New Issues Approved by CMS


All new issues that are identified by Cotiviti RAC 4 must first be approved by CMS.

New Issues Table
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NameDescriptionNumberProvider TypeReview TypeDate ApprovedPosted OnRegion 4 StatesRegion 4 MACSDates of ServiceAdditional Information
Inpatient Hospital MS-DRG Coding ValidationMS-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 code MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. 0001Inpatient Acute Care HospitalComplex11/23/201604/13/2017All Region 4 statesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Medical Record Request date (complex review).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 Program Integrity Manual, CMS Publication 100-08; Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review 9. CMS Quality Improvement Organization (QIO) Manual, Chapter 4- Case Review, Section 4130- DRG Validation Review ICD-10 CM Official Guidelines for Coding and Reporting, and Addendums 10. ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums 11. Coding Clinic for ICD-10-CM and ICD-10-PCS
Sacral Neurostimulation Medical Necessity and Documentation RequirementsSacral nerve stimulation (SNS) is a pulse generator that transmits electrical impulses to the sacral nerves through an implanted wire. These impulses cause the bladder muscles to contract, which give the patient ability to void more properly. Treatment using SNS is one of several alterative modalities for patients who have failed behavioral and/or pharmacologic therapies. SNS device consists of an implantable pulse generator that delivers controlled electrical impulses. Sacral nerve stimulation involves both a temporary test simulation to determine if an implantable stimulator would be effective and a permanent implantation. Note: Both the test and the permanent implantation are covered. Permanent implantation of a sacral nerve stimulator may be considered medically necessary in patients who meet all of the following criteria (NCD 230.18): There is a diagnosis of at least one of the following: • Urinary urge incontinence • Urgency-frequency syndrome • Non-obstructive urinary retention; AND • The patient must be refractory to conventional therapies (documented behavioral, pharmacologic and/or surgical corrective therapy); AND • The patient must be an appropriate surgical candidate such that implantation with anesthesia can occur; AND • Incontinence is not related to stress incontinence, urinary obstruction or specific neurologic disease (e.g., diabetes with peripheral nerve involvement) with associated secondary manifestations of the above indications are excluded from coverage for test stimulation and permanent implantation of sacral nerve stimulation; AND • A trial stimulation period demonstrates at least 50% improvement in symptoms. Patient must have had a successful test stimulation in order to support subsequent implantation. Before a patient is eligible for permanent implantation, he/she must demonstrate a 50% or greater improvement through test stimulation. Improvement is measured through voiding diaries; AND • Patient must be able to demonstrate adequate ability to record voiding diary data such that clinical results of the implant procedure can be properly evaluated.0003Outpatient HospitalComplex11/23/201610/24/2017All Region 4 StatesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Medical Record Request date 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. National Coverage Determination 230.18- Sacral Nerve Stimulation for Urinary Incontinence, Effective 1/1/2002 6. Medicare Claims Processing, Chapter 32- Billing Requirements for Special Services, Section 40- Sacral Nerve Stimulation 7. Novitas Solutions, Inc., LCD L35449- Sacral Nerve Stimulation, Effective 10/1/2015; Revised 04/18/2019; Retired 8/13/2020 8. Noridian Healthcare Solutions, LLC, LCA A53017- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 01/01/2020 9. Noridian Healthcare Solutions, LLC, LCA A53359- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 01/01/2020 10. CPT Assistant, December 2012, Volume 22, Issue 12, page 14- Surgery: Nervous System, Placement Permanent Neurostimulator Electrode Array with Implant of Pulse Generator
Cataract Removal: Medical Necessity and Coding RequirementsMedicare coverage for cataract extraction is based on services that are reasonable and medically necessary for the treatment of beneficiaries who have a cataract. Cataract patients must have an impairment of visual function due to cataract(s) resulting in the decreased ability to carry out activities of daily living such as reading, viewing television, driving or meeting occupational or vocational expectations.0002Ambulatory Surgical Center; Outpatient HospitalComplex11/23/201604/13/2017All Region 4 StatesAB MACsClaims having a claim paid date with three years of the ADR date1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party 4. 42 CFR §405.986- Good Cause for Reopening 5. Medicare 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; Effective 10/03/2003; Revised 02/15/2019 6. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction Effective 10/03/03; Revised 02/15/2019 7. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10 Anesthesia and Pain Management, §80- Eye, §80.12- Intraocular Lenses (IOLs), Effective 10/03/2003; Revised 02/15/2019 8. 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 9. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 10/01/19 10. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 10/01/2019; 11. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery), Effective 10/01/2015; Revised 07/11/21 12. Noridan LCA A57195 Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2020
Complex Medical Necessity Bariatric SurgeryThe 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.0008Outpatient HospitalComplex11/23/201611/02/2021All Region 4 StatesAB MACsClaims having a “claim paid date” which is less than 3 years prior to the Demand Letter date1. 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. 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 6. 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 7. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Morbid Obesity 8. Novitas LCD L35022- Bariatric Surgical Management of Morbid Obesity; Effective 10/01/2015; Revised 05/13/2021 9. Noridian LCA A53026- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2021 10. Noridian LCA A53028- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2020, Revision Ending 09/30/2021 11. Novitas LCA A56422- Billing and Coding: Bariatric Surgical Management of Morbid Obesity: Effective 03/28/2019; Revised 10/01/2020
Inappropriate Billing of Home Visit Professional Service E&M Codes During InpatientHome 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.0011Professional Services (Physician/Non-Physician Practitioner)Automated Review01/17/201704/13/2017All Region 4 StatesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date.1) Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.14 2) CPT Manual 2013-present
Automated Inpatient Psych Billed without Source of Admission Equal to “D”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.0022Inpatient Acute Care Hospital; Inpatient Psychiatric HospitalAutomated Review02/17/201704/13/2017All Region 4 StatesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date.1. Claims Processing Manual (100-04), Chapter 3, Section 190.6.4 2. Claims Processing Manual (100-04), Chapter 3, Section 190.6.4.1
Hospital Services: Excessive Units Both Initial Hospital Care codes (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(s) of the same specialty from the same group practice.0037Professional Services (Physician/Non-Physician Practitioner)Automated Review02/23/201704/13/2017All Region 4 StatesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date.1. Title XVIII of the Social Security Act (SSA), Section 1833(e) 2. 42 Code of Federal Regulations §424.5(a)(6) 3. Medicare Claims Processing Manual: Publication 100-04; Chapter 12, § 30.6.9 4. American Medical Association (AMA), Current Procedure Terminology 2013 to present.
Visits to Patients in Swing Beds: Incorrect CodingIf 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.0038Professional Services (Physician/Non-Physician Practitioner)Automated Review02/23/201704/13/2017All Region 4 statesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date.1. Social Security Act, Section 1833. [42 U.S.C. 1395l] (e) 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.9.
Ophthalmology Codes for New Patient: Incorrect CodingProviders 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. This query is limited to new and established visits for ophthalmology services.0039Professional Services (Physician/Non-Physician Practitioner)Automated Review03/08/201704/13/2017All Region 4 statesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Informational Letter date.1. Social Security Act, Section 1833. [42 U.S.C. 1395l] (e) 2. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 30.6.7 (A)
New Patient Visits: Incorrect CodingProviders 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.0043Professional Services (Physician/Non-Physician Practitioner)Automated Review03/08/201704/13/2017All Region 4 StatesAB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Demand Letter date Internet Only Manual, CMS Pub. 100-04 (Medicare Claims Processing Manual), Chapter 12 (Physicians/Non-physician Practitioners), Sections 30.6.7.A (Definition of New Patient for Selection of E/M Visit Code) (Effective 1/1/2016), 30.6.1.1 (Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV]) (Effective 1/27/2014), and 30.6.9 (Payment for Inpatient Hospital Visits – General) (Effective 1/1/2011) AMA CPT Manual, Evaluation and Management Services Guidelines (1999 through present)
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