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FAQs
Issues Under Review
Forms and Sample Documents
Additional Documentation Submission Requirements
Provider Contact Information
Claim Status
RELATED SITES
CMS RAC Website
CMS Manuals
CMS Additional Documentation Request Limits
American Hospital Association
NHIC
National Government Services
Highmark
WPS
CMS Approved Audit Issues
| Issue Name: | Oxygen Accessories |
| Issue Number | A000332009 |
| Issue Description: | A potential issue may exist if certain oxygen accessories are billed when an oxygen system rental has been billed in the month prior to the date of service or in the subsequent month. Therefore, an issue may exist when these accessories are billed and reimbursed under Medicare Part B in this manner. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | February 17, 2010 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD L11468; LCD Policy Article A33768 |
| Issue Name: | MS-DRG Validation for MS-DRGs with Ventilator Support of 96+ Hours (At this time, Medical Necessity is excluded from review.) |
| Issue Number | A000302009 |
| Issue Description: | DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRGs 003, 004, 207, 870, 927 and 933; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. |
| Type of Review | DRG Validation |
| State(s) Affected: | DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | Inpatient Hospitals |
| Date Posted: | January 19, 2010 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG Validation Review, DRG Desk Reference Ingenix 2009. CodeWrite, April 2007; AHIMA |
| Issue Name: | MS-DRG Validation for MS-DRG 189 Pulmonary Edema & Respiratory Failure (At this time, Medical Necessity is excluded from review.) |
| Issue Number | A000352009 |
| Issue Description: | DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 189, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. |
| Type of Review | DRG Validation |
| State(s) Affected: | DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | Inpatient Hospitals |
| Date Posted: | January 19, 2010 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3, Section A - C - DRG Validation Review, OIG Report DRG 87: Pulmonary Edema and Respiratory Failure, August 1989 |
| Issue Name: | MS-DRG Validation for MS-DRGs for Tracheostomy (At this time, Medical Necessity is excluded from review.) |
| Issue Number | A000362009 |
| Issue Description: | DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS DRGs 003, 004, 011, 012, 013; principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. |
| Type of Review | DRG Validation |
| State(s) Affected: | DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | Inpatient Hospitals |
| Date Posted: | January 19, 2010 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | ICD-9-CM Coding Manual (for dates of service on claim), ICD-9-CM Addendums and Coding Clinics, PIM Ch 6.5.3 A-C DRG Validation Review; UHDDS - Reporting of Inpatient Data Elements, July 31, 1985, Federal Register (Vol. 50, No. 147), Pages 31038-31040 |
| Issue Name: | Ambulance Unbundled Services During an Inpatient Hospital Stay |
| Issue Number | A00062009 |
| Issue Description: | Ambulance services should be billed to the inpatient provider for services for inpatients. Therefore, an issue may exist when a beneficiary received ambulance services during an inpatient stay, which have been billed and reimbursed under Medicare Part B. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | Ambulance Providers |
| Date Posted: | January 07, 2010 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | Internet Only Manual, Medicare Benefit Policy Manual Publication 100-02 Chapter 10, Section 10 and 10.3.3. Internet Only Manual, Medicare Processing Manual, Publication 100-04, Chapter 3, Sections 10.4 and 10.5. Internet Only Manual, Medicare Claims Processing Manual, Publication 100-04, Chapter 15, Section 10.2, Summary of Benefit and 30.A, Modifier specific to Ambulance Services. |
| Issue Name: | Solid Insert with Seat or Back Wheelchair Cushions |
| Issue Number | A000262009 |
| Issue Description: | Code E0992 (solid seat insert) is not separately payable when provided with a seat or a seat back wheelchair cushion. Therefore an issue may exist when E0992 is billed and reimbursed under Medicare Part B with a seat or seat back wheelchair cushion. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD Policy Article A17918 |
| Issue Name: | Lower Limb Suction Valve Prosthesis |
| Issue Number | A000252009 |
| Issue Description: | Codes L5647 and L5652 describe a modification to a prosthetic socket that incorporates a suction valve in the design. The items described by these codes are not components of a suspension locking mechanism (L5671). Therefore, an issue may exist when such a locking mechanism is billed and reimbursed under Medicare Part B along with a suction valve suspension. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD Policy Article A25310, Region A DMERC PSC Bulletin |
| Issue Name: | Prosthetic Additions with Initial or Preparatory Knee Prosthesis |
| Issue Number | A000282009 |
| Issue Description: | When an initial below knee prosthesis (L5500) or a preparatory below knee prosthesis (L5510-L5530, L5540) is provided, prosthetic substitutions and/or additions of procedures and components are covered in accordance with the functional level assessment, except for certain codes. Therefore, an issue may exist when these codes are billed and reimbursed under Medicare Part B with such a prosthesis. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD Policy L11464 |
| Issue Name: | Multiple DME Rentals within a Month |
| Issue Number | A000042009 |
| Issue Description: | Certain procedure codes may not be billed in conjunction with other procedure codes for the same date of service and for the same beneficiary. Therefore an issue may exist when these codes are billed and reimbursed under Medicare Part B on the same date of service and for the same beneficiary. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | CMS Pub 100-04, Ch 20, § 30.1, 30.2, 30.5, 30.7, 130.8, Social Security Act, Volume I, Title XVIII, Section 1834 |
| Issue Name: | Headrest with a Power Operated Vehicle or a Power Wheelchair with a Captain's Chair Seat |
| Issue Number | A000272009 |
| Issue Description: | Headrests (E0955) may not be billed on the same date of service as a Power Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair seat. Therefore, an issue may exist when a beneficiary receives a Power Operated Vehicle (POV) or Power Wheelchair (PWC) with a captain's chair seat and a headrest, which has been billed and reimbursed under Medicare Part B, on the same date of service. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD Policy L15845 |
| Issue Name: | Wheel Attachment with New Non-Wheeled Walker |
| Issue Number | A000292009 |
| Issue Description: | Wheel attachment (E0155) cannot be paid on the same day or within one month of the initial issue of a nonwheeled walker. Therefore, an issue may exist when a beneficiary receives this wheel attachment, which has been billed and reimbursed under Medicare Part B, within a month of an initial issue of a nonwheeled walker. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | December 22, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD Policy L11472 |
| Issue Name: | Clinical Social Worker (CSW) Services |
| Issue Number | A000222009 |
| Issue Description: | CSW services rendered during an inpatient acute care or skilled nursing facility stay are not separately payable under Medicare Part B, instead they are included in the facility’s Prospective Payment System (PPS) payment. CSW providers are expected to render services under arrangement with the facility. Therefore, an issue may exist when a beneficiary received CSW services during an inpatient stay, which have been billed and reimbursed under Medicare Part B. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | MA, ME, NH, RI, VT |
| Providers Affected: | CSW Providers |
| Date Posted: | December 11, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | Medicare Benefit Policy Manual: Pub 100-02, Ch 15, § 170. CMS MedLearn Matters Article #: SE0439. |
| Issue Name: | Pharmacy Supply and Dispensing Fees |
| Issue Number | A000052009 |
| Issue Description: | Pharmacy supply and dispensing fees when billed by a DME supplier are required to be accompanied with an oral anti-cancer, oral anti-emetic, immunosuppressive drug or inhalation drug. The absence of one of the aforementioned drugs billed on the same date of service or a denial of one of the aforementioned drugs represents a potential issue. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | September 18, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | Internet Only Manual 100-04 (Medicare Claims Processing Manual), Chapter 17 (Drugs and Biologicals), Section 80.7. Transmittal 754, Change Request 3990, Requirement 3990.15. DME MAC Jurisdiction A Article for Nebulizers A24944 (LCD L11499). DME MAC Jurisdiction A Article for Oral Anticancer Drugs A25227 (LCD L5057). DME MAC Jurisdiction A Article for Oral Antiemetic Drugs A25228 (LCD L5058). DME MAC Jurisdiction A Article for Immunosuppressive Drugs A23662 (LCD L11531). |
| Issue Name: | Wheelchair Bundling |
| Issue Number | A000202009 |
| Issue Description: | A potential issue may exist if certain procedure codes are billed in conjunction with other procedure codes for the same date of service and the same beneficiary. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | September 18, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | LCD L11473, CMS Pub 100-03, Ch 1, § 280.1 & 280.3 |
| Issue Name: | Urological Bundling |
| Issue Number | A000192009 |
| Issue Description: | A potential issue may exist if certain urological procedure codes are billed in conjunction with other urological procedure codes for the same date of service and same beneficiary. |
| Type of Review | Automated Review for Overpayments |
| State(s) Affected: | DC, CT, MA, MD, ME, DE, NJ, NY, NH, PA, RI, VT |
| Providers Affected: | DME Suppliers |
| Date Posted: | September 18, 2009 |
| Dates of Service: | October 1, 2007 - Present |
| Issue References | CMS Pub.100-3, Ch1, § 230.17; LCD L5080 LCD Policy Article 25230 |