02/2023;
  17. Palmetto GBA LCA A58739- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022; Revised 01/01/2025
  18. Wisconsin Physicians Service Insurance Corporation LCD L36000- Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 12/17/2015; Revised 6/27/2024
  19. Wisconsin Physicians Service Insurance Corporation LCA A57596- Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 11/01/2019; Revised 2/27/2025
  20. AMA CPT Codebook
Muscle Flap with Breast Reconstruction or Breast Prosthesis Insertion: Unbundling _0217 Complex Physician/Non-physician Practitioner (NPP) Region-1, Region-2, All Region 1 and Region 2 states 06/02/2023 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Documentation will be reviewed to determine if CPT code 15734 warranted separate reimbursement given that a flap is considered inclusive to breast reconstruction (19357-19364, 19367-19369) or breast prosthesis (19340, 19342) procedures. This review will determine if the flap (15734) was performed at a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. Billed services that are not supported by the medical record will be denied as unbundling. Affected codes: Target: CPT 15734 Reference: CPT 19357, 19361, 19364, 19367, 19368, 19369, 19340 and 19342
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. 42 CFR §424.5(a)(6)- Basic conditions- Sufficient information
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. NCCI Policy Manual, Chapter 1- General Correct Coding Policies
  11. NCCI Policy Manual, Chapter 3- Surgery: Integumentary System; CPT codes 10000-19999; J. Breast (Incision, Excision, Introduction, Repair and Reconstruction), #7
  12. AMA CPT Codebook
  13. CPT Assistant, July 2021, Volume 31, Issue 7, Page 8-Surgery-Integumentary System, 15734
  14. CPT Assistant, April 2014, Volume 24, Issue 4, Page 10- Surgery: Integumentary System, Repair Abdominal Wall After Free Flap for Breast Reconstruction, 15734
  15. CPT Assistant, December 2012, Volume 22, Issue 12, page 6- Island Pedicle Flaps
Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS): Medical Necessity and Documentation Requirements _0214 Complex Outpatient Hospital, Ambulatory Surgery Center (ASC), and Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 05/01/2023 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Documentation will be reviewed to determine whether transurethral waterjet ablation services met Medicare coverage criteria and were reasonable and necessary. Affected codes: Primary Code: 0421T / Secondary Code: C2596
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. CGS Administrators, LLC, LCD L38378- Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective 4/01/2020; Revised 4/4/2024
  9. CGS Administrators, LLC, LCA A57926- Billing and Coding: Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective 4/01/2020; Revised 4/4/2024
  10. First Coast Service Options, Inc., LCD L38726- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
  11. First Coast Service Options, Inc., LCA A58264- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
  12. National Government Services, Inc., LCD L38367- Fluid Jet System Treatment for LUTS/BPH; Effective 4/01/2020; Revised 4/01/2024
  13. National Government Services, Inc., LCA A56797- Billing and Coding: Fluid Jet System Treatment for LUTs/BPH; Effective 4/01/2020; Revised 4/01/2024
  14. Noridian Healthcare Solutions, LLC, LCD L38705- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020 ; Revised 01/28/2024
  15. Noridian Healthcare Solutions, LLC, LCD L38707- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020 ; Revised 01/28/2024
  16. Noridian Healthcare Solutions, LLC, LCA A58227- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/28/2024
  17. Noridian Healthcare Solutions, LLC, LCA A58229- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/28/2024
  18. Novitas Solutions, Inc., LCD L38712- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
  19. Novitas Solutions, Inc., LCA A58243- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020
  20. Palmetto GBA LCD L38549- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/29/2023
  21. Palmetto GBA LCA A58008- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/01/2024
  22. Wisconsin Physicians Service Insurance Corporation LCD L38682- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 9/26/2024
  23. Wisconsin Physicians Service Insurance Corporation LCA A58209- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 10/27/2022
  24. AMA CPT Codebook
  25. HCPCS Level II Codebook
Prolonged Service Codes: Unbundling _0211 Automated Professional Services (Physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 02/15/2023 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review), with DOS in 2020. Per the 2020 AMA CPT manual, do not report CPT codes 99358 and/or 99359 during the same calendar month as CPT codes 99484, 99487, 99489, 99490, 99491, 99492, 99493, 99494. Affected codes: 99358, 99359
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 12 – §30.6.15.2 – Prolonged Services without Direct Face-to-Face Patient Contact Service (Codes 99358 – 99359)
  9. AMA CPT Codebook 2020
Skilled Nursing Facility with Patient-Driven Payment Model: Medical Necessity and Documentation Requirements _0190 Complex SNF Region-1, Region-2, All Region 1 and Region 2 states 08/01/2022 Details Exclude claims having a “claim paid date” greater than 3 years prior to the ADR date. Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: N/A
  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 1814(a)(2)- Conditions of and Limitations on Payment for Services
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §409.30- Basic Requirements
  9. 42 CFR §409.31- Level of care requirement
  10. 42 CFR §409.32- Criteria for skilled services and the need for skilled services
  11. 42 CFR §409.33- Examples of skilled nursing and rehabilitation services
  12. 42 CFR §409.34- Criteria for “daily basis”
  13. 42 CFR §409.35- Criteria for “practical matter”
  14. 42 CFR §409.36- Effect of discharge from posthospital SNF care
  15. 42 CFR §411.15(p)- Services furnished to SNF residents
  16. 42 CFR §413.337- Methodology for calculating the prospective payment rates
  17. 42 CFR §413.343- Resident Assessment data
  18. 42 CFR §424.5(a)(6) – Basic conditions
  19. 42 CFR §424.11(b)- Obtaining the certification and recertification statements
  20. 42 CFR §424.20- Requirements for posthospital SNF care
  21. 42 CFR §483.20- Resident assessment
  22. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40- Certification and Recertification by Physicians for Extended Care Services
  23. Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services
  24. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3- Certification and Recertification of Need for Treatment and Therapy Plans of Care
  25. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §30- Billing SNF PPS Services; §120- Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
  26. Medicare Claims Processing Manual, Chapter 25- Completing and Processing the Form CMS-1450 Data Set
  27. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  28. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Claims; §6.1.4- Medical Review Process; §6.3 Medical Review of Certification and Recertification of Residents in SNFs
  29. MDS 3.0 RAI Manual, October 2019 (on or before 09/30/2023)
  30. MDS 3.0 RAI Manual, version 1.18.11 v5, October 2023 (on or after 10/01/2023)
  31. MDS 3.0 RAI Manual, version 1.19.1 October 2024 (on or after 10/01/2024)
  32. CMS.gov Minimum Data Set (MDS) 3.0 Technical Information: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation
  33. ICD-10-CM
Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements _0210 Complex Outpatient Hospital, Ambulatory Surgical Center, Professional Services Region-1, Region-2, All Region 1 and Region 2 states 07/01/2022 Details Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date. Hypoglossal nerve stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea (OSA) when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary. Affected codes: CPT 64582
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits
  3. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 240.4.1 -Sleep Testing for Obstructive Sleep Apnea (OSA)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Palmetto GBA, LCD L38276- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, Effective 06/21/2020, Revised 04/13/2023
  10. Palmetto GBA, LCA A58075- Billing and Coding: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, Effective 06/21/2020; Revised 01/01/2022
  11. First Coast Service Options, Inc., LCD L38398- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020
  12. First Coast Service Options, Inc., LCA A56953 – Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/16/2020; Revised 01/01/2022
  13. Novitas Solutions, Inc., LCD L38385- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020
  14. Novitas Solutions, Inc., LCA A56938- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 01/01/2022
  15. National Government Services, Inc., LCD L38387-Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 04/01/2020
  16. National Government Services, Inc., LCA A57092- Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 01/01/2022
  17. Wisconsin Physicians Service Insurance Corporation, LCD L38528- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 06/14/2020, Revised 04/25/2024
  18. Wisconsin Physicians Service Insurance Corporation, LCA A57944-Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 06/14/2020; Revised 01/01/2025
  19. Noridian Healthcare Solutions, LLC, LCD L38310(JE)- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020
  20. Noridian Healthcare Solutions, LLC, LCD L38312(JF)- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020
  21. Noridian Healthcare Solutions, LLC, LCA A57948(JE)- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 12/01/2024
  22. Noridian Healthcare Solutions, LLC, LCA A57949(JF)- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 12/01/2024
  23. CGS Administrators, LLC, LCD L38307- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 03/06/2025
  24. CGS Administrators, LLC, LCA A57149- Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 03/06/2025
  25. American Hospital Association (AHA) Coding Clinic for HCPCS- Volume 22, Number 2, Second Quarter 2022, Page 1-2, New CPT code for drug-induced sleep endoscopy
  26. AMA CPT Assistant, March 2022, Volume 32, Issues 3, Page 7, Reporting Hypoglossal Nerve Stimulator Services
  27. AMA CPT Codebook
Spinal Cord Stimulation: Medical Necessity and Documentation Requirements _0207 Complex Outpatient hospital, Ambulatory Surgical Center, and Professional Services Region-1, Region-2 All Region 1 and Region 2 states 06/01/2021 Details Include claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date. Dorsal Column (Spinal cord) stimulation involves surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space. The implantation consists of two stages: the first stage contains an implantation of neurostimulator electrode(s) and a connection of an external neurostimulator. In some cases, temporary electrodes are used. It is a short trial to assess the patient’s suitability for ongoing treatment with a permanent surgically implanted nerve stimulator. If pain relief is achieved, the temporary system may be transitioned to a permanent system. The second stage involves subcutaneous insertion of a permanent neurostimulator with connection of the implanted electrode(s). Spinal cord neurostimulators (SCS) may be covered as therapies for the relief of chronic intractable pain, and medical records will be reviewed to determine if the implantation of SCS meets Medicare coverage criteria and documentation requirements. Affected codes: 63685
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)-
  4. Payment of Benefit
  5. 42 CFR §405.929 – Post-payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  8. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and
  9. Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening
  10. Initial Determinations and Redeterminations Requested by a Party
  11. 42 CFR §405.986- Good Cause for Reopening
  12. 42 CFR §424.5- Basic Conditions, (a)(6)- Sufficient Information
  13. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)- Any Services Not Reasonable and
  14. Necessary
  15. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.2 Treatment of Motor
  16. Function Disorders with Electric Nerve Stimulation and §160.7 Electrical Nerve Stimulators, (B)
  17. Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators)
  18. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective
  19. Actions, §§3.1- 3.6.6
  20. Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations, §13.5.4
  21. Reasonable and Necessary Provision in LCDs
  22. First Coast Local Coverage Determination L36035- Spinal Cord Stimulation for Chronic Pain; Effective
  23. 10/01/2015; Revised 11/28/2019
  24. First Coast Local Coverage Article A57709- Billing and Coding: Spinal Cord Stimulation for Chronic
  25. Pain; Effective 10/03/2018
  26. Novitas Local Coverage Determination L35450- Spinal Cord Stimulation (Dorsal Column Stimulation);
  27. Effective 10/01/2015; Revised 09/26/2019
  28. Novitas Local Coverage Article A57023- Billing and Coding: Spinal Cord Stimulation (Dorsal Column
  29. Stimulation); Effective 09/26/2019; Revised 09/26/2019
  30. Palmetto Local Coverage Determination L37632- Spinal Cord Stimulators for Chronic Pain; Effective
  31. 01/29/2018; Revised 05/13/21
  32. Palmetto Local Coverage Article A56876- Billing and Coding: Spinal Cord Stimulators for Chronic
  33. Pain; Effective 08/22/2019; Revised 05/13/21
  34. Noridian Local Coverage Determination L36204- Spinal Cord Stimulators for Chronic Pain; Effective
  35. 06/01/2016; Revised 12/01/2019
  36. Noridian Local Coverage Determination L35136 – Spinal Cord Stimulators for Chronic Pain; Effective
  37. 10/01/2015; Revised 12/01/2019
  38. Effective: 04/15/2023
  39. Noridian Local Coverage Article A57791 – Billing and Coding: Spinal Cord Stimulators for Chronic
  40. Pain; Effective 12/01/2019, Revised 01/01/2022
  41. Noridian Local Coverage Article A57792 – Billing and Coding: Spinal Cord Stimulation for Chronic
  42. Pain; Effective 12/01/19, Revised 01/01/2022
  43. American Hospital Association (AHA) Coding Clinic for HCPCS
  44. American Medical Association (AMA) Current Procedure Terminology Assistant
  45. National Correct Coding Initiative Policy Manual for Medicare Services, Chapter VIII – Surgery:
  46. Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems, CPT Codes 60000 – 69999
  47. American Medical Association (AMA) Current Procedural Terminology (CPT) Manual
Next Generation Sequencing: Medical Necessity and Documentation Requirements _0205 Complex Laboratory Region-1, Region-2, All Region 1 and Region 2 states 05/25/2021 Details Exclude claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the National Coverage Determination (NCD) requirements are met. The documentation will be reviewed to determine if NGS as a diagnostic laboratory test was medically necessary according to the indications in the NCD. Affected codes: 0111U, 0022U, 0037U
  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. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §410.32-Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions, (a)-Ordering diagnostic tests
  8. Medicare National Coverage Determination (NCD) Manual, Chapter 1, Part 2- Coverage Determinations, §90.2-Next Generation Sequencing for Patients with Somatic (Acquired) and Germline (Inherited) Cancer; Effective: 01/27/2020; Implementation: 11/13/2020
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. U.S Food & Drug Administration- https://www.fda.gov/medical-devices/vitro-diagnostics/list-cleared-or-approved-companion-diagnostic-devices-vitro-and-imaging-tools
  11. AMA CPT Codebook
  12. Annual ICD-10-CM Manual
Positron Emission Tomography for Initial Treatment Strategy in Oncologic Conditions: Medical Necessity and Documentation Requirements _0206 Complex Hospital Outpatient; Professional Services Region-1, Region-2, All Region 1 and Region 2 states 05/25/2021 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) is covered only in clinical situations in which PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal location to perform an invasive procedure. PET would also be considered reasonable and necessary when clinical management of the patient would differ depending on the staging of the cancer identified, and in clinical situations in which the stage of the cancer remains in doubt after completing a standard diagnostic workup or it is expected that conventional imaging study information is insufficient for clinical management of the patient. Medical records will be reviewed to determine if the utilization of FDG PET studies for initial anti-tumor treatment strategy is medically necessary according to Medicare coverage indications. Affected codes: 78608, 78811, 78812, 78813, 78814, 78815, 78816, and A9552
  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 Benefit
  3. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §411.15 – Particular Services Excluded from Coverage, (k) – Any Services Not Reasonable and Necessary
  8. National Coverage Determination Manual, Ch. 1, Part 4, §220.6.17 Positron Emission Tomography (PET) (FDG) for Oncologic Conditions
  9. Medicare Claims Processing Manual, Ch. 13 – Radiology Services and Other Diagnostic Procedures, §60 – Positron Emission Tomography (PET) Scans – General Information; §60.1 – Billing Instructions, (D)- Post-Payment Review for PET Scans; §60.16 – Billing and Coverage Changes for PET Scans Effective for Services on or After April 3, 2009 (A) – Summary of Changes; §60.17 – Billing and Coverage for PET Scans for Cervical Cancer Effective for Services on or After November 10, 2009; §60.3.1 – Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005; §60.3.2 – Tracer Codes Required for Positron Emission Tomography (PET) Scans; §60.7 – Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001, §60.8 – Expanded Coverage of PET Scans for Breast Cancer Effective for Dates of Service on or After October 1, 2002, https://www.cms.gov/medicare/coverage/determinationprocess/downloads/petforsolidtumorsoncologicdxcodesattachment_NCD220_6_17.pdf
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. Noridian LCA A54666: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023
  12. Noridian LCA A54668: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023
  13. Novitas LCA A53132: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 10/01/2015; Revised date 10/01/2021; Retired date 03/24/2022
  14. First Coast Service Options, Inc LCA A58826: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 04/01/2021; Revised date 10/01/2021; Retired date 03/24/2022
  15. AHA ICD-10-CM Diagnosis Codebook
  16. AMA CPT Codebook
  17. HCPCS Level II Codebook
Vagus Nerve Stimulation: Medical Necessity and Documentation Requirements _0204 Complex Outpatient hospital, Ambulatory Surgery Center (ASC), Professional Services Region-1, Region-2, All Region 1 and Region 2 states 02/16/2021 Details Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Vagus Nerve Stimulation (VNS) is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is reasonable and necessary for treatment-resistant depression through Coverage with Evidence Development (CED). VNS for treatment of resistant depression is non-covered when furnished outside of a CMS-approved CED study. Medical documentation will be reviewed to determine if the vagus nerve stimulator meets Medicare coverage criteria and/or is reasonable and necessary. Denied services will result in an overpayment. Affected codes: 64568, 95976, 95977, C1827
  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. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determination (NCD) Manual, Chapter 1-Coverage Determinations, §160.18- Vagus Nerve Stimulation (VNS)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §200- Billing Requirements for Vagus Nerve Stimulation (VNS)
  10. Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS
  11. AMA CPT Codebook
Air Ambulance: Medical Necessity and Documentation Requirements _0200 Complex Ambulance Region-1, Region-2, All Region 1 and Region 2 states 01/18/2021 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR Letter date This complex review will be examining rotatory wing (helicopter) aircraft claims or fixed wing (airplane) claims to determine if air ambulance transport was reasonable and medically necessary as well as whether documentation requirements have been met. Affected codes: A0430, A0431, A0435, A0436
  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 1861(s)(7)- Medical and Other Health Services
  4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 (I)(14)- Establishment of Fee Schedule for Ambulance Services
  5. 42 CFR §405.929- Post-Payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 §410.40- Coverage of ambulance services, (c) Levels of service; (e) Medical necessity requirements
  10. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements.
  11. 42 CFR §414.605 Definitions
  12. 42 CFR §414.610 Basis of Payment
  13. 42 CFR §424.36- Signature Requirements
  14. 42 CFR §424.37- Evidence of Authority to Sign on behalf of the Beneficiary
  15. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
  16. Medicare Benefit Policy Manual (MBPM), Chapter 10- Ambulance Services, §10.4 Air Ambulance Services, §20.1.2 Beneficiary Signature Requirements, §30.1.2 Air Ambulance Services Medicare Claims Processing Manual, Chapter 15- Ambulance, §20.3 Air Ambulance
  17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  18. HCPCS Level II Codebook
Skilled Nursing Facility (SNF) Consolidated Billing for Ambulance Transports: Unbundling _0202 Automated Ambulance suppliers Region-1, Region-2, All Region 1 and Region 2 states 01/18/2021 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter (RRL) date (automated review) Certain ambulance services are included in SNF consolidated billing and may not be billed as Part B services to the A/B MAC, when the beneficiary is in a Part A stay. Affected codes: A0426, A0427, A0428, A0429, A0434, A0425
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR § 409.27(c) – Other services generally provided by (or under arrangements made by) SNFs
  8. Medicare Claims Processing Manual, Chapter 6 – SNF Inpatient Part A Billing, §20.3.1 – Ambulance Services
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. General Explanation of the Major Categories I. – V. for Skilled Nursing Facility (SNF) Consolidated Billing – https://www.cms.gov/files/document/09majorcatexplpdf
  11. SNF Consolidated Billing – https://www.cms.gov/medicare/coding-billing/skilled-nursing-facility-snf-consolidated-billing
  12. HCPCS Level II Codebook
Deep Brain Stimulation- Outpatient Procedure: Medical Necessity and Documentation Requirements _0196 Complex Outpatient Hospital; Professional Services Region-1, Region-2, All Region 1 and Region 2 states 11/17/2020 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Deep brain stimulation (DBS) is an established treatment for people with movement disorders, such as essential tremor, Parkinson’s disease and dystonia. DBS involves implanting electrodes within certain areas of the brain; these electrodes produce electrical impulses that regulate abnormal impulses within the brain. The amount of stimulation is controlled by a pacemaker-like device placed under the skin in the chest and connects to the electrodes in the brain. Medicare will consider whether the initial placement of Deep Brain Stimulation is reasonable and necessary for the treatment of Parkinson’s disease and Essential Tremor, under certain conditions. Affected codes: 61885, 61886, 95970, 95971, 95984
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations Manual, Chapter 1, Part 2, §160.24 – Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease
  8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §50 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease; §50.1- Coverage Requirements; §50.2- Billing Requirements; §50.4.3- Healthcare Common Procedure Coding System (HCPCS)
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. AMA CPT Codebook
Deep Brain Stimulation- Inpatient Procedure: Medical Necessity and Documentation Requirements _0198 Complex Inpatient hospital Region-1, Region-2, All Region 1 and Region 2 states 11/17/2020 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Deep brain stimulation (DBS) is an established treatment for people with movement disorders, such as essential tremor, Parkinson’s disease, and dystonia. DBS involves implanting electrodes within certain areas of the brain; these electrodes produce electrical impulses that regulate abnormal impulses within the brain. The amount of stimulation is controlled by a pacemaker-like device placed under the skin in the chest and connects to the electrodes in the brain. Medicare will consider DBS to be reasonable and necessary for the treatment of Parkinson’s disease under certain conditions. Affected codes: 00H00MZ, 0H80XZZ, 0HSSXZZ
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations Manual, Chapter 1, Part 2, §160.24 – Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease
  8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §50 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease; §50.1- Coverage Requirements; §50.2.1- – Part A Intermediary Billing Procedures; §50.4.2- Allowable Covered Procedure Codes
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. AHA ICD-10-PCS Procedure Codebook
Implantable Automatic Defibrillators- Inpatient Procedure: Medical Necessity and Documentation Requirements _0195 Complex Inpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 10/19/2020 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications. Affected codes: 0JH608Z, 0JH609Z, 0JH638Z, 0JH639Z, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual: Chapter 1 – Coverage Determinations, Part 1, §20.4- Implantable Cardioverter Defibrillators (ICDs)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §270- Claims Processing for Implantable Automatic Defibrillators; §270.1- Coding Requirements for Implantable Automatic Defibrillators; §270.2- Billing Requirements for Patients Enrolled in a Data Collection System
  10. CGS Local Coverage Article A57994- Billing and Coding: Implantable Automatic Defibrillators; Effective 01/01/2021; Revised 11/22/2023
  11. First Coast Local Coverage Article A56341- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Retired 7/6/2021
  12. NGS Local Coverage Article A56326- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 3/03/2023
  13. Noridian Local Coverage Article A56340- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 7/31/2023
  14. Noridian Local Coverage Article A56342- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 7/31/2023
  15. Novitas Local Coverage Article A56355- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Retired 7/6/2021
  16. Palmetto Local Coverage Article: A56343- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 10/01/2023
  17. WPS Local Coverage Article A56391- Billing and Coding: Implantable Automatic Defibrillators; Effective 5/13/2019; Revised 10/01/2023
  18. AHA ICD-10-CM Codebook
  19. AHA ICD-10-PCS Codebook
Ventricular Assist Device: Medical Necessity and Documentation Requirements _0192 Complex Inpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 09/22/2020 Details Exclude from review claims with Dates of Service prior to May 12, 2023 A ventricular assist device (VAD) is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood. The documentation will be reviewed to determine if initial insertion of a left ventricular assist device (LVAD) was placed for a Medicare-covered indication. Affected codes: 02HA0QZ, 02HA0RJ, 02HA0RS, 02HA0RZ, 02HA3QZ, 02HA3RJ, 02HA3RS, 02HA3RZ, 02HA4QZ, 02HA4RJ, 02HA4RS, 02HA4RZ
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual, Chapter 1- Coverage Determinations, §20.9.1 – Ventricular Assist Devices (VADs)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §320.3-§320.3.2- Ventricular Assist Devices (VADs)
  10. AMA CPT Codebook
  11. CMS ICD-10 PCS: https://www.cms.gov/medicare/coding-billing/icd-10-codes
Nerve Conduction Studies: Excessive Units _0187 Complex Outpatient Region-1, Region-2, All Region 1 and Region 2 states 09/21/2020 Details Exclude claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Medical documentation will be reviewed to determine if the use of nerve conduction studies meets Medicare coverage criteria and is reasonable and necessary. Affected codes: 95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913
  1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  3. 42 Code of Federal Regulations (CFR) §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening
  8. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.23- Sensory Nerve Conduction Threshold Tests (sNCTs)
  9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80- Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. CGS, Local Coverage Determination L35897- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 05/09/2024
  12. First Coast Local Coverage Determination L34859- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 12/10/2023
  13. NGS, Local Coverage Determination L35098- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 11/21/2019
  14. Noridian Healthcare Solutions, LLC, Local Coverage Determination L36524- Nerve Conduction Studies and Electromyography; Effective: 06/01/16; Revised 12/01/2019
  15. Noridian Healthcare Solutions, LLC, Local Coverage Determination L36526- Nerve Conduction Studies and Electromyography; Effective: 06/01/2016; Revised 12/01/2019
  16. Novitas Solutions, Inc., Local Coverage Determination L35081- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 12/10/2023
  17. Palmetto GBA Local Coverage Determination L35048- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 11/16/2023
  18. WPS Local Coverage Determination L34594- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 06/01/2023
  19. CGS, Local Coverage Article A57307- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 9/26/2019; Revised 05/09/2024
  20. First Coast Local Coverage Article A57123- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/03/2018; Revised 01/01/2024
  21. First Coast Local Coverage Article A56035- Nerve Conduction Studies and Electromyography- Revision to the Part A and Part B LCD; Effective: 5/31/2018, Retired 09/24/2021
  22. NGS, Local Coverage Article A57668- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 11/21/2019; Revised 01/01/2024
  23. Noridian Healthcare Solutions, LLC, Local Coverage Article A54969- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/01/2016; Revised 01/01/2024
  24. Noridian Healthcare Solutions, LLC, Local Coverage Article A54992- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/01/2016; Revised 01/01/2024
  25. Novitas Solutions, Inc., Local Coverage Article A54095- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 01/01/2024
  26. Palmetto GBA Local Coverage Article A56619- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/13/2019; Revised 01/01/2024
  27. WPS Local Coverage Article A57478- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/31/2019; Revised 01/01/2024
  28. 28. AMA CPT Codebook
Polysomnography: Medical Necessity and Documentation Requirements _0191 Complex Outpatient Region-1, Region-2, All Region 1 and Region 2 states 09/21/2020 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR Letter date. Polysomnography (PSG) refers to the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep furnished in a sleep laboratory facility that includes physician review, interpretation and report. PSG is distinguished from sleep studies by the inclusion of sleep staging. This review will determine if the polysomnography test is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Affected codes: 95808, 95810; 95811
  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. 42 CFR §405.929- Post-Payment Review
  4. 42CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
  8. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.4.1- Sleep Testing for Obstructive Sleep Apnea (OSA)
  9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §70.B- Medical Conditions for Which Testing is Covered; §70.C- Polysomnography for Chronic Insomnia Is Not Covered
  10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6
  12. CGS Administrators, LLC, LCD L36902- Polysomnography and Other Sleep Studies; Effective 3/6/2017; Revised 02/27/25
  13. CGS Administrators, LLC, LCA A57049- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 9/26/2019; Revised 02/27/25
  14. First Coast Service Options, Inc., LCD L33405- Polysomnography and Sleep Testing; Effective 10/01/2015; Revised 7/01/2020
  15. First Coast Service Options, Inc., LCA A57496- Billing and Coding: Polysomnography and Sleep Testing; Effective 10/03/2018; Revised 5/16/2024
  16. Noridian Healthcare Solutions, LLC, LCD L34040- Polysomnography and Other Sleep Studies; Effective 10/01/2015; Revised 12/01/2019
  17. Noridian Healthcare Solutions, LLC, LCD L36861- Polysomnography and Other Sleep Studies; Effective 06/05/2017; Revised 12/01/2019
  18. Noridian Healthcare Solutions, LLC, LCA A57697- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019
  19. Noridian Healthcare Solutions, LLC, LCA A57698- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019
  20. Novitas Solutions, Inc., LCD L35050- Outpatient Sleep Studies; Effective 10/01/2015; Revised 01/01/2021
  21. Novitas Solutions, Inc., LCA A56923- Billing and Coding: Outpatient Sleep Studies; Effective 9/12/2019; Revised 01/01/2023
  22. Palmetto GBA, LCD L36593- Polysomnography; Effective 6/13/2016; Revised 03/20/25
  23. Palmetto GBA, LCA A56995- Billing and Coding: Polysomnography; Effective 9/12/2019; Revised 03/07/2024
  24. WPS, LCD L36839- Polysomnography and Other Sleep Studies; Effective 2/16/2017; Revision effective 07/27/2023
  25. WPS, LCA A56903- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 8/29/2019; Revised 07/27/2023
  26. National Government Services, Inc., LCA A53019- Polysomnography and Sleep Studies- Medical Policy Article; Effective 10/01/2015; Revised 10/31/2019
  27. AMA CPT Codebook
Reduction of Technical Component, Diagnostic, Cardiovascular Services _0182 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 08/16/2020 Details Claims that have a “claim paid date” which is less than 3 years prior to the review results letter date (automated review). CPT/HCPCS Codes with a Multiple Procedure Indicator of “6” are subject to a 25% reduction of the Technical Component (TC) when multiple procedures are billed on the same date of service, for the same patient, by the same physician, on the same claim. Claims incorrectly processed will be re-priced with the 25% reduction and the overpaid amount will be recovered. If the CPT/HCPCS code has a Multiple Procedure Indicator of ‘6’ then 75% of the TC portion (Codes with an Indicator of ‘1’) will be allowed and if the PC/TC Indicator is ‘3’ (Technical component only codes) 75% of the Full Fee Schedule for that code will be allowed. Affected codes: CPT/HCPCS Codes with a multiple procedure indicator of “6” (Diagnostic cardiovascular services subject to the MPPR methodology) per the Medicare Physician Fee Schedule (indicated under the “Multiple Procedure” column)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30.2 – MPFSDB Record Layout
  8. Note: Beginning with the 2019 MPFSDB, and thereafter, the MPFSDB File Record Layout will no longer be revised annually in this section for the sole purpose of changing the calendar year but will only be revised when there is a change to a field. Previous MPFSDB file layouts (for 2018 and prior) can be found on the CMS web site on the Physician Fee Schedule web page at: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/index.html.
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. CMS.gov – Multiple Procedure Payment Reduction File (based on the dates of service), Diagnostic Cardiovascular Services Subject to the Multiple Procedure Payment Reduction (MPPR)
  11. MPFS (Medicare Physician Fee Schedule) Relative Value Files- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files
  12. AMA CPT Codebook
  13. HCPCS Level II Codebook
Specialty Care Transport: Medical Necessity and Documentation Requirements _0183 Complex Ambulance Region-1, Region-2, All Region 1 and Region 2 states 08/16/2020 Details Exclude from review claims having a “paid claim date” which is more than 6 months prior to the ADR letter date Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle. SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Medical documentation for SCT will be reviewed to determine the Medicare defined conditions have been met for payment. Affected codes: A0434- Specialty Care Transport (SCT) A0425- Ground Mileage, per statute mile
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions, (c) Levels of service, and (e)(1) and (3) Medical necessity requirements
  8. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements.
  9. 42 CFR §414.605 Definitions
  10. 42 CFR §414.610 Basis of Payment
  11. 42 CFR §424.36- Signature Requirements
  12. 42 CFR §424.37- Evidence of Authority to Sign In on behalf of the Beneficiary
  13. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
  14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  15. Medicare Benefit Policy Manual (MBPM), Chapter 10 Ambulance Services, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services
  16. Medicare Claims Processing Manual, Chapter 15 Ambulance, §10.2 Summary of the Benefit; §30 General Billing Guidelines, (A) Modifiers Specific to Ambulance Service Claims and (B) HCPCS Codes
  17. HCPCS Level II Codebook
Total Hip Arthroplasty: Medical Necessity and Documentation Requirements _0184 Complex Inpatient Hospital; Outpatient Hospital; Ambulatory Surgical Center; Professional Services Region-1, Region-2, All Region 1 and Region 2 states 08/16/2020 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date, and WPS claims with dates of service on or after 10/13/2024. Documentation will be reviewed to determine if total hip arthroplasty meets Medicare coverage requirements. Affected codes: CPT Codes- 27130, 27132, 27134, 27137, 27138 (FCSO, NGS, Novitas, Palmetto, Noridian, WPS) PCS Codes (FCSO ONLY) – 0SP90JZ, 0SPB0JZ, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90EZ, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRB019, 0SRB01A,0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0EZ, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SW90JZ, 0SWB0JZ
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019
  9. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 04/11/2024
  10. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
  11. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 8/8/2019; Revised 5/02/2022
  12. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
  13. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 11/30/2023
  14. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023
  15. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 4/01/2024
  16. Noridian Healthcare Solutions, LLC, LCD L34163- Total Hip Arthroplasty; Effective 10/01/2015; Revised 12/01/2019
  17. Noridian Healthcare Solutions, LLC, LCD L36573- Total Hip Arthroplasty; Effective 9/7/2016; Revised 12/01/2019
  18. Noridian Healthcare Solutions, LLC, LCA A57683- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
  19. Noridian Healthcare Solutions, LLC, LCA A57684- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019
  20. Wisconsin Physicians Service Insurance Corp., LCD L39911 – Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025
  21. Wisconsin Physicians Service Insurance Corp., LCA A59811 – Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024
  22. AMA CPT Codebook
  23. ICD-10-PCS Procedure Codebook
Total Knee Arthroplasty: Medical Necessity and Documentation Requirements _0185 Complex Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Professional Services Region-1, Region-2, All Region 1 and Region 2 states 08/16/2020 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date, and WPS (J5 and J8) claims with DOS on or after 10/13/2024 Documentation will be reviewed to determine if total knee arthroplasty meets Medicare coverage requirements. Affected codes: CPT Codes- 27445, 27447, 27486, 27487 PCS Codes (FCSO ONLY) – 0SPC0JZ, 0SPD0JZ, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0EZ, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0M9, 0SRC0MA, 0SRC0MZ, 0SRC0N9, 0SRC0NA, 0SRC0NZ, 0SRD0EZ, 0SRD0M9, 0SRD0MA, 0SRD0MZ, 0SRD0N9, 0SRD0NA, 0SRD0NZ, 0SRC0KZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ, 0SWC0JZ, 0SWD0JZ
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019
  9. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 04/11/2024
  10. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019
  11. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 08/08/2019; Revised 05/02/2022
  12. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019
  13. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 11/30/2023
  14. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023
  15. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 4/01/2024
  16. Noridian Healthcare Solutions, LLC, LCD L36575- Total Knee Arthroplasty; Effective 9/7/2016; Revised 12/01/2019
  17. Noridian Healthcare Solutions, LLC, LCA A57685- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019
  18. Noridian Healthcare Solutions, LLC, LCD L36577- Total Knee Arthroplasty; Effective 9/7/2016; Revised 12/01/2019
  19. Noridian Healthcare Solutions, LLC, LCA A57686- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019
  20. Wisconsin Physicians Service (WPS) Insurance Corporation, LCD L39911: Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025
  21. Wisconsin Physicians Service (WPS) Insurance Corporation, LCA A59811: Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024
  22. AMA CPT Codebook
  23. AHA ICD-10-PCS Procedure Codebook
Duplex Scans of Extracranial Arteries: Medical Necessity and Documentation Requirements _0186 Complex Outpatient Region-1, Region-2, All Region 1 and Region 2 states 06/01/2020 Details Review claims having a “paid claim date” which is less than 3 years prior to the ADR letter date This review will determine if a duplex scan of the extracranial arteries was reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied. Affected codes: 93880- Duplex scan of extracranial arteries; complete bilateral study. 93882- Duplex scan of extracranial arteries; unilateral or limited study
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §410.32(a)- Ordering Diagnostic Tests
  8. 42 CFR §410.32(b)- Diagnostic x-ray and other diagnostic tests
  9. 42 CFR §410.33- Independent Diagnostic Testing Facility
  10. National Coverage Determinations Manual, Chapter 1, Part 1, §20.17- Noninvasive Tests of Carotid Function
  11. National Coverage Determinations Manual, Chapter 1, Part 4, §220.5- Ultrasound Diagnostic Procedures
  12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80- Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
  13. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §10.1 – Billing Part B Radiology Services and Other Diagnostic Procedures
  14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1 –3.6 .6
  15. CGS LCD L34045: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 11/02/2023
  16. First Coast LCD L33695: Non-Invasive Extracranial Arterial Studies; Effective 10/01/2015; Revised 01/08/2019
  17. NGS LCD L33627: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 10/01/2019
  18. Novitas LCD L35397: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 10/17/2019
  19. WPS LCD L35753: Non-Invasive Cerebrovascular Studies; Effective 10/01/2015; Revised 10/26/2023
  20. CGS LCA A56697: Billing and Coding: Non-Invasive Vascular Studies; Effective 07/11/2019; Revision Effective: 01/01/2024
  21. First Coast LCA A57670: Billing and Coding: Non-Invasive Extracranial Arterial Studies; Effective 10/03/2018
  22. NGS LCA A56758: Billing and Coding: Non-Invasive Vascular Studies; Effective 08/01/2019; Revised: 10/01/2023
  23. Novitas LCA A52992: Billing and Coding: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 8/02/2019
  24. WPS LCA A57592: Billing and Coding: Non-Invasive Cerebrovascular Studies; Effective 11/01/2019; Revised 10/01/2023
  25. AMA CPT Codebook
Annual Wellness Visits: Incorrect Coding _0176 Complex Physician/Non-physician Practitioner Region-1, Region-2, All Region 1 and Region 2 states 02/01/2020 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Claims for HCPCS code G0402- Initial Preventative Physical Examination (IPPE), may not be billed more than 12 months after the effective date of the beneficiary’s first part B coverage, or more than once in a lifetime. Claims for HCPCS code G0438- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); initial, may not be billed more than once in a lifetime. Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, may not be billed within 12 months of G0438 or G0439 Affected codes: G0402, G0438, G0439
  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 1861 (s)(2)(W)- an initial preventive physical exam
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (s)(2)(FF)- Medical and other health services- personalized prevention plan services
  4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (ww)- Initial Preventive Physical Examination
  5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (hhh)-Annual Wellness Visit
  6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  7. 42 CFR §405.929- Post-Payment Review
  8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  9. 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
  10. 42 CFR §405.986- Good Cause for Reopening
  11. 42 CFR §410.15 – Annual Wellness Visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage
  12. 42 CFR §410.16-Initial Preventative Physical Examination: Conditions for and limitations on coverage
  13. Medicare Benefit Policy Manual- Chapter 15- Covered Medical and Other Health Services, §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)
  14. Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, §30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV]
  15. Medicare Claims Processing Manual- Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit
  16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  17. AMA HCPCS/CPT Codebook
Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements _0171 Complex Professional Services (Physicians and Non-Physician Practitioners), Hospital Outpatient Region-1, Region-2, All Region 1 and Region 2 states 12/25/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Erythropoiesis stimulating agents (ESAs) stimulate the bone marrow to make more red blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need for blood transfusion in patients with specific clinical indications. Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria. Affected codes: J0881, J0885, and Q5106 that were billed with modifiers EA and EB.
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. National Coverage Determinations (NCD) Manual, Chapter 1- Coverage Determinations, Part 2, §110.21 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions
  8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §50 Drugs and Biologicals
  9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals, §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §80.9- Required Modifiers for ESAs Administered to Non-ESRD Patients; and §80.12- Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. CGS Administrators, LLC, LCD L34356- Erythropoiesis Stimulating Agents (ESA); Effective 10/01/2015; Revised 03/06/2025
  12. First Coast LCD L36276- Erythropoiesis Stimulating Agents; Effective 10/01/2015; Retired 02/09/2023
  13. Palmetto GBA LCD L39237- Erythropoiesis Stimulating Agents; Effective 07/24/2022; Revised 03/13/2025
  14. WPS LCD L34633- Erythropoiesis Stimulating Agents (ESAs); Effective 10/01/2015; Revised 06/01/2023
  15. CGS Administrators, LLC, LCA A56462- Billing and Coding: Erythropoiesis Stimulating Agents (ESA), Effective 10/03/2019; Revised 03/06/2025
  16. First Coast LCA A57628- Billing and Coding: Erythropoiesis Stimulating Agents; Effective 10/03/2018; Retired 02/09/2023
  17. Palmetto LCA A58982- Billing and Coding: Erythropoiesis Stimulating Agents; Effective 07/24/2022; Revised 04/01/2025
  18. WPS LCA A56795- Billing and Coding: Erythropoiesis Stimulating Agents (ESAs); Effective 08/01/2019; Revised 06/27/2024
  19. AMA CPT Codebook
  20. HCPCS Level II Codebook
  21. AHA ICD-10-CM Diagnosis Codebook
Outpatient Services within 3 Days Prior to and Including the Date of a Hospital Admission: Unbundling _0169 Automated Outpatient Facility Region-1, Region-2, All Region 1 and Region 2 states 11/26/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review). All diagnostic (including clinical diagnostic laboratory tests) services and related non-diagnostic services provided to a beneficiary by the admitting hospital within 3 days (for IPPS Hospitals) prior to or 1 day (NON IPPS Hospitals) prior to and including the date of the beneficiary’s admission are deemed to be inpatient services and included in the inpatient payment. Unbundled services will be denied and result in an overpayment. Affected codes: Diagnostic codes are identified as any CPT/HCPCS code billed with a revenue code: 0254, 0255, 030X, 031X, 032X, 0341, 0343, 035X, 0371, 0372, 040X, 046X, 0471, 0481 or 0489 (billed with HCPCS 93451-93464, 93503, 93505, 93530-93533 (deleted 01/01/2022), 93561-93562 (deleted 01/01/2022), 93563-93568, 93571-93572, 93593-93598 (effective 01/01/2022), and G0278), 0482, 0483, 053X, 061X, 062X, 073X, 074X, 0918, 092X
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3(B)- Outpatient Services Treated as Inpatient Services – Preadmission Diagnostic Services; §40.3(D) Outpatient Services Treated as Inpatient Services – Other Preadmission Services
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
  10. HCPCS Level II Codebook
Therapeutic, Prophylactic, and Diagnostic Infusions: Incorrect Coding and Documentation Requirements _0161 Complex Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 11/19/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Documentation will be reviewed to determine if correct billing, coding, and documentation guidelines for Therapeutic, Prophylactic, and Diagnostic Infusions were met. Affected codes: 96365 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 96366 – Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); each additional hour (list separately in addition to code for primary procedure)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §230- Billing and Payment for Drugs and Drug Administration
  8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals
  9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §90.2- Drugs, Biologicals, and Radiopharmaceuticals
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
Renal and Peripheral Angiography: Medical Necessity and Documentation Requirements _0170 Complex Outpatient Hospital (OPH); Ambulatory Surgery Center (ASC); Professional Services Region-1, Region-2, All Region 1 and Region 2 states 11/19/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Documentation will be reviewed to determine if diagnostic (aka stand-alone) renal and peripheral angiography procedures meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. Affected codes: 36245, 36246, 36247, 36248, 36251, 36252, 36253, 36254
  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 Benefits1. 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. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. First Coast LCD L36767 – Aortography and Peripheral Angiography; Effective 10/31/2016; Revised 10/01/2019
  10. First Coast LCA A57056 – Billing and Coding: Aortography and Peripheral Angiography; Effective 10/03/18; Revised date 05/19/25
  11. Novitas LCD L35092 – Diagnostic Abdominal Aortography and Renal Angiography Effective 10/01/2015; Revised date 11/7/2019
  12. Novitas LCA A56682- Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography; Effective date 7/11/2019; Revised date 05/19/25
  13. AMA CPT Codebook
  14. AMA CPT Codebook, Appendix L
  15. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  16. 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
  17. 42 CFR §405.986- Good Cause for Reopening
  18. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  19. First Coast LCD L36767 – Aortography and Peripheral Angiography; Effective 10/31/2016; Revised 10/01/2019
  20. First Coast LCA A55847 – Aortography and Peripheral Angiography Coding Guidelines; Effective 10/31/16; Retired 10/01/2019
  21. First Coast LCA A57056 – Billing and Coding: Aortography and Peripheral Angiography; Effective 10/03/18; Revised date 03/01/2024
  22. Novitas LCD L35092 – Diagnostic Abdominal Aortography and Renal Angiography Effective 10/01/2015; Revised date 11/7/2019
  23. Novitas LCA A56682- Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography; Effective date 7/11/2019; Revised date 03/01/2024
  24. AMA CPT Codebook
  25. AMA CPT Codebook, Appendix L
Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements _0067 Complex Inpatient Hospital (8), Inpatient Psychiatric Facility (IPF) (15) Region-1, Region-2, All Region 1 and Region 2 states 11/15/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Inpatient hospital services furnished to a patient of an inpatient psychiatric facility will be reviewed to determine that services were medically reasonable and necessary. Services determined to be not medically reasonable and necessary will result in an overpayment. Affected codes: N/A
  1. Title XVIII of the Social Security Act (SSA), Section 1814(a)(2)(A) and (4)- Conditions of and Limitations on Payment for Services
  2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1815(a)- Payment to Providers of Services
  3. Title XVIII of the Social Security Act (SSA), Section 1833(e)- Payment of Benefits
  4. Title XVIII of the Social Security Act (SSA), Section 1835(a)- Procedure for Payment of Claims of Providers of Services
  5. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer
  6. 42 CFR §405.929- Post-Payment Review
  7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  8. 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
  9. 42 CFR §405.986 – Good Cause for Reopening
  10. 42 CFR 409.62- Lifetime Maximum on Inpatient Psychiatric Care
  11. 42 CFR 412.27(c)- Excluded Psychiatric Units: Additional Requirements
  12. 42 CFR 412.404- Conditions for Payment under the Prospective Payment System for Inpatient Hospital Services of Psychiatric Facilities
  13. 42 CFR 424.14- Requirements for Inpatient Services of Inpatient Psychiatric Facilities
  14. 42 CFR §424.5(a)(6)- Sufficient Information
  15. 42 CFR 482.61- Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals
  16. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10.9- Inpatient Psychiatric Facility Services Certification and Recertification
  17. Medicare Benefit Policy Manual, Chapter 2- Inpatient Psychiatric Hospital Services, section 20- Admission Requirements; section 30- Medical Records Requirements; section 30.1- Development of Assessment/Diagnostic Data; section 30.2- Psychiatric Evaluation; section 30.2.1- Certification and Recertification Requirements; section 30.2.1.1- Certification; section 30.2.1.2- Recertification; section 30.2.1.3- Delayed/Lapsed Certification and Recertification; section 30.3- Treatment Plan; section 30.3.1- Individualized Treatment or Diagnostic Plan; section 30.3.2- Services Expected to Improve the Condition or for Purpose of Diagnosis; section 30.4 – Recording Progress; section 30.5- Discharge Planning and Discharge Summary
  18. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, section 190- Inpatient Psychiatric Facility Prospective Payment System (IPF PPS)
  19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  20. American Psychiatric Association Diagnostic and Statistical Manual, Text Revision, Fifth Edition
  21. ICD-10-CM codebook, Chapter 5- Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
  22. Inpatient Psychiatric Facility PPS FY Addendum A Final PPS Payment Updates https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientPsychFacilPPS/tools
  23. MS-DRG Payment Book current year
Positron Emission Tomography for Dementia and Neurodegenerative Diseases: Medical Necessity and Documentation Requirements _0165 Complex Outpatient Hospital, Professional Services Region-1, Region-2, All Region 1 and Region 2 states 09/24/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the ADR letter date. Under specific requirements, Medicare covers FDG (fluorodeoxyglucose) Positron Emission Tomography (PET) scans for the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease (AD). Medical records will be reviewed to determine if the utilization of PET scan for the diagnosis or treatment of dementing neurodegenerative diseases is medically necessary according to Medicare coverage indications. Affected codes: 78608, A9552
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions
  8. Medicare National Coverage Determinations Manual, Ch. 1, Part 4-Coverage Determinations, §220.6.13-FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative Diseases
  9. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.1- Billing Instructions, (D)- Post-Payment Review for PET Scans
  10. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.12- Coverage for PET Scans for Dementia and Neurodegenerative Diseases
  11. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.3.1- Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005
  12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  13. First Coast A59049- Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions; Effective 4/22/2022; Revised 10/13/2023
  14. Novitas LCA A53134- Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions; Effective 10/01/2015; Revised 10/13/2023
  15. Noridian LCA A54666- Billing and Coding: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Retired 10/01/2023
  16. Noridian LCA A54668- Billing and Coding: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Retired 10/01/2023
  17. AMA CPTCodebook
  18. HCPCS Level II Codebook
Bilateral Indicator ‘3’: Incorrect Coding _0164 Automated Professional Services (Physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 09/23/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter. A Bilateral Indicator of “3” indicates the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with either a modifier 50 or modifiers RT and LT, and a ‘2’ in the units field, reimbursement is based on 100% of the Medicare allowed amount for each side less any applicable multiple procedure pricing rules. This query identifies claims with underpayments due to code being submitted with a quantity of “1” when performed bilaterally. Affected codes: Bilateral Indicator ‘3’ codes (indicated in the Medicare Physician Fee Schedule (MPFSDB) – the bilateral indicator field provides the appropriate indicator code for each CPT code) See Appendix D
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §40.7- Claims for Bilateral Surgeries C.3
  9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6 Physician Fee Schedule Payment Policy Indicator File Record Layout
  10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements – Addendum – Medicare Physician Fee Schedule Database (PFSDB) Record Layouts and Field Descriptions
  11. Physician Fee Schedule | CMS
  12. Physician Fee Schedule Relative Value Files- PFS Relative Value Files | CMS
  13. AMA CPT Codebook
Intravenous Immune Globulin for the Treatment of Autoimmune Blistering Diseases: Medical Necessity and Documentation Requirements _0160 Complex Hospital Outpatient; Ambulatory Surgery Center; Professional Services (physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 08/19/2019 Details Exclude claims having a “paid claim date” which is more than 3 years prior to the Review Results letter date. Medical documentation will be reviewed to determine if the use of intravenous immune globulin for the treatment of Autoimmune Blistering Diseases (AMBDs) meets Medicare coverage criteria and is reasonable and necessary. Affected codes: J1459, J1552, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1554, J1576, J1599
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual, Part 4- Coverage Determinations, §250.3- Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases
  8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §80.6- Intravenous Immune Globulin
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4 Reasonable and Necessary Provisions in LCDs
  11. CGS Administrators LCD L35891- Intravenous Immune Globulin; Effective 10/01/2015; Revised 03/27/2025
  12. First Coast Service Options (FCSO) LCD L34007- Immune Globulin; Effective 10/01/2015; Revised 02/05/2023
  13. Palmetto GBA LCD L34580- Intravenous Immunoglobulin (IVIG); Effective 10/01/2015; Revised 04/04/2024
  14. NGS LCA A52446- Intravenous Immune Globulin IVIG; Effective 10/01/2015; Revised 10/01/2022, Retired 10/31/2022
  15. CGS LCA A56779- Billing and Coding: Intravenous Immune Globulin; Effective 08/01/2019; Revised 03/27/2025
  16. First Coast Service Options (FCSO) LCA A57778- Billing and Coding: Immune Globulin; Effective 10/03/2018: Revised 01/01/2025
  17. Noridian LCA A57187- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 07/01/2023
  18. Noridian LCA A54641- Intravenous Immune Globulin: (IVIg) – NCD – 250.3; Effective 11/07/2015
  19. Noridian LCA A54643- Intravenous Immune Globulin: (IVIg) – NCD – 250.3; Effective 11/07/2015; Revised 11/07/2015
  20. Noridian LCA A57194- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 07/01/2023
  21. Novitas LCA A56786- Billing and Coding: Immune Globulin; Effective 08/08/2019; Revised 01/01/2025
  22. Palmetto LCA A56718- Billing and Coding: Intravenous Immune Globulin (IVIG); Effective 07/25/2019; 10/01/2024
  23. WPS LCA A57554- Billing and Coding: Immune Globulins; Effective 11/01/2019: Revised 10/01/2024
  24. HCPCS Level II Codebook
  25. AHA ICD-10-CM Diagnosis Codebook
Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements _0162 Complex Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 07/13/2019 Details Exclude claims that have a ‘claim paid date’ which is more than 3 years prior to the Additional Documentation Request (complex review). Documentation will be reviewed to determine if Computed Tomography (CT) Coronary Angiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: CPT 75574 (computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(7)-
  4. Routine physical checkups
  5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)-
  6. Payment of Benefits
  7. 42 CFR §405.929- Post-Payment Review
  8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  9. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  10. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and
  11. Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening
  12. Initial Determinations and Redeterminations Requested by a Party
  13. 42 CFR §405.986- Good Cause for Reopening
  14. 42 CFR §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests:
  15. Conditions.
  16. 42 CFR §411.15(a)(1)- Particular services excluded from coverage; Routine physical checkups
  17. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1-
  18. Definitions.
  19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective
  20. Actions, §§3.1- 3.6.6
  21. Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1)
  22. Coverage Determinations §220.1- Computed Tomography (CT) §A- General, and §F- Computed
  23. Tomographic Angiography (CTA)
  24. CGS Local Coverage Determination LCD L33947- Cardiac Computed Tomography (CCT) and Coronary
  25. Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 10/6/2022
  26. CGS Local Coverage Article LCA A56451- Billing and Coding: Cardiac Computed Tomography (CCT)
  27. and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2016; Revised
  28. 10/01/2022
  29. First Coast Local Coverage Determination LCD L33282- Computed Tomographic Angiography of the
  30. Chest, Head and Coronary Arteries; Effective 10/01/2015; Revised 10/01/2019
  31. First Coast Local Coverage Article LCA A57061- Billing and Coding: Computed Tomographic
  32. Angiography of the Chest, Heart, and Coronary Arteries; Effective 10/03/2018; Revised 10/01/2022
  33. NGS Local Coverage Determination LCD L33559- Cardiac Computed Tomography (CCT) and Coronary
  34. Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 4/01/2022
  35. NGS Local Coverage Article LCA A56737- Billing and Coding: Cardiac Computed Tomography (CCT)
  36. and Coronary Computed Tomography Angiography (CCTA); Effective 08/01/2019; Revised
  37. 10/01/2022
  38. Palmetto Local Coverage Determination LCD L33423- Cardiac Computed Tomography and
  39. Angiography (CCTA); Effective 10/01/2015; Revised 04/22/2021
Outpatient Therapy Services During Home Health: Unbundling _0158 Automated Hospital Outpatient, SNF Outpatient, Outpatient Rehabilitation Facility, Comprehensive Outpatient Rehabilitation Facility Region-1, Region-2, All Region 1 and Region 2 states 07/11/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review). On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x. Therapy services should not be billed separately during a home health episode of care as the services are bundled into the Home Health Consolidated Billing payment. Affected codes: CPT/HCPCS codes billed with Revenue codes 042x, 043x or 044x
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20- Home Health Prospective Payment System (HH PPS) Consolidated Billing
  9. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2.2 – Therapy Editing
  10. AMA CPT Codebook
  11. HCPCS Level II Codebook
Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements _0157 Complex Hospital Outpatient; Ambulatory Surgery Center (ASC) Region-1, Region-2, All Region 1 and Region 2 states 06/26/2019 Details Exclude from review claims having a “claim paid date” which is more than 3 years prior to the ADR date Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable both to outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifiers 73 and 74. Affected codes: Paid HCPCS with one of the following ICD-10-CM diagnosis codes- Z53, Z53.0, Z53.01, Z53.09, Z53.1, Z53.2, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. 42 CFR §419.44 Payment Reductions for Procedures
  9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.5- Discounting; §20.6- Use of Modifiers, §20.6.1- Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4- Modifiers 73 and 74
  10. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40.4- Payment for Terminated Procedures
  11. AMA CPT Codebook
  12. AMA CPT Codebook, Appendix A Modifiers
  13. ICD-10-CM Diagnosis Codebook
  14. AHA Coding Clinic for HCPCS, 2007, Volume 7, Number 1, Page 1- Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS
  15. AHA Coding Clinic for HCPCS, 2008, Volume 8, Number 2, Pages 1-4- Special Issue: Modifiers 52, 73, and 74
  16. AHA Coding Clinic for HCPCS, 2016, Volume 16, Number 1, Page 12- Appropriate Use of Modifiers for Discontinued Services under the OPPS
  17. AMA CPT Assistant, September 2003, Page 3- Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’
Ambulatory Surgical Center Coding Validation _0153 Complex Ambulatory Surgical Center (ASC) Region-1, Region-2, All Region 1 and Region 2 states 05/26/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Ambulatory Surgical Center (ASC) coding requires that procedural information, as coded and reported by the ASC on its claim, match both the physician description and the information contained in the beneficiary’s medical record. Reviewers will validate the CPT/HCPCS coding and associated modifiers by reviewing the procedures affecting or potentially affecting payment. Affected codes: Claims with payment indicator A2; G2; J8; P2; P3, R2
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §424.5(a)(6)- Sufficient information
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package
  10. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; §40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; §40.5- Payment for Multiple Procedures
  11. Ambulatory Surgical Center Payment System; Addendum AA; Payment indicators A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight), G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate. ASC Payment rates, P2 (Office-based surgical procedure on ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight), P3 (Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on MPFS non-facility PE RVUs), and R2 (Office-based surgical procedure on ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight) available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html
  12. National Correct Coding Initiative (NCCI) Policy Manual
  13. AMA CPT Codebook
  14. HCPCS Level II Codebook
  15. AMA CPT Assistant
  16. AHA Coding Clinic for HCPCS
Non-Emergency Ambulance Services- Advanced Life Support and Basic Life Support: Medical Necessity and Documentation Requirements _0154 Complex Ambulance Region-1, Region-2, All Region 1 and Region 2 states 05/20/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date as well as state/date exclusions below: 1. Exclude NJ, PA, SC, DE, DC, MD, NC, VA, and WV 2. For DOS on or after 12/01/2021- exclude AR, CO, LA, MS, NM, OK, TX 3. For DOS on or after 2/01/2022- exclude AL, AS, CA, GA, GU, HI, MP, NV, TN 4. For DOS on or after 4/01/2022- exclude FL, IL, IA, KS, MN, MO, NE, PR, WI, VI 5. For DOS on or after 6/01/2022- exclude CT, IN, ME, MA, MI, NH, NY, RI, VT 6. FOR DOS on or after 8/01/2022- exclude AK, AZ, ID, KY, MT, ND, OH, OR, SD, UT, WA, WY Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment. Affected codes: A0426: Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1) A0428: Ambulance service, basic life support, non-emergency transport, (BLS) A0425: Ground mileage, per statute mile
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(7)- Medical and Other Health Services
  9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)- (16)- Establishment of Fee Schedule for Ambulance Services
  10. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions; (b) Basic rules; (c) Levels of service; (e) Medical necessity requirements
  11. 42 CFR 410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements
  12. 42 CFR 414.605 Definitions
  13. 42 CFR 414.610 Basis of Payment
  14. 42 CFR 424.36- Signature Requirements
  15. 42 CFR 424.37 Evidence of Authority to Sign on behalf of the Beneficiary.
  16. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
  17. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services
  18. Medicare Claims Processing Manual, Chapter 15- Ambulance, §10.2 – Summary of the Benefit
  19. HCPCS Level II Codebook
Mohs Micrographic Surgery: Incorrect Coding and Incorrect Units Billed _0150 Complex Professional Services Region-1, Region-2, All Region 1 and Region 2 states 04/30/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Mohs Micrographic Surgery is a two-step process in which: 1) The tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s); and 2) Additional excision and evaluation is performed until all margins are clear. This review will verify that the physician who performs the Mohs surgery is acting as both surgeon and pathologist. Reviewers will determine if the correct number of units have been billed for additional Mohs micrographic technique staging unit(s) for HCPCS 17312 and 17314. Billing of excessive or insufficient units or a change in coding will be adjusted accordingly. Affected codes: 17312, 17314
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. AHA Coding Clinic for HCPCS, Third Quarter 2013, Volume 13, Number 3, Page 1-3 Reporting MOHS micrographic surgery (MMS)
  9. CPT Assistant, October 2014, Volume 24, Issue 10, Page 14-Frequently Asked Questions, Surgery-Integumentary System, Mohs Surgery, Tissue Block
  10. CPT Assistant, November 2006, Volume 16, Issue 11, Pages 1-7 Mohs Micrographic Surgery
  11. CPT Assistant, February 2014, Volume 24, Issue 2, Page 10-Coding Clarification: Mohs Surgery (17311-17315)
  12. AMA CPT Codebook
Radiologic Examination of the Chest: Medical Necessity and Documentation Requirements _0136 Complex Outpatient hospital Region-1, Region-2, All Region 1 and Region 2 states 04/25/2019 Details Exclude from review claims with Dates of Service prior to May 12, 2023 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. Claims that are billed inappropriately or that do not meet medical necessity requirements will result in an overpayment. Affected codes: 71045 – Radiologic Examination, chest; single view 71046 – Radiologic Examination, chest; 2 views 71047 – Radiologic Examination, chest; 3 views 71048 – Radiologic Examination, chest; 4 or more views
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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
  6. 42 CFR §405.986- Good Cause for Reopening
  7. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions.
  8. 42 CFR §411.15(a)(1) – Particular services excluded from coverage, (a) Routine physical checkups (1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening
  9. –
  10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §§80.4-80.4.4- Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician
  11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions
  12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  13. Noridian Local Coverage Determination: L37547- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019
  14. Noridian Local Coverage Article (LCA): A57497- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021
  15. Noridian Local Coverage Determination: L37549- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019
  16. Noridian Local Coverage Article (LCA): A57498- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021
  17. AMA CPT Codebook
Physician/Non-Physician Practitioner Coding Validation _0151 Complex Physician/Non-Physician Practitioner Region-1, Region-2, All Region 1 and Region 2 states 04/23/2019 Details Exclude claims that have a “paid claim date” which is more than 3 years prior to the ADR letter date. The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Documentation will be reviewed to determine if professional services affecting MPFS payment meet Medicare coverage criteria and applicable coding guidelines. Affected codes: CMS Medicare Physician Fee Schedule status code “A”
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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- – Establishing Good Cause for Reopening
  7. 42 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
  8. 42 CFR §414.40- Coding and Ancillary Policies
  9. 42 CFR §415- Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings
  10. 42 CFR §419.44- Payment Reductions for Procedures
  11. Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners
  12. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements
  13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  14. AMA CPT Codebook
  15. HCPCS Level II Codebook
  16. AMA CPT Assistant
  17. National Correct Coding Initiatives (NCCI) Policy Manual
  18. CMS Medicare Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
  19. American Hospital Association (AHA) Coding Clinic
Subsequent Hospital Visit and Discharge Day Management on the Same Day: Unbundling _0149 Automated Professional Services; exclude non-physician practitioner codes 50 (NP) and 97 (PA) Region-1, Region-2, All Region 1 and Region 2 states 04/18/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review) CMS does not reimburse a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same physician. CPT codes 99231 – 99233 will be considered overpayments and will be recovered. Affected codes: 99231 – 99233 (see Appendix D for code list and long descriptions)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physicians/ Nonphysician Practitioners, §30.6.5- Physicians in Group Practice
  8. Medicare Claims Processing Manual, Chapter 12-Physicians/ Nonphysician Practitioners, §30.6.9.2(C)- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. AMA CPT Codebook
Ambulatory Surgical Center Services Billed During a Covered Part A Skilled Nursing Facility Stay: Unbundling _0142 Automated Ambulatory Surgery Center (ASC) Skilled Nursing Facility (SNF) Region-1, Region-2, All Region 1 and Region 2 states 04/01/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review). Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates are overpayments and will be recovered. Affected codes: Annual SNF Consolidated Billing Part A MAC Codes
  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. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, §1815(a)- Payment to Providers of Services
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §424.5(a)(6)- Sufficient Information
  9. 42 CFR § 424.32(a)(1) – Basic requirements for all claims
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. Medicare Claims Processing Manual, 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
  12. Medicare Claims Processing Manual, 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
  13. SNF Consolidated Billing – Annual Updates for Part A MAC https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  14. General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing- General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing (cms.gov)
  15. HCPCS Level II Codebook
  16. AMA CPT Codebook
Pulmonary Rehabilitation: Medical Necessity and Documentation Requirements _0140 Complex Hospital Outpatient Region-1, Region-2, All Region 1 and Region 2 states 03/27/2019 Details Exclude from review claims with Dates of Service prior to May 12, 2023. Pulmonary rehabilitation is a physician or nonphysician practitioner-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. Affected codes: 94625, 94626
  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) – Medical and Other Health Services- (fff) Pulmonary Rehabilitation Program
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR § 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage
  9. 42 CFR §411.15(k)(1)- Particular services excluded from coverage
  10. 42 CFR §424.5(a)(6)- Basic Conditions, Sufficient Information
  11. Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 240.8 – Pulmonary Rehabilitation Services
  12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2024
  13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010
  14. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services,
  15. §140.4- PR Services Effective for Dates of Service On or After January 1, 2024
  16. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4.1- PR Services Furnished on or After January 1, 2010
  17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  18. Noridian LCA A52770 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/01/2015; Revised 10/01/2023
  19. Noridian LCA A56152 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/08/2018; Revised 10/01/2023
  20. AMA CPT Code Book
  21. HCPCS Level II Codebook
Magnetic Resonance Imaging Procedures: Excessive Units _0147 Automated Professional Services, Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 03/27/2019 Details Claims that have a “claim paid date” which is less than three years prior to the Review Results Letter date (automated review). When a more extensive Magnetic Resonance Imaging (MRI) Procedure is performed on the same site as a less extensive MRI procedure, the less extensive MRI procedure is bundled into the more extensive MRI procedure. Affected codes: 70540, 70542, 70543, 70544, 70545, 70546, 70547. 70548, 70549, 70551, 70552, 70553, 70557, 70558, 70559, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 75557, 75559, 75561
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 12 -Physicians/Non-physician Practitioners, Sections 30 – Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures
  9. AMA CPT Codebook
Computed Tomography Scans: Excessive Units _0146 Automated Professional Services; Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 03/26/2019 Details Claims that have a “paid claim date” which is less than 3 years prior to the Review Results Letter Date (automated review) When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan. Affected codes: 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 74176, 74177, 74178, 74261, 74262
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12 -Physicians/Non-physician Practitioners, Section 30- Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
Cardiac Rehabilitation: Medical Necessity and Documentation Requirements _0135 Complex Hospital Outpatient Region-1, Region-2, All Region 1 and Region 2 states 03/07/2019 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Cardiac rehabilitation (CR) is a physician or nonphysician practitioner-supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meets Federal guidelines and Medicare coverage criteria. Affected codes: 93797, 93798, G0422, G0423
  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 1848(b)(5)- Treatment of Intensive Cardiac Rehabilitation Program
  4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(2)(CC), (DD)- Medical and Other Services- Cardiac Rehabilitation Program, Intensive Cardiac Rehabilitation Program
  5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(eee)(1), (4)(A)- Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation Program
  6. 42 CFR §405.929- Post-Payment Review
  7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  8. 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
  9. 42 CFR §405.986- Good Cause for Reopening
  10. 42 CFR §410.49 – Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage
  11. Medicare National Coverage Determinations (NCD), Part 1 – Coverage Determinations, § 20.10.1 – Cardiac Rehabilitation Programs for Chronic Heart Failure; §20.31 – Intensive Cardiac Rehabilitation (ICR) Programs; §20.31.1 – The Pritikin Program; §20.31.2 – Ornish Program for Reversing Heart Disease; §20.31.3 – Benson-Henry Institute Cardiac Wellness Program
  12. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, §232 – Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished on or After January 1, 2010
  13. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §140- Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs; §140.2- Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010; §140.3- Intensive Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010
  14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  15. AMA CPT Codebook
  16. HCPCS Level II Codebook
Skilled Nursing Facility Consolidated Billing for Therapies: Unbundling _0138 Automated Physician/Non-Physician Practitioner, Physical Therapist, Occupational Therapist, Speech-Language Pathologist Region-1, Region-2, All Region 1 and Region 2 states 02/19/2019 Details Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date (automated review). Physical therapy, Occupational therapy, and/or Speech-Language pathology services, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional, 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 residents during noncovered stays) and must be billed by the SNF alone for its Part B residents on a 22x type of bill. Services found to be unbundled will be denied. Affected codes: Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing files: https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  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. Social Security Act (SSA) 1888(e)(2)(A)(ii)- Services excluded
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing, §10.3- Types of Services Subject to the Consolidated Billing Requirement for SNFs, §20.5- Therapy Services
  9. Medicare Claims Processing Manual, Chapter 6-SNF Inpatient Part A Billing, §20.1.1-Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement
  10. Medicare Claims Processing Manual, Chapter 7- SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §110- Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  12. Medicare SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  13. AMA CPT Codebook
  14. HCPCS Level II Codebook
Vertebroplasty or Kyphoplasty: Medical Necessity and Documentation Requirements _0139 Complex Outpatient Hospital (OPH); Ambulatory Surgery Center (ASC); Professional Services [Physician/Non-Physician Practitioner (NPP)] Region-1, Region-2, All Region 1 and Region 2 states 02/19/2019 Details Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date Vertebroplasty and kyphoplasty will be reviewed for medical necessity whether billed as an initial procedure, a repeat procedure (beyond once in a lifetime) or if performed at more than one vertebral level. Services that were not medically reasonable and necessary will be denied and will result in an overpayment. Affected codes: 22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. CGS Administrators, LLC, LCD L38201- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 10/03/2024
  9. CGS Administrators, LLC, LCA A57282- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 10/03/2024
  10. First Coast Service Options, Inc., LCD L34976- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
  11. First Coast Service Options, Inc., LCA A57872- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 07/12/2020
  12. National Government Services, Inc., LCD L33569- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 12/01/2020
  13. National Government Services, Inc., LCA A56178- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 12/01/2020
  14. Noridian Healthcare Solutions, LLC, LCD L34106- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
  15. Noridian Healthcare Solutions, LLC, LCD L34228- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021
  16. Noridian Healthcare Solutions, LLC, LCA A56572- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 01/10/2021
  17. Noridian Healthcare Solutions, LLC, LCA A56573- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 01/10/2021
  18. Novitas Solutions, Inc., LCD L35130- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 7/11/2021
  19. Novitas Solutions, Inc., LCA A57752- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/21/2019; Revised 7/12/2020
  20. Palmetto GBA LCD L38737- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 7/20/2023
  21. Palmetto GBA LCA A58275- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 8/21/2022
  22. Wisconsin Physicians Service Insurance Corp., LCD L38213- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 8/01/2024
  23. Wisconsin Physicians Service Insurance Corp., LCA A57630- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 8/01/2024
  24. AMA CPT Codebook
Evaluation and Management Same Day as Admission to a Nursing Facility: Unbundling _0132 Automated Physician/ Non-Physician Practitioner Region-1 All Region 1 states 02/15/2019 Details Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational letter date CMS will not pay for an emergency department visit or an office visit E&M service on the same day as a comprehensive nursing facility assessment when both the E&M service and the comprehensive nursing facility assessment are performed by the same physician, at a site other than the nursing facility. The E&M service is bundled into the comprehensive nursing facility assessment code. The E&M service is not separately payable. Affected codes: CPT 99201 -99215, 99281 – 99285 (Please refer to Appendix D for complete CPT code descriptors)
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  4. 1833(e)- Payment of Benefits
  5. 42 CFR §405.929- Post-Payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  8. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial
  9. Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and
  10. Requirements for Reopening Initial Determinations and Redeterminations Requested by a
  11. Party
  12. 42 CFR §405.986- Good Cause for Reopening
  13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking
  14. Corrective Actions, §§3.1- 3.6.6
  15. Medicare Claims Processing Manual: Chapter 12 – Physicians/Nonphysician Practitioners,
  16. §30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits
  17. (Codes 99201 – 99215), (C) Office/Outpatient or Emergency Department E/M Visit on Day of
  18. Admission to Nursing Facility
  19. Medicare Claims Processing Manual: Chapter 12- Physicians/Nonphysician Practitioners,
  20. §30.6.11 Emergency Department Visits (Codes 99281 – 99288), (D) Emergency Department or
  21. Office/Outpatient Visits on Same Day As Nursing Facility Admission
  22. Medicare Claims Processing Manual: Chapter 12 -Physicians/Nonphysician Practitioners,
  23. §30.6.13 Nursing Facility Services, (A) Visits to Perform the Initial Comprehensive Assessment
  24. and Annual Assessments
Cryosurgery of the Prostate: Medical Necessity and Documentation Requirements _0134 Complex Outpatient Hospital, Ambulatory Surgery Center (ASC) and Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 02/14/2019 Details Exclude claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Documentation will be reviewed to determine whether Cryosurgery of the Prostate Gland services met Medicare coverage criteria and were reasonable and necessary. Affected codes: 55873 – Cryosurgical ablation of the prostate (includes ultrasonic guidance and monitoring)
  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 424.5(a)(6)-Sufficient Documentation
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. Medicare National Coverage Determinations Manual (NCD), Chapter 1 Coverage Determinations, Part 4 (Sections 200-310.1), §230.9 Cryosurgery of Prostate; Effective 7/1/01; Revised 8/17/23
  9. Medicare Claims Processing Manual, Chapter 32 Billing Requirements for Special Services, §180 Cryosurgery of the Prostate Gland
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
Technical Component of Diagnostic Procedures During Inpatient: Unbundling _0123 Automated Physician/Non-Physician Practitioner Independent Diagnostic Testing Facility (IDTF) Region-1, Region-2, All Region 1 and Region 2 states 12/10/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the review results letter date (automated review). When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay. Incorrect billing of the technical component will be denied. Affected codes: CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3;
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30.1-Provider-Based Physician Services
  8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Record Layout and Field Descriptions
  9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30- Services Paid Under the Medicare Physician’s Fee Schedule
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. Physician Fee Schedule, https://www.cms.gov/medicare/physician-fee-schedule/search
  12. AMA CPT Codebook
Monthly Capitation Payment for End-Stage Renal Disease: 4 or more Visits per Month _0112 Automated Professional Services Region-1 All Region 1 states 12/01/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review). A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. The claim/claim line with a single paid unit of 90957 or 90960 is the covered service. All additional claim(s)/claim line(s) of 90957-90962, are the overpayments and will be recovered in full. Affected codes: 90957, 90958, 90959, 90960, 90961, 90962
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)-
  4. Payment of Benefits
  5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  6. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and
  7. Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening
  8. Initial Determinations and Redeterminations Requested by a Party
  9. 42 CFR §405.929- Post-Payment Review
  10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  11. 42 CFR §405.986- Good Cause for Reopening
  12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective
  13. Actions, §§3.1- 3.6.6
  14. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and
  15. Physician/Supplier Claims, §140- Monthly Capitation Payment Method for Physicians’ Services
  16. Furnished to Patients on Maintenance Dialysis; §140.1- Payment for ESRD-Related Services Under
  17. the Monthly Capitation Payment (Center Based Patients); and §140.4- Controlling Claims Paid Under
  18. the Monthly Capitation Payment Method
  19. AMA CPT Codebook
Destruction of Premalignant Lesions: Excessive Units _0121 Automated All Provider Specialties Region-1 All Region 1 states 12/01/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review). Based on CPT Code descriptions, CPT Code 17000 may only be billed once per date of service; CPT Code 17003 may only be billed thirteen times per date of service, and CPT Code 17004 may only be billed once per date of service. If billed in excess of these limits, excess units of CPT codes 17000, 17003 and/or 17004 will be recovered. Affected codes: 17000, 17003, 17004
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)-
  4. Payment of Benefits
  5. 42 CFR §405.929- Post-Payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  8. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and
  9. Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening
  10. Initial Determinations and Redeterminations Requested by a Party
  11. 42 CFR §405.986- Good Cause for Reopening
  12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective
  13. Actions, §§3.1- 3.6.6
  14. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current
  15. (Destruction, Benign or Premalignant Lesions)
  16. Palmetto GBA LCA A56346- Billing and Coding: Removal of Benign and Malignant Skin Lesions;
  17. Effective 01/01/2019; Revised 5/12/2022
  18. CGS Administrators, LLC, LCA A57044- Billing and Coding: Removal of Benign Skin Lesions; Effective
  19. 09/26/2019; Revised 7/29/202111. NGS LCA A54602- Billing and Coding: Removal of Benign Skin Lesions; Effective 10/01/15; Revised
  20. 5/07/2020
  21. Novitas LCA A57113- Billing and Coding: Removal of Benign Skin Lesions; Effective 09/26/19; Revised
  22. 01/12/2022
  23. WPS, Local Coverage Article (LCA) A57482- Billing and Coding: Removal of Benign Skin Lesions;
  24. Effective 10/31/2019; Revised 10/28/2021
Part B Therapies during Inpatient: Unbundling _0124 Automated Professional Services (Physical Therapist, Occupational Therapist, Speech-Language Pathologist) Region-1, Region-2, All A/B MACs 11/29/2018 Details Claims having a "claim paid date" which is less than 3 years prior to the informational letter date (automated review). HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist, or speech language therapist in private practice. Unbundled services will be denied and result in an overpayment. Affected codes: HCPCS/CPT Codes with a PC/TC Indicator of “7” in the MPFSDB (See Appendix D for complete list of HCPCS/CPT code and descriptions)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual: CMS Publication 100-04; Chapter 23, – Fee Schedule Administration and Coding Requirements; Addendum- MPFSDB File Record Layout and Field Descriptions (For Historical Medicare Physician Fee Schedule Database (MPFSDB) Layouts 2001 – 2018, refer to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Historical-MPFSDB-Layouts.pdf located on the CMS Physician Fee Schedule web page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
  10. HCPCS Level II Codebook
Endoscopy Procedures: Diagnostic and Surgical Billed Same Day _0126 Automated Outpatient Facility; Ambulatory Surgical Center (ASC); Professional Services Region-1, Region-2, All Region 1 and Region 2 states 11/27/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the date of the Review Results Letter. Surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported. Affected codes: 45378, 45330
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §30- Correct Coding Policy, (E)- Separate Procedures, (G)- Family of Codes, and (H)- Most Extensive Procedures
  9. National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter VI – Digestive System CPT Codes 40000 – 49999, §C – Endoscopic Services
  10. AMA CPT codebook
Modifiers TC and 26: Incorrect Coding _0116 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1 All Region 1 states 11/01/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the informational Letter date (automated review) 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. Findings will be the difference between the original Provider Paid Amount and the Re-Calculated Provider Paid Amount. Affected codes: HCPCS Codes with a PC/TC Indicator of “1” as identified in the CMS MPFSDB
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6- Physician Fee Schedule Payment Policy Indicator File Record Layout
  9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum – MPFSDB Record Layouts 20 – Professional Component (PC)/Technical Component (TC) Indicator
  10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum – MPFSDB Record Layout and Field Descriptions; MPFSDB File Record Layout for 2018 and prior may be found on the CMS website: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched
  11. AMA CPT Codebook
Professional Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered _0115 Automated Professional Claims (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 10/16/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review). Home Visits for professional services should not overlap an active Inpatient Stay. Professional claims billed with a home-related place of service that overlaps an inpatient hospital stay will be denied. Affected codes: 90901, 90912, 90913, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92601, 92602, 92603, 92604, 92605, 92606, 92607, 92608, 92609, 92610, 92611, 92612, 92614, 92616, 95851, 95852, 96000, 96001, 96002, 96003, 96105, 96125, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97537, 97542, 97545, 97546, 97597, 97598, 97602, 97605, 97606, 97750, 97755, 97760, 97761, 97763, 97799, 20999, G0279, G0281, G0283, G0329
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2(B)- Exact Duplicate Claims, Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers)
  9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Record Layout and Field Descriptions
  10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30- Services Paid Under the Medicare Physician’s Fee Schedule
  11. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, §10.5- Place of Service Codes and Definitions
  12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30- Physician Services
  13. AMA CPT Codebook
  14. HCPCS Level II Codebook
  15. CMS Medicare Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html
Inpatient Rehabilitation Facility: Medical Necessity and Documentation Requirements _0073 Complex Inpatient Rehabilitation Facility Region-1, Region-2, All Region 1 and Region 2 states 10/12/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Medicare only pays for services that are reasonable and necessary for the setting billed. The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for beneficiaries who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. In order for IRF care to be considered reasonable and necessary, the documentation in the beneficiary’s IRF medical record must demonstrate a reasonable expectation that CMS criteria, as defined in 42 C.F.R. §§412.600-622 and CMS Pub. 100-02, Ch. 1 section 110, was met at the time of admission to the IRF. Claims that do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment Affected codes: N/A
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1815(a)- Payment to Providers of Services
  2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits
  4. Social Security Act (SSA), Title XVII- Health Insurance for the Aged and Disabled, §1834(m)(4)(F)- Telehealth Service
  5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1886(j)- Prospective Payment for Inpatient Rehabilitation Services
  6. 42 CFR §400.200- Subchapter A, General Provisions, Definitions for Public Health Emergency
  7. 42 CFR §405.929- Post-Payment Review
  8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  9. 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
  10. 42 CFR 405.986- Good Cause for Reopening
  11. 42 CFR §411.15(k)(1)- Any Services that are not Reasonable and Necessary
  12. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system
  13. 42 CFR 412.604(c)- Completion of patient assessment instrument
  14. 42 CFR 412.606(b)- Comprehensive Assessments
  15. 42 CFR 412.612(a) – Responsibilities of the clinician
  16. 42 CFR §412.620- Patient classification system
  17. 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, (5)- Interdisciplinary Team Approach to Care, and (c) Definitions- Week
  18. 42 CFR 414.65- Payment for Telehealth Services
  19. 42 CFR §424.32- Basic requirements for all claims
  20. 45 CFR §162.1002(c)- Medical data code sets, for the period on or after October 1, 2015
  21. Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services
  22. Medicare Claims Processing Manual, Ch. 1- General Billing Requirements, §80.3.2.2- Consistency Edits for Institutional Claims
  23. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS
  24. Medicare Program Integrity Manual MPIM, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
Transthoracic Echocardiography: Medical Necessity and Documentation Requirements _0111 Complex Hospital Inpatient (Medicare Part B only); Outpatient; Skilled Nursing- Inpatient (Medicare Part B only) Region-1, Region-2, All Region 1 and Region 2 states 10/12/2018 Details Claims that have a “paid claim date” which is less than 3 years prior to the ADR letter date. Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary. Affected codes: 93303, 93306, 93307, C8921, C8923
  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 1862(a)(7)-Exclusions from Coverage and Medicare as a Secondary Payer-for routine physical checkups
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 Code of Federal Regulations §410.32(a) – Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions
  9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests
  10. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.4- Cardiovascular System (Codes 92950- 93799)
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  12. CGS Administrators, LLC, LCD L34338- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/03/2024
  13. First Coast LCD L33768- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Retired 3/01/2023
  14. NGS LCD L33577- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019
  15. Palmetto GBA LCD L37379- Echocardiography; Effective 9/18/2017; Revised 6/10/2021
  16. CGS Administrators, LLC, LCA A57306- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 9/26/2019; Revised 10/03/2024
  17. First Coast LCA A57182- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 10/03/2018; Retired 3/01/2023
  18. NGS LCA A56781- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 8/01/2019; Revised 01/01/2025
  19. Palmetto GBA LCA A56625- Billing and Coding: Echocardiography; Effective 6/20/2019; Revised 10/01/2024
  20. AMA CPT Codebook
Skilled Nursing Facility Consolidated Billing: Part B – Use of Modifier 26, Professional Component _0110 Automated Physician/Non-Physician Practitioner (professional services) Region-1, Region-2, All Region 1 and Region 2 states 09/20/2018 Details Include Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date. When a Part B CPT/HCPCS code listed on File 2 (Professional Components of Services to be Submitted with a 26 Modifier) is billed during a paid inpatient Part A SNF stay, without modifier 26, the Part B claim will be repriced with modifier 26 to reflect the professional component reduction. The overpayment is identified by the difference between the original paid Part B amount and the re-calculated paid amount based on modifier 26 pricing. Affected codes: CPT/HCPCS codes listed on the CMS File 2 – Part A Stay – Professional Components of Services to be Submitted with a 26 Modifier. (https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation.html)
  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 CFR §405.929- Post-Payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 6 SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.1.1- Physician’s Services and Other Professional Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement
  9. Medicare Claims Processing Manual, Chapter 25 – Completing and Processing the Form CMS-1450 Data Set, §75.3 – – Form Locators 31-41, Guidelines for Occurrence and Occurrence Span Utilization
  10. SNF Consolidated Billing – Part B Medicare Administrative Contractor (MAC) File Explanation – https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  11. AMA CPT Codebook
  12. HCPCS Level II Codebook
Epidural Steroid Injection: Medical Necessity and Documentation Requirements _0119 Complex Professional services, Outpatient Hospital Region-1 & Region-2, MAC jurisdictions JF/JE, JH/JL 09/19/2018 Details Exclude claims having a “claim paid date” which is more than 3 years prior to the Additional Documentation Request Letter date, and the following limitations: • Noridian: select DOS on or after 6/19/2022 Epidural injections are generally performed to treat pain arising from spinal nerve roots. These procedures may be performed via three distinct techniques, each of which involves introducing a needle into the epidural space by a different route of entry. These are termed the interlaminar, caudal, and transforaminal approaches. The procedures involve the injection of a solution containing local anesthetic with or without corticosteroids. In order to be considered medically necessary, they must meet certain indications and procedural requirements. Affected codes: 62321, 62323, 64479, 64480, 64483, 64484
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. CGS Administrators, LLC, Local Coverage Determination L39015- Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/9/2023
  9. CGS Administrators, LLC, Local Coverage Article A58731- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 03/13/2025
  10. First Coast Service Options, Inc., Local Coverage Determination L33906- Epidural Steroid Injections for Pain Management; Effective 10/01/2015; Revised 12/12/2021
  11. First Coast Service Options, Inc., Local Coverage Article A56651- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 10/03/2018; Revised 11/16/2023
  12. National Government Services, Inc., Local Coverage Determination L39036- Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/23/2023
  13. National Government Services, Inc., Local Coverage Article A58745- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/23/2023
  14. Noridian Healthcare Solutions, LLC (JE), Local Coverage Determination; L39240 Epidural Steroid Injections for Pain Management; Effective: 6/19/2022
  15. Noridian Healthcare Solutions, LLC, Local Coverage Determination L39242- Epidural Steroid Injections for Pain Management; Effective: 6/19/2022
  16. Noridian Healthcare Solutions, LLC, Local Coverage Article A58993- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 6/19/2022; Revised 11/15/2023
  17. Noridian Healthcare Solutions, LLC, Local Coverage Article A58995- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 6/19/2022; Revised 11/15/2023
  18. Novitas Solutions, Inc., Local Coverage Determination L36920- Epidural Injections for Pain Management; Effective: 5/4/2017; Revised 12/12/2021
  19. Novitas Solutions, Inc., Local Coverage Article A56681- Billing and Coding: Epidural Injections for Pain Management; Effective: 7/11/2019; Revised 11/16/2023
  20. Palmetto GBA, Local Coverage Determination L38994- Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/16/2023
  21. Palmetto GBA, Local Coverage Article A58695- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/16/2023
  22. Wisconsin Physicians Service, Local Coverage Determination L39054- Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 02/01/2024
  23. Wisconsin Physicians Service, Local Coverage Article A58777- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/30/2023
  24. AMA CPT Codebook
Facility vs Non-Facility Reimbursement: Incorrect Coding _0108 Automated Physician/Non-Physician Practitioner Region-1, Region-2, All Region 1 and Region 2 states 09/14/2018 Details Claims having a "claim paid date" that is more than 6 months prior to the Review Results Letter date will be excluded. Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and non-facility settings. The rate, facility or non-facility, which a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), , the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred. Affected codes: All CPT/HCPCS codes with site-of-service differentials
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual Chapter 12- Physician/Non-Physician Practitioners, §20.4.2- Site of Service Payment Differential
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
Ambulatory Payment Classification Coding Validation _0101 Complex Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 07/26/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician’s description of service and the information contained in the beneficiary’s medical record. Reviewers will validate the APC by reviewing the billed services affecting or potentially affecting APC reimbursement. Affected codes: Claims with status indicators (SI) = J1, S, or T
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. 42 CFR §419- Prospective Payment System for Hospital Outpatient Department Services
  9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§10.1-10.5, 20, 40-50
  10. AMA CPT Codebook
  11. American Medical Association (AMA), Current Procedure Terminology (CPT), Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1), APCs for Hospital Part B services paid through a comprehensive APC (SI = J1), Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies (SI = T)
  12. AMA CPT Assistant
  13. Medicare National Correct Coding Initiative (NCCI) Policy Manual
  14. CMS Hospital Outpatient PPS, Addendum B Updates, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html
Add-on Code Paid without Primary Code and/or Denied Primary Code – Ambulatory Surgical Center _0104 Automated Ambulatory Surgery Center (ASC) Region-1, Region-2, All Region 1 and Region 2 states 07/26/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review) CMS has designated certain codes as “add-on procedures”. These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also paid. ASC providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Denials will result in an overpayment. Affected codes: Add-on Codes https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims
  9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30- Correct Coding Policy
  10. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens
  11. Medicare Claims Processing Manual, Chapter 29- Appeals of Claim Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals
  12. Add-on Code Edits, as updated by CMS- https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
  13. AMA CPT Codebook
Add-On Code Paid without Primary Code and/or Denied Primary Code: Clinical Laboratory _0100 Automated Laboratory Region-1, Region-2, All Region 1 and Region 2 states 06/21/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date. CMS has designated certain codes as “add-on procedures”. These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. Clinical Laboratory providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied. Affected codes: Primary- 17311-17315, 81265, 81415, 81425, 81535, 82951, 86825, 87186, 87188, 87502, 87903, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88172, 88174, 88175, 88184, 88302, 88304, 88305, 88307, 88309, 88329, 88331, 88333, 88342, 88346, 88365, 88367, 88368 Add- on- 81266, 81416, 81426, 81536, 82952, 86826, 87187, 87503, 87904, 99155, 88155, 88177, 88185, 88314, 88332, 88334, 88341, 88350, 88364, 88369, 88373, 88388
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930 – Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual Chapter 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims
  8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.D- Coding Services Supplemental to Principal Procedure (Add-On Codes) Code
  9. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens
  10. Medicare Claims Processing Manual, Chapter 29- Appeals of Claim Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6
  12. National Correct Coding Initiative, Add-on Code Edits https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
  13. AMA CPT Codebook
Skilled Nursing Facility Consolidated Billing: Unbundling _0099 Automated Outpatient Facility Region-1, Region-2, All Region 1 and Region 2 states 06/20/2018 Details Exclude claims having a "claim paid date" which is more than 3 years prior to the informational letter (automated review) Payment for the Skilled Nursing Facility (SNF) services, listed in the SNF Consolidated Billing Table, Major Category I.F and V.A., provided to beneficiaries by the outpatient facility, in a Medicare covered Part A SNF stay, are included in a bundled prospective payment and are not separately payable. Payment for those services will be recouped as identified overpayments. Affected codes: CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A. https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Biling, §§10-10.4- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview; §§20- 20.6- Services Included in Part A PPS Payment Not Billable Separately by the SNF
  9. CMS SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling
  10. AMA CPT Codebook
  11. HCPCS Level II Codebook
Critical Care Professional Services: Unbundling _0098 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 06/13/2018 Details Claims that have a claim paid date which is less than 3 years prior to the informational letter date (automated review) Certain CPT codes for Part B Professional services for the same Beneficiary, same Date of Service, and Same Provider will be recovered as overpayments as they are not payable when performed on the same day a physician bills for critical care. These services are included in the critical care service and should not be reported separately. Affected codes: 36000, 36410, 36415, 36591, 36600, 43752, 43753, 71045, 71046, 92953, 93561, 93562, 93598, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762 (see appendix D for long descriptors).
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, § 30.6.12– Critical Care Visits and Neonatal Intensive Care (CPT Codes 99291-99292)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
Implantable Automatic Defibrillators- Outpatient Procedure: Medical Necessity and Documentation Requirements _0093 Complex Outpatient Hospital, ASC (TOB 13X and 83X), ASC (ASC facilities = service type ‘F’) Region-1, Region-2, All Region 1 and Region 2 states 05/15/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications. Affected codes: 33216, 33217, 33224, 33225, 33230, 33231, 33240, 33249
  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. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual: Chapter 1 – Coverage Determinations, Part 1, Section 20.4- Implantable Cardioverter Defibrillators (ICDs)
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §270- Claims Processing for Implantable Automatic Defibrillators; §270.1- Coding Requirements for Implantable Automatic Defibrillators; §270.2- Billing Requirements for Patients Enrolled in a Data Collection System
  10. CGS Local Coverage Article A57994- Billing and Coding: Implantable Automatic Defibrillators; Effective 01/01/2021; Revised 11/22/2023
  11. First Coast Local Coverage Article A56341- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 07/06/2021
  12. NGS Local Coverage Article A56326- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Revised 03/03/2023
  13. Noridian Local Coverage Article A56340- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Revised 07/31/2023
  14. Noridian Local Coverage Article A56342- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Revised 07/31/2023
  15. Novitas Local Coverage Article A56355- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 07/06/2021
  16. Palmetto Local Coverage Article: A56343- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Revised 04/01/2025
  17. WPS Local Coverage Article A56391- Billing and Coding: Implantable Automatic Defibrillators; Effective 05/13/2019; Revised 05/01/2025
  18. AMA CPT Codebook
Duplicate Claims- Professional Services _0091 Automated Part B Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 05/11/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date (automated review). Duplicate payments are any payments paid across more than one claim number for the same Beneficiary, CPT/HCPCS code, and service date by the same provider, in excess of a code’s Medically Unlikely Edit (MUE). Affected codes: All CPT, HCPCS Codes
  1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  3. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments
  9. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2(B)- Exact Duplicates, Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers)
  10. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.2- Site of Service Payment Differential
  11. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, §10.5- Place of Service Codes (POS) and Definitions
  12. AMA CPT Codebook
  13. HCPCS Level II Codebook
Percutaneous Implantation of Neurostimulator Electrode Array: Medical Necessity and Documentation Requirements _0092 Complex Outpatient Hospital; Ambulatory Surgery Center; Professional Services (physician/non-physician practitioner) Region-1, Region-2, All Region 1 and Region 2 states 05/08/2018 Details Claims having a “paid claim date” which is less than 3 years prior to the ADR letter date The review shall identify claims billed incorrectly as percutaneous implantation of neurostimulator electrode arrays when the medical record demonstrates the transcutaneous placement of a device. Affected codes: 64553- Percutaneous implantation of neurostimulator electrode array; cranial nerve 64555- Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve) L8679-Implantable neurostimulator, pulse generator, any type
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determination Manual, Chapter 1, Part 1, §30.3- Acupuncture
  8. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.7.1(B)- Assessing Patients Suitability for Electrical Nerve Stimulation Therapy
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L34328 Peripheral Nerve Stimulation Original Effective Date: 10/01/2015, Revised 12/01/2019
  11. Noridian Healthcare Solutions, LLC LCD L37360 Peripheral Nerve Stimulation Original Effective Date: 08/27/2018; Revised 12/01/19
  12. Noridian Healthcare Solutions, LLC LCA A55530 Billing and Coding Peripheral Nerve Stimulation (JE) Original Effective Date: 8/27/2018, Revised 03/01/2024
  13. Noridian Healthcare Solutions, LLC LCA A55531 Billing and Coding: Peripheral Nerve Stimulation (JF) Original Effective Date: 8/27/2018, Revised 03/01/2024
  14. Wisconsin Physicians Service Insurance Corporation Local Coverage Article (LCA) A56062 Billing and Coding: Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT), Original Effective Date: 8/01/2018, Revised 05/26/2022, Retired 01/26/2023
  15. First Coast Service Options, Inc LCA A54794 Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) Original Effective Date: 12/24/2015, retired 01/01/22
  16. Novitas Solutions, Inc. LCA A55240- Billing and Coding: Auricular Peripheral Nerve Stimulation (Electro-Acupuncture Device); Original Effective Date: 8/11/2016; Revised 01/01/2023
  17. AMA CPT Codebook
Laboratory/Pathology Technical Component for Inpatient or Outpatient Hospitals: Unbundling _0090 Automated Physician/Non-Physician Practitioner Lab Independent Diagnostic Testing Facility (IDTF) Region-1, Region-2, All Region 1 and Region 2 states 04/04/2018 Details Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Informational letter date The technical component (TC) of lab/pathology services furnished to patients in an inpatient or outpatient hospital setting are not separately payable. Affected codes: All Lab/Pathology CPT/HCPCS codes with TC/PC Indicator 1 or 3
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physician/Non-Physician Practitioners, §60 (B) Payment for Technical Component (TC) Services
  8. Medicare Claims Processing Manual, Chapter 23 – Fee Schedule Administration and Coding Requirements, Addendum – MPFSDB File Record Layout and Field Descriptions
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. Medicare Physician Fee Schedule (MPFS) Physician Fee Schedule | CMS
  11. AMA CPT Codebook
Laboratory Services Rendered During an Inpatient Stay: Unbundling _0085 Automated Laboratory/Ambulance; Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 03/19/2018 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date Laboratory services are covered under Part A, excluding anatomic pathology services and certain clinical pathology services. If billed separately, these are considered unbundled services. Affected codes: Applicable CPT codes 80047-87912
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients
  9. AMA CPT Codebook
Observation Evaluation & Management (E&M) Services Billed Same Day as Inpatient Admission: Unbundling _0086 Automated Professional Services Region-1, Region-2, All Region 1 and Region 2 states 03/19/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the Review Results Letter date and dates of service on and after 1/1/2023. Hospital outpatient observation care (initial, subsequent and/or discharge management) rendered on the same date as a hospital inpatient admission by the same physician is not separately payable. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. Affected codes: 99217, 99218, 99219, 99220, 99221, 99222, 99223, 99224, 99225, 99226
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.8 (B)- Physician Billing for Observation Care Following Initiation of Observation Services & (D)- Admission to Inpatient Status Following Observation Care
  8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9- Payment for Inpatient Hospital Visits- General
  9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.1- Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services)
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
Clinical Social Worker during Inpatient: Unbundling _0089 Automated Professional Services Region-1, Region-2, All Region 1 and Region 2 states 03/19/2018 Details Claims having a “claim paid date” that is more than 3 years prior to the Informational Letter date will be excluded. Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facility’s PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility. Affected codes: Psychiatry CPT Codes 90785 – 90899 (See attached table – Appendix D)
  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 §1861(hh)- Clinical Social Worker, (hh)(2)- Clinical Social Worker Services
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §409.10(a)(4)- Included Services- Medical Social Services
  9. 42 CFR §410.73- Clinical Social Worker Services
  10. 42 CFR §412.509(b)- Furnishing of Inpatient Hospital Services Directly or Under Arrangements
  11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §170- Clinical Social Worker (CSW) Services
  12. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients
  13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  14. AMA CPT Codebook
Laboratory Services for End-Stage Renal Disease Subject to Part B Consolidated Billing: Unbundling _0087 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 03/16/2018 Details Claims having a "claim paid date" that is more than 3 years prior to the Informational letter date will be excluded The ESRD PPS includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and are not separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility. Affected codes: Labs subject to ESRD Consolidated Billing found on www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Benefit Policy Manual, Chapter 11- End Stage Renal Disease, §20.2- Laboratory Services
  8. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §60.1- Lab Services
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. ESRD PPS Consolidated Billing- www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html
  11. AMA CPT Codebook
  12. HCPCS Level II Codebook
Ancillary Services Billed Without an Approved Surgical Procedure _0088 Automated Ambulatory Surgery Center (ASC) Region-1, Region-2, All Region 1 and Region 2 states 03/16/2018 Details Claims having a "claim paid date" that is more than 3 years prior to the Review Results Letter date will be excluded. Covered ancillary items and services are not payable if there is no approved Ambulatory Surgical Center (ASC) surgical procedure on the same claim or in history for the same date of service and same provider. Affected codes: All ancillary services- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §260- Ambulatory Surgical Center Services
  9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40- Payment for Ambulatory Surgery
  10. CMS Ambulatory Surgery Center Approved HCPCS Code and Payment Rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates
  11. AMA CPT Codebook
  12. HCPCS Level II Codebook
Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements _0129 Complex Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 01/29/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to ADR letter date For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere pressure. The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least thirty (30) days of treatment with standard wound therapy and must be used in addition to standard wound care. Medical records will be reviewed to determine if Hyperbaric Oxygen Therapy (HBOT) for diabetic wounds is medically necessary according to Medicare coverage indications. HBOT for diabetic wounds that do not meet Medicare guidelines will result in overpayment. Affected codes: G0277 Hyperbaric oxygen under pressure, full body chamber, per 30-minute interval
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 Code of Federal Regulations §424.5- Basic Conditions, (a)(6)- Sufficient Information
  8. 42 Code of Federal Regulations §411.15- Particular Services Excluded from Coverage, (k)- Any Services not Reasonable and Necessary, (1)
  9. CMS National Coverage Determination Manual, Chapter 1- Coverage determinations, §20.29- Hyperbaric Oxygen Therapy
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. HCPCS Level II Codebook
  12. AHA ICD-10-CM Diagnosis Codebook
Annual Wellness Visit Billed Sooner Than Eleven Whole Months Following the Initial Preventive Physical Examination _0077 Automated Professional Services Region-1, Region-2, All Region 1 and Region 2 states 01/15/2018 Details Claims having a "claim paid date" that is more than 3 years prior to the Review Results letter date will be excluded. Claims for HCPCS Code G0439 will be recovered as overpayment as it is not payable if an Initial Preventive Physical Examination (IPPE) or an Annual Wellness Visit (AWV) has been paid within the past eleven (11) whole months. Affected codes: G0439, G0402
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §411.15- Particular Services Excluded from Coverage, (a)(1)- Routine Checkups
  8. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(15), (16)- Any Services that are not Reasonable and Necessary, (15)-additional preventive services; (16) Annual Wellness Visit with PPE
  9. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit (AWV)
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. HCPCS Level II Codebook
Drugs and Biologicals in Single-Dose Vials: Incorrect Units Billed _0074 Complex Outpatient Hospital; Professional Services Region-1, Region-2, All Region 1 and Region 2 states 01/11/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. Claims billed with excessive or insufficient units will be reviewed to determine the actual amount administered and the correct number of billable/payable units. Affected codes: C9132, J0178, J0180, J0202, J0221, J0256, J0475, J0485, J0490, J0583, J0585, J0588, J0775, J0881, J0894, J0897, J1299, J1300, J1439, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1602, J1745, J1786, J1930, J2182, J2323, J2326, J2350, J2353, J2357, J2505, J2507, J2562, J2778, J3101, J3262, J3357, J3380, J3385, J3489, J7312, J7325, J7326, J7327, J9022, J9023, J9033, J9035, J9041, J9042, J9043, J9047, J9055, J9145, J9173, J9176, J9179, J9205, J9228, J9263, J9264, J9271, J9280, J9285, J9299, J9301, J9303, J9305, J9306, J9307, J9308, , J9311, J9312, J9315, J9354, J9395, Q2043, Q2050, J0220, J0480, J0584, J0586, J0587, J0598, J1442, J1610, J1640, J2278, J3111, J3370, J7170, J7179, J7198, J7201, J7205, J7207, J9025, J9032, J9153, P9045, P9047 Added 2/15/2021: J1750, Q0138 Added 10/15/2021: J0179, J0207, J0222, J0223, J0257, J0291, J0401, J0517, J0565, J0596, J0597, J0598, J0638, J0791, J0795, J0840, J0841, J0850, J0875, J0896, J1162, J1190, J1290, J1303, J1322, J1458, J1571, J1575, J1743, J1746, J1931, J1943, J1944, J2350, J2407, J2425, J2426, J2724, J2783, J2786, J2794, J2860, J3032, J3060, J3095, J3241, J3245, J3304, J3358, J3396, J9039, J9044, J9050, J9119, J9120, J9144, J9155, J9203, J9204, J9207, J9210, J9227, J9229, J9309, J9317, J9325, J9330, J9352, J9357, J9358, J9400 Added 7/01/2022: C9074, J0224, J1305, J1823, J2506, J7168, J7311, J7313, J7314, J9047, J9061, J9177, J9223, J9247, J9261, J9266, J9272, J9281, J9308, J9316, J9318, J9319, J9353, Q5103, Q5104, Q5107, Q5108, Q5111, Q5115, Q5118, Q5119, Q5120, Q5121, Q5122 Added 11/15/2023: J0129, J0219, J0491, J0717, J0741, J1302, J1306, J1437, J1448, J1449, J1556, J1559, J1628, J1826, J1952, J2356, J2406, J2777, J3145, J3240, J3315, J7169, J7318, J7322, J7351, J7511, J9037, J9198, J9202, J9245, J9268, J9269, J9274, J9298, J9302, J9332, J9349, J9355, J9356, J9359, J9600, Q3027, Q5123, Q5124, Q5126, Q5128, Q5130 Corrected 4/15/2024: Drug Administration Codes: Category 2: 20610, 20611, 67028, 96360, 96365, 96369, 96372, 96373, 96374, 96377; Category 3: 96361, 96366, 96367, 96368, 96370, 96371, 96375, 96376 Added 12/15/2024: J0225, J0289, J1576, J1932, J2327, J7177, J7187, J7189, J7202, J9057, J9063, J9259, J9273, J9347, J9350, J9380, Q5127, Q5129 Removed 12/15/2024: J2505, J9310, C9132, J9315, C9074, J7318, J7322, J7326, J7327, J9202, J7325, J2425, J0129 Long Descriptors Updated 12/15/2024: J0401, J2426, Q5108, Q5111, Q5122
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §414.904(a)(3)- Average sales price as the basis for payment; Method of payment
  8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1- Incident to Physician’s Professional Services
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient”
  11. Medicare Alpha-Numeric HCPCS File- Alpha-Numeric HCPCS | CMS
  12. AMA CPT Codebook
  13. HCPCS Level II Codebook
  14. Medicare Part B Drug Average Sales Price; ASP Pricing File- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice
  15. U.S. National Library of Medicine DailyMed
Cardiac Pacemakers: Medical Necessity and Documentation Requirements _0078 Complex Outpatient Hospital, Ambulatory Surgical Center (ASC) Region-1 All Region 1 states 01/09/2018 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines,and/or are medically reasonable and necessary. Affected codes: 33206, 33207, 33208
  1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section
  2. 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
  3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)-
  4. Payment of Benefits
  5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations,
  6. Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and
  7. Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening
  8. Initial Determinations and Redeterminations Requested by a Party
  9. 42 CFR §405.929- Post-Payment Review
  10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  11. 42 CFR §405.986- Good Cause for Reopening
  12. Medicare National Coverage Determinations (NCD), Chapter 1, Part 1, §20.8.3- Cardiac Pacemakers:
  13. Single Chamber and Dual Chamber Permanent Cardiac Pacemakers
  14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective
  15. Actions, §§3.1- 3.6.6
  16. CGS Local Coverage Article A54961- Billing and Coding: Single Chamber and Dual Chamber
  17. Permanent Cardiac Pacemakers; Effective 05/01/2016; Revised 03/24/2022
  18. First Coast Local Coverage Article A54926- Billing and Coding: Single Chamber and Dual Chamber
  19. Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019
  20. NGS Local Coverage Article A54909- Billing and Coding: Single Chamber and Dual Chamber
  21. Permanent Cardiac Pacemakers; Effective 4/15/2016; Revised 5/7/2020
  22. Noridian Local Coverage Article A54929- Single Chamber and Dual Chamber Permanent Cardiac
  23. Pacemakers- Coding and Billing; Effective 4/15/2016; Revised 10/01/2019
  24. Noridian Local Coverage Article A54931- Single Chamber and Dual Chamber Permanent Cardiac
  25. Pacemakers- Coding and Billing; Effective 4/15/2016, Revised 10/01/2019
  26. Novitas Local Coverage Article A54982- Billing and Coding: Single Chamber and Dual Chamber
  27. Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019
  28. Palmetto Local Coverage Article A54831- Billing and Coding: Single Chamber and Dual Chamber
  29. Permanent Cardiac Pacemakers; Effective 01/13/2016; Revised 05/06/2021
  30. WPS Local Coverage Article A54958- Billing and Coding: Single Chamber and Dual Chamber
  31. Permanent Cardiac Pacemakers; Effective 5/15/2016; Revised 08/26/2021
  32. Annual American Medical Association CPT Manual, Coding Guidelines
Outpatient Service Overlapping or During an Inpatient Stay: Duplicate Payments _0072 Automated Hospital Outpatient, Hospital Inpatient Part B Region-1, Region-2, All Region 1 and Region 2 states 10/26/2017 Details Claims having a "claim paid date" that is more than 3 years prior to the review results letter date will be excluded. Outpatient services for the same beneficiary, same or different service provider, where the date(s) of service on the outpatient claim falls within an inpatient admission or overlap the admission date of the inpatient claim are considered exact duplicates and should be rejected. Affected codes: Eligible codes with TOB 11x, 12x and 13x
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §412.50- Furnishing of inpatient hospital services directly or under arrangements
  8. Medical Benefit Policy Manual, Chapter 6- Hospital Services Covered under Part B, §10.2- Other Circumstances in Which Payment Cannot Be Made Under Part A
  9. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims
  10. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2 (A)- Exact Duplicates- Submission of Institutional Claims
  11. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3 (B)- Outpatient Services Treated as Inpatient Services- Preadmission Diagnostic Services
  12. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling
  13. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §200.2- Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD)
  14. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4- CWF Editing of Ambulance Claims for Inpatients
  15. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §10.2- Billing Requirements
  16. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments
  17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  18. AMA CPT Codebook
  19. HCPCS Level II Codebook
Untimed Therapy: Excessive Units _0060 Automated Outpatient Hospital, Skilled Nursing Facility (SNF), Outpatient Rehabilitation Facility (ORF), Comprehensive Outpatient Rehabilitation Facility (CORF), Physician and Non-physician Practitioner/Provider Specialty, Therapists in Private Practice Region-1, Region-2, All Region 1 and Region 2 states 09/20/2017 Details Exclude from this automated review, claims having a paid claim date which is more than 3 years prior to the Review Results Letter date When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider may not exceed (1) in the units billed column per date of service. Affected codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 97012, 97016, 97018, 97022, 97024, 97028, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, G0281, G0283, G0329
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Benefit Policy Manual: Chapter 15- Covered Medical and Other Health Services, §220- Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance; §230- Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
  9. Medicare Claims Processing Manual, Chapter 5- Part B Outpatient Rehabilitation and CORF Services, §10.3.2- Exceptions Process; §10.6- Functional Reporting; §20.2- Reporting of Service Units with HCPCS
  10. AMA CPT Codebook
  11. HCPCS Level II Codebook
Nursing Facility Services: Excessive Units _0061 Automated Professional (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 09/08/2017 Details Exclude claims having a paid claim date which is more than 3 years prior to the Informational letter date. The Nursing Facility Services codes represent a “per day” service. As such, these codes may only be reported once per day, per Beneficiary, Provider, and date of service. Relevant CPT codes billed more than once per day will result in an overpayment. Affected codes: CPT Codes: 99304, 99305, 99306, 99307, 99308, 99309, 99310
  1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  2. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) – Exclusions from Coverage and Medicare as a Secondary Payer
  3. 42 Code of Federal Regulations §405.929- Post-Payment Review
  4. 42 Code of Federal Regulations §405.930- Failure to Respond to Additional Documentation Request
  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 Code of Federal Regulations §405.986- Good Cause for Reopening
  7. Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners, § 30.6.13 Nursing Facility Services, (B) Visits to Comply with Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF and NF).
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Novitas Local Coverage Determination: Evaluation and Management Services Provided in a Nursing Facility (L35068), Effective for services performed on or after 10/01/15, Retired 01/01/2023
  10. Novitas Local Coverage Article: Billing and Coding: Evaluation and Management Services Provided in a Nursing Facility (A56712), Effective 07/25/19, Retired 01/01/2023
  11. First Coast Local Coverage Determination: Evaluation and Management Services in a Nursing Facility (L36230), Effective for services performed on or after 11/15/15, Retired 01/01/2023
  12. First Coast Local Coverage Article: Billing and Coding: Evaluation and Management Services in a Nursing Facility (A57724), Effective 10/03/2018, Retired 01/01/2023
  13. AMA CPT Codebook
Radiology: Technical Component during Inpatient Stay _0062 Automated Radiologists and other Part B providers performing radiology services Region-1, Region-2, All Region 1 and Region 2 states 09/07/2017 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date. Carriers may not pay for the technical component (TC) of radiology services furnished to patients during inpatient stay. Query identifies TC portion of radiology paid to entities other than the inpatient facility. Findings are limited to claim lines billed with modifier TC and claim lines for service codes with TC/PC Indicator “1” and/or “3” for TC component only. Affected codes: All CPT/HCPCS codes with TC/PC Indicator 1 and/or 3; Type of Service Indicator code 4 and/or 6; CPT/HCPCS modifier TC (technical component) CPT/HCPCS modifier 26 (professional component). Overpaid claims are limited to CPT Codes in the 70000-79999 range (https://www.cms.gov/medicare/payment/fee-schedules/physician/pfs-relative-value-files with status code “A” (Active Code)).
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 13 Radiology Services and Other Diagnostic Procedures, § 20.2.1 Hospital and Skilled Nursing Facility (SNF) Patients
  8. Medicare Claims Processing Manual, Chapter 23, – Fee Schedule Administration and Coding Requirements; Addendum- MPFSDB File Record Layout and Field Descriptions (For Historical Medicare Physician Fee Schedule Database (MPFSDB) Layouts 2001 – 2018, refer to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Historical-MPFSDB-Layouts.pdf located on the CMS Physician Fee Schedule web page https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched)
  9. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, § 10.7 – Type of Service (TOS)
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
Facility Duplicate Claims _0064 Automated Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility (SNF) Region-1, Region-2, All Region 1 and Region 2 states 09/07/2017 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the Review Results Letter date. Duplicate claims or line date of service items will be denied. Affected codes: All CPT and All HCPCS
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 1 – General Billing Requirements, §120.2- Exact Duplicates
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
  10. HCPCS Level II Codebook
Ambulance Transfer between Skilled Nursing Facilities: Unbundling _0049 Automated Ambulance Providers and Suppliers Region-1, Region-2, All Region 1 and Region 2 states 08/09/2017 Details Claims that have a claim paid date which is less than 3 years prior to the Review Results Letter date. Algorithm identifies all paid Ambulance Claims billed with one of the following HCPCS codes: A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434 with modifier NN on the same line, for SNF claims. Under the prospective payment system, some ambulance transportation provided by outside suppliers to SNF residents is included in the SNFs’ Medicare Part A payments and is subject to consolidated billing. Therefore, Medicare Part B payments that suppliers receive for the ambulance transportation are overpayments. Affected codes: A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR §411.15(p)(3)(iv)- Services furnished to SNF residents
  8. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10.3.3- Separately Payable Ambulance Transport Under Part B Versus Patient Transportation That is Covered Under a Packaged Institutional Service
  9. Medicare Claims Processing Manual; Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.3.1- Ambulance Services
  10. Medicare Claims Processing Manual, Chapter 15- Ambulance, § 30.2.2- SNF Billing
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  12. HCPCS Level II Codebook
Evaluation and Management Services in Skilled Nursing Facilities: Incorrect Coding _0056 Automated Physician/Non-physician Practitioner (NPP) Region-1, Region-2, All Region 1 and Region 2 states 08/02/2017 Details Claims that have a “claim paid date” which is less than 3 years prior to the Informational Letter date (automated review). Claims with CPT inpatient hospital care evaluation and management (E/M) codes billed for services rendered to a patient residing in a skilled nursing facility (SNF), with no inpatient hospital facility claim for the same date of service, will be adjusted to equivalent CPT SNF E/M codes. Affected codes: 99223, 99232, 99233
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physician/Nonphysician Practitioners, §30.6.13- Nursing Facility Services
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
Skilled Nursing Facility: Medical Necessity and Documentation Requirements _0004 Complex SNF Region-1, Region-2, All Region 1 and Region 2 states 06/01/2017 Details Exclude claims having a “claim paid date” greater than 3 years prior to the ADR date. Exclude claims with dates of service on or after October 1, 2019 Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.
  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 Code of Federal Regulations 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 Code of Federal Regulations 405.986- Good Cause for Reopening
  5. 42 Code of Federal Regulations 409.30-409.36- Basic requirement; Level of care requirement; Criteria for skilled services and the need for skilled services; Examples for skilled nursing and rehabilitation services; Criteria for “daily basis”; Criteria for “practical matter”; Effect of discharge from posthospital SNF care.
  6. 42 Code of Federal Regulations 424.20- Requirements for posthospital SNF care
  7. 42 Code of Federal Regulations 483.30 – Physician Services
  8. 42 Code of Federal Regulations 483.20- Resident assessment
  9. 42 Code of Federal Regulations 411.15(k)(1)- Particular services excluded from coverage
  10. 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
  11. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40.4- Timing of Recertifications for Extended Care Services, §40.5- Delayed Certifications and Recertifications for Extended Care Services
  12. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services; §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills; §6.1.3- Bill Review Requirements; §6.1.4- Medical Review Process; §6.3- Medical Review of Certification and Recertification of Residents in SNFs
  13. Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services
  14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3- Certification and Recertification of Need for Treatment and Therapy Plans of Care
Ambulance Billed during Inpatient: Unbundling _0054 Automated Ambulance Providers Region-1, Region-2, All Region 1 and Region 2 states 05/31/2017 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date. Ambulance services during an Inpatient stay are included in the facility’s PPS payment and are not separately payable under Part B, excluding the date of admission, date of discharge and any leave of absence days. Ambulance providers are expected to seek reimbursement from the inpatient facility. The edits will capture improper payment of ambulance services during an inpatient hospital stay. Affected codes: A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434
  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. 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 CFR §405.929- Post-Payment Review
  6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  7. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling
  8. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4 CWF Editing of Ambulance Claims for Inpatients
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. AMA CPT Codebook
Panretinal (Scatter) Laser Photocoagulation: Excessive Frequency _0047 Automated Outpatient Hospital (OPH), Physician/Non-physician Practitioner Region-1, Region-2, J6, JK, J15 04/28/2017 Details Claims having a "claim paid date" that is more than 3 years prior to the informational letter date will be excluded. CPT code 67228 (Treatment of extensive or progressive retinopathy), may not be billed more frequently than once per eye within the global surgery period. Affected code: 67228
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. CGS Administrators, LLC, Local Coverage Determination L34064- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 4/4/2024
  9. National Government Services, Inc., Local Coverage Determination L33628- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 9/19/2019
  10. CGS Administrators, LLC, Local Coverage Article A56594- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 10/03/2019; Revised 4/4/2024
  11. National Government Services, Inc., Local Coverage Article A56550- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 8/01/2019; Revised 9/19/2019
  12. AMA CPT Codebook
Add-on Codes Paid without Primary Code and/or Denied Primary Code _0050 Automated Professional Services; Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 04/11/2017 Details Exclude claims that have a “claim paid date” which is more than 3 years prior to the Informational Letter date (automated review). CPT has designated certain codes as “add-on procedures”. These services are always done in conjunction with another procedure and are only payable when an appropriate primary service is also billed. Add-on codes paid without a paid or denied primary code will result in an overpayment and be recouped. Affected codes: Add-on Codes listed as type 1- https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 1- General Billing Requirements, §70 Time Limitations for Filing Part A and Part B Claims
  8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.D- Coding Services Supplemental to Principal Procedure (Add-On Codes) Code
  9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.7. F. Add-On Code for Office/Outpatient E/M Visit Complexity ; §40.1 Definition of a Global Surgical Package; §40.8- Claims for Co-Surgeons and Team Surgeons; §40.9- Procedures Billed With Two or More Surgical Modifiers
  10. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6.
  12. Add-on Code Edits, as updated by CMS- https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits
  13. AMA CPT Codebook
  14. HCPCS Level II Codebook
Annual Wellness Visits: Excessive Units _0028 Automated Physician/Non-Physician Region-1, Region-2, All Region 1 and Region 2 states 03/30/2017 Details Exclude from the automated review claims having a paid claim date more than 3 years prior to the Review Results Letter. Claims for HCPCS code G0438 billed more than once in a lifetime will be denied. HCPCS code G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit) is a “one time” allowed Medicare benefit per beneficiary. Affected codes: G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 Code of Federal Regulations (CFR) §410.15-Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage
  8. 42 Code of Federal Regulations (CFR) §411.15(a)(1)- Particular services excluded from coverage (a) -Routine physical checkups (1)- Examinations performed for a purpose
  9. 42 Code of Federal Regulations (CFR) §411.15(k)(15)- Particular services excluded from coverage (k)- Any services that are not reasonable and necessary (15)- In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter.
  10. Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS)
  11. Medicare Claims Processing Manual, Chapter 18 (Preventive and Screening Services), §140- Annual Wellness Visit
  12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6
  13. HCPCS Level II Codebook
Ophthalmology Codes for New Patient: Incorrect Coding _0039 Automated Physician; Professional Services Region-1, Region-2, All Region 1 and Region 2 states 03/09/2017 Details Algorithm excludes from this automated review, claims having a paid claim date which is more than 3 years prior to the Review Results Letter date. Providers are only allowed to bill the CPT codes for New Patient visits if the patient has not received any face-to-face service from the physician or physician group practice (limited to physicians of the same specialty) within the previous 3 years. This query identifies claims for patients who have been seen by the same provider in the last 3 years but for which the provider is billing a new (instead of established) visit code. Findings are limited to line with overpayments only. Affected codes: 92002, 92004
  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 1861 (s)(2)(FF)- Medical and Other Health Services- personalized prevention plan services (as defined in subsection (hhh))
  4. 42 CFR §405.929- Post-Payment Review
  5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. Medicare Claims Processing Manual, Chapter 12 Physicians/Non-physician Practitioners, § 30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201-99215), (A) Definition of New Patient for Selection of E/M Visit Code
  10. AMA CPT Codebook
Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect Coding _0042 Automated Professional Services (Physician/Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 03/09/2017 Details Claims that have a “claim paid date” less than 6 months prior to the informational Letter date (automated review). Office or other outpatient visits for evaluation and management services cannot be billed for patients while they are admitted to a hospital setting. Billing these services incorrectly will result in an overpayment and the amount will be recovered. Affected codes: CPT Codes 99202-99215, Evaluation and Management codes when services are provided in the physician’s office, in an outpatient or other ambulatory facility
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 3, §40.2- Determining Covered/Noncovered Days and Charges, §40.2.2- Charges to Beneficiaries for Part A Services, §140.3.1- Shared Systems and CWF Edits
  8. Medicare Claims Processing Manual, Chapter 4, §290.2.1- Revenue Code Reporting
  9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6- – Evaluation and Management Service Codes – General (Codes 99202 – 99499), §30.6.9.1- Payment for Initial Hospital Inpatient or Observation Care Services and Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services), §30.6.9.2- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231-99239), §30.6.10- Consultation Services, and §190 – Medicare Payment for Telehealth Services
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. CMS Transmittal 10505, Change Request 12071 12/4/2020 Summary of Policies in the Calendar Year 2021 Medicare Physician Fee Schedule Final Rule, Office/Outpatient Evaluation & Management Visits
  12. AMA CPT Codebook
New Patient Visits: Incorrect Coding _0043 Automated Physician/Non- Physician Practitioner Region-1, Region-2, All Region 1 and Region 2 states 03/09/2017 Details Claims that have a “claim paid date” which is less than 6 months prior to the Review Results Letter. A new patient is one who has not received any professional services, [e.g., E/M service or other face-to-face service (e.g., surgical procedure)] from the physician or physician group practice (same physician specialty) within the previous 3 years. Affected codes: 92002, 92004, 99202, 99203, 99204, 99205, 99341, 99342, 99344, 99345
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners,
  8. §30.6.1.1 – Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV]
  9. Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, §30.6.7.A-Definition of New Patient for Selection of E/M Visit Code
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
  12. HCPCS Level II Codebook
Hospital Services: Excessive Units _0037 Automated Professional Services; exclude non-physician practitioner Specialty Codes 50 (NP) and 97 (PA) Region-1, Region-2, All Region 1 and Region 2 states 02/23/2017 Details Exclude claims having a paid claim date which is more than 3 years prior to the Informational letter date. Both Initial Hospital Care (CPT codes 99221 – 99223) and Subsequent Hospital Care codes (CPT codes 99231 – 99233 are “per diem” services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice. Affected codes: CPT Codes 99221-99223 (Initial Hospital Care) and 99231-99233 (Subsequent Hospital Care)
  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. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9- Payment for Inpatient Hospital Visits- General
  8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.1- Payment for Initial Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services)
  9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.2- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231 – 99239)
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. AMA CPT Codebook
Visits to Patients in Swing Beds: Incorrect Coding _0038 Automated Professional Services (Physician/ Non- Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 02/23/2017 Details Exclude from review claims having a paid claim date which is more than 3 years prior to the Review Results Letter (RRL) date. If the inpatient care is being billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is being billed by the hospital as nursing facility care, then the nursing facility codes apply. Hospital care codes billed while being in a swing bed will be recovered. Affected codes: 99221-99223, 99231-99233, 99238-99239
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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- Establishing Good Cause for Reopening
  7. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.D – Visits to Patients in Swing Beds
  8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  9. AMA CPT Codebook
Sacral Neurostimulation: Medical Necessity and Documentation Requirements _0003 Complex Inpatient hospital-acute care; outpatient hospital; professional services (physician/non-physician practitioner); ASC (Ambulatory Surgical Center) Region-1, Region-2, All Region 1 and Region 2 states 02/17/2017 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Documentation will be reviewed to determine if sacral nerve stimulation for urinary or fecal incontinence meets Medicare coverage criteria, and/or is medically reasonable and necessary. Affected codes: 64561, 64581, 64590
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §230.18- Sacral Nerve Stimulation for Urinary Incontinence
  8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §40- Sacral Nerve Stimulation
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. Noridian Healthcare Solutions, LLC, LCA A53017- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 01/01/2024
  11. Noridian Healthcare Solutions, LLC, LCA A53359- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 01/01/2024
  12. CGS Administrators, LLC, LCA A55835- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 2/01/2018; Revised 02/27/2025
  13. Palmetto, LCD L39543 – Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence, Effective 11/05/23
  14. Palmetto, LCA A59332 – Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence, Effective 11/05/23, Revised 01/01/24
  15. AMA CPT Codebook
  16. HCPCS Level II Codebook
Inpatient Psychiatric Admission Billed without Source of Admission Equal to “D” _0022 Automated Inpatient Hospital, Inpatient Psychiatric Facility (IPF) Region-1, Region-2, All Region 1 and Region 2 states 02/09/2017 Details Claims that have a “claim paid date” which is less than 3 years prior to the Review Results Letter date. Under the Medicare PPS for inpatient psychiatric facilities (IPF), CMS makes an additional payment to an IPF or a distinct part unit (DPU) for the first day of a beneficiary’s stay to account for emergency department costs if the IPF has a qualifying emergency department. However, CMS does not make this payment if the beneficiary was discharged from the acute care section of a hospital to its own hospital based IPF. In that case, the costs of emergency department services are covered by the Medicare payment that the acute hospital received for the beneficiary’s inpatient acute stay. Source of admission code ‘D’ has been designated for usage when a patient is discharged from an acute hospital to their own psychiatric DPU. This code will prevent the additional payment for the beneficiary’s first day of coverage at the DPU. An overpayment occurs when source of admission code ‘D’ is not billed for these transfer claims. Affected codes: Claims without Source of Admission Code D
  1. Social Security Act, 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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
  3. 42 CFR §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. 42 CFR 412.424(d)(1)(v)- Adjustment for IPF with qualifying emergency departments
  8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.6.4- Emergency Department (ED) Adjustment
  9. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.6.4.1- Source of Admission for IPF PPS Claims for Payment of ED Adjustment
  10. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §190.10.1- General Rules
  11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
Cataract Removal: Medical Necessity and Documentation Requirements _0002 Complex Ambulatory Surgery Center (ASC); Outpatient Hospital Region-1, Region-2, CGS, First Coast, NGS, Noridian, Novitas, Palmetto **please note-WPS is excluded** 02/07/2017 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Affected codes: 66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66987, 66988, Palmetto and WPS only- 66989, 66991
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 National Coverage Determinations Manual, Chapter 1, Part 1, §10- Anesthesia and Pain Management, §10.1- Use of Visual Tests Prior to and General Anesthesia During Cataract Surgery
  8. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80- Eye, §80.10- Phaco-Emulsification Procedure – Cataract Extraction; §80.12- Intraocular Lenses (IOLs)
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 01/04/2024
  11. CGS LCA A56453- Billing and Coding: Cataract Extraction; Effective 10/01/2016; Revised 01/04/2024
  12. NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019
  13. NGS LCA A56544- Billing and Coding: Cataract Extraction; Effective 08/01/2019; Revised 01/01/2024
  14. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 07/30/2023
  15. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 07/30/2023
  16. Noridian LCA A57195- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2024
  17. Noridian LCA A57196- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2024
  18. Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 11/21/2024
  19. Palmetto LCA A56613- Billing and Coding: Cataract Surgery; Effective 06/13/2019; Revised 04/30/2023
  20. Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2022
  21. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery); Effective 10/01/2015; Revised 07/11/21
  22. Novitas LCA A56615- Billing and Coding: Cataract Extraction (including Complex Cataract Surgery); Effective 06/13/2019; Revised 07/11/2021
  23. First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019
  24. First Coast LCD L38926- Extraction (including Complex Cataract surgery); Effective 07/11/2021
  25. First Coast LCA A58592- Cataract Extraction (including Complex Cataract Surgery); Effective 07/11/2021
  26. WPS LCD L39716- Cataract Extraction; Effective 2/11/2024; Retired 10/13/2024
  27. WPS LCA A59556- Billing and Coding: Cataract Extraction: Effective 2/11/2024; Retired 10/13/2024
  28. WPS LCD L39905- Cataract Surgery; Effective 10/13/2024
  29. WPS LCA A59805- Billing and Coding: Cataract Surgery; Effective 10/13/2024; Revised 11/14/2024
  30. AMA CPT Codebook
Inpatient Hospital MS-DRG Coding Validation _0001 Complex Inpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 02/01/2017 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. MS-DRG Coding 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 for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Affected codes: All MS-DRGs (001-999)
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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 §424.5(a)(6)- Sufficient information
  7. 42 CFR §405.986- Good Cause for Reopening
  8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §20- Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs)
  9. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §§20.1.2.4. B & C, 40.2.4
  10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  11. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review, §6.5.4 – Review of Procedures Affecting the DRG
  12. Inpatient Prospective Payment System (IPPS) Final Rule and Correcting Amendment Tables: Acute Inpatient PPS | CMS
  13. ICD-10 Clinical Modification (ICD-10-CM) and ICD-10- Procedural Coding System (PCS) (ICD-10-PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums
  14. AHA Coding Clinic for ICD-10
Bariatric Surgery: Medical Necessity and Documentation Requirements _0008 Complex Inpatient Hospital (Part A or Part B), Outpatient Hospital Region-1, Region-2, All Region 1 and Region 2 states 02/01/2017 Details Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date. The surgical management for the treatment of morbid obesity is considered reasonable and necessary for Medicare beneficiaries who have a BMI ≥ 35, have at least one co-morbidity related to obesity and have been previously unsuccessful with the medical treatment of obesity. Claims reporting surgical services for beneficiaries that do not meet all the Medicare coverage guidelines will be denied as not medically necessary and may result in an overpayment. Affected codes: 43770, 43644, 43645, 43845, 43846, 43847, 43775, for ICD-10-PCS see Appendix D
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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. National Coverage Determinations Manual, Chapter 1, Part 2, Section 100.1- Bariatric Surgery for Treatment of Co-Morbid Conditions Related to Morbid Obesity, Effective 9/24/2013
  8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity
  9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
  10. First Coast LCD L33411- Surgical Management of Morbid Obesity; Effective 10/1/2015; Revised 10/01/2019
  11. Palmetto GBA LCD L34576- Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 10/1/2015; Revised 01/11/2024
  12. Novitas LCD L35022- Bariatric Surgical Management of Morbid Obesity; Effective 10/01/2015; Revised 05/13/2021
  13. NGS LCA A52447- Laparoscopic Sleeve Gastrectomy (LSG)- Medical Policy Article; Effective 10/01/2015; Revision 10/01/2021
  14. Noridian LCA A53026- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2024
  15. Noridian LCA A53028- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2024
  16. Novitas LCA A56422- Billing and Coding: Bariatric Surgical Management of Morbid Obesity: Effective 03/28/2019; Revised 10/01/2024
  17. WPS LCA A54923- Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity; Effective 3/01/2016; Revised: 10/01/2024
  18. Palmetto GBA LCA A56852- Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 08/15/2019; Revised 10/01/2024
  19. First Coast LCA A57145- Billing and Coding: Surgical Management of Morbid Obesity; Effective 10/03/2018; Revised 10/01/2024
  20. First Coast LCA A55930- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 3/15/2018, Retired 10/15/2021
  21. First Coast LCA A56182- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 11/06/2018, Retired 10/15/2021
  22. AMA CPT Codebook
  23. AHA ICD-10-CM Diagnosis Codebook
  24. AHA ICD-10-PCS Procedure Codebook
Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes During Hospital Inpatient Stay _0011 Automated Professional Services (Physician/ Non-Physician Practitioner) Region-1, Region-2, All Region 1 and Region 2 states 02/01/2017 Details Claims that have a “claim paid date” which is less than 3 years prior to the informational letter date. Home Services Billed for Hospital Inpatients – Home Services CPT Codes may not be used for billing services provided in settings other than in the private residence of a beneficiary. Affected codes: CPT Codes 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
  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 §405.929- Post-Payment Review
  4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
  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, §§3.1- 3.6.6
  8. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioners, § 30.6.14- Home Care and Domiciliary Care Visits (For dates of service prior to 01-01-2023)
  9. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioners, § 30.6.14- Home or Residence Services (Codes 99341-99350); Effective: 01-01-2023
  10. AMA CPT Codebook

Inpatient & Facility Audits

Performant Healthcare SolutionsSM provides correct coding evaluation along with evidence-based clinical validation via complex...

Outpatient Audits

Audit Advantage for Outpatient helps health plans identify improper payments for the spectrum of outpatient claims while protecting critical provider relationships.

Post-Acute & Home Care Audits

Durable medical equipment, home infusion therapy, and home health claims are a well-known area of healthcare fraud and improper payment.

High Risk & Specialty Audits

Labs, genetic testing, high-cost drugs and outlier claims represent a significant category of spend for health plans and are the source of costly, improper payments.
Audit Advantage Overview

Contract Compliance Reviews

Our collaborative, consultative approach mitigates leakage resulting from vague or complex contract language...

Provider Billing & Coding

Depending on the health plan’s ability to quickly transfer and receive data, Performant Healthcare SolutionsSM...

Coordination of Benefits & Eligibility

Even plans with mature programs and large COB teams struggle with changes at the group and member levels that alter (or flip)

System Limitation, Benefits & Policy Rules

Data mining is not just automation and claims edits. Performant Healthcare SolutionsSM ...
Data Mining Overview

MSP Advantage

Our eligibility experts leverage an extensive database and proprietary algorithms to identify and validate other coverage...
Learn More

TPL Advantage

While regulations support other forms of coverage as primary before Medicaid, there is no single source...
Learn More

Recovery Advantage

Performant Healthcare SolutionsSM foundation is built on delivering solutions that quickly and efficiently...
Learn More

CMS RAC

A distinction of Performant’s services is our commitment to provider outreach on behalf of our health plan clients.

Overview
Secure Provider Portal
Update Provider Contact Information

Resources

News & Alerts

For Investors

Performant provides technology-enabled audit, recovery, and analytics services in the United States with a focus in the healthcare payment integrity industry.

Overview
News
Events & Presentations

Stock Information

Financials

Resources

Governance

Why Performant?
Solutions
CMS RAC
About Us
For Investors
Contact Us
Back to Main Menu

Solutions

MSP Advantage®
TPL Advantage®
Recovery Advantage®
Back to Main Menu

CMS RAC

A distinction of Performant’s services is our commitment to provider outreach on behalf of our health plan clients.

Overview

Resources

News & Alerts
Secure Provider Portal
Update Provider Contact Information
Back to Main Menu

About Us

Back to Main Menu

For Investors

Performant provides technology-enabled audit, recovery, and analytics services in the United States with a focus in the healthcare payment integrity industry.

Overview

Stock Information

Financials

Governance

Resources

News
Events & Presentations