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 validate MS-DRGs for principal and secondary diagnosis and procedures affecting or potentially affecting the MS-DRG assignment. Coding changes may result in a partial overpayment or under payment. Non-receipt of records will result in a full overpayment. Review of Length of Stay and Clinical Validation is not permitted. 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
Cataract Removal: Medical Necessity and Documentation RequirementsDocumentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. 0002Ambulatory Surgical Center; Outpatient HospitalComplex11/23/201604/13/2017All Region 4 StatesAB MACsClaims having a claim paid date within 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. CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 12/24/20 10. NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019 11. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 10/01/19 12. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 10/01/2019; 13. Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 10/10/19 14. Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2020 15. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery), Effective 10/01/2015; Revised 07/11/21 16. First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019 17. Cahaba LCD L34287- Cataract Extraction; Effective 10/01/2015, PART B ONLY; Retired 02/25/2018 18. NGS LCA A56544- Cataract Extraction; Effective 08/01/2019; Revised 01/01/2020 19. Noridan LCA A57195 Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 01/01/2020
Sacral Neurostimulation: Medical Necessity and Documentation RequirementsClaims for sacral nerve stimulation for urinary or fecal incontinence not deemed to be medically necessary will be denied.0003Outpatient Hospital; Ambulatory Surgical Center; Inpatient Acute Care Hospital; Professional Services (Physician/Non-Physician Practitioner)Complex11/23/201610/24/2017All 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 §405.929- 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 Determination 230.18- Sacral Nerve Stimulation for Urinary Incontinence, Effective 1/1/2002 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. Medicare Claims Processing, Chapter 32- Billing Requirements for Special Services, Section 40- Sacral Nerve Stimulation 10. First Coast Service Options, Inc., LCD L36296- Sacral Neuromodulation, Effective 10/1/2015; Revised 08/06/2019; Retired 8/13/2020 11. First Coast Service Options, Inc., LCA A56508 - Billing and Coding: Sacral Neuromodulation, Effective 01/08/2019, Retired 08/13/2020 12. Novitas Solutions, Inc., LCD L35449- Sacral Nerve Stimulation, Effective 10/1/2015; Revised 04/18/2019; Retired 8/13/2020 13. Noridian Healthcare Solutions, LLC, LCA A53017- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 01/01/2020 14. Noridian Healthcare Solutions, LLC, LCA A53359- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015; Revised 01/01/2020 15. CGS Administrators, LLC, LCA A55835- Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 02/01/2018; Revised 03/03/2022 16. AMA CPT Codebook 17. HCPCS Level II Codebook
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 Evaluation and Management Codes During Hospital Inpatient StayHome 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. 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 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 Care or Residence Services (Codes 99341-99350); Effective: 01-01-2023, 10. American Medical Association (AMA) Current Procedural Terminology (CPT) Manual
Inpatient Psychiatric Stay 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. 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
Hospital Services: Excessive UnitsBoth 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. 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(dd)(1) Hospice Care; Hospice 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 Code of Federal Regulations (CFR) §418.54(a)- Standard: Initial Assessment 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Medicare Benefit Policy Manual, Chapter 9- Coverage of Hospice Services Under Hospital Insurance, §40.1.9- Other Items and Services 11. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims, §50- Billing and Payment for Services Unrelated to Terminal Illness 12. HCPCS Level II Codebook
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. Hospital Care CPT codes 99221-99223, 99231-99233 and 99238-99239 will result in an overpayment and payment will be recovered.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 (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. 2 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 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/Nonphysician Practitioners, §30.6.9.D - Visits to Patients in Swing Beds 9. AMA CPT Codebook
Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect CodingOffice or other outpatient visits for evaluation and management services may not be billed for patients while admitted to a hospital setting. Services billed incorrectly will result in an overpayment and will be recouped. 0042Professional 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 (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
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. Findings are limited to line with overpayments only.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 (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
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