Cotiviti Approved Issues List as of April 27, 2017

Transcription

1 Cotiviti Approved Issues List as of April 27, 2017 Ambulatory Surgery Center (ASC); Outpatient Hospital 23 Inpatient Hospital 25 Inpatient Hospital; Inpatient Psychiatric Facility 27 Inpatient; Outpatient; ASC; Physician 29 Outpatient Hospital 31 Outpatient Hospital (OPH), Physician/Non-physician 37 Outpatient Hospital, ASC 40 Outpatient Hospital; Physician 42 Physician/NPP ; ASC 62 Professional 64 Description Issue Name Claim Type Date of Service Regions and States Additional Information Issue Type Date Approved Approval Status CMS NCD 10.1, Effective 8/31/1992; CMS NCD 80.10; CMS NCD 80.12, Effective 5/19/1997; CGS LCD L31860, Effective Date 4/30/2011, Revision 10/17/2011, Retirement Date 9/30/2015; CGS LCD L33954, Effective Date 10/01/2015; NGS LCD L26853, Effective date 7/1/2008, Revision 11/1/2014, Retirement Date 9/30/15; NGS LCD L33558, Effective Date 10/1/2015, Revision 11/1/2016; Noridian LCD L33681, Effective Date 09/16/2013, Revision 09/1/2014, Retirement Date 9/30/2015; Noridian LCD L34203, Effective Date 10/01/2015; Palmetto Documentation will be reviewed to determine if Cataract LCD L32379, Effective Date 03/05/2012, Surgery meets Medicare coverage criteria, meets applicable Ambulatory Surgery Center 2 - all applicable states; Complex Cataract Removal 3 years from initial determination date Revision 08/27/2015, Retirement Date Complex coding guidelines, and/or is medically reasonable and (ASC); Outpatient Hospital excluding WPS 9/30/2015; Palmetto Article A52100, necessary. Effective Date 1/14/2013, Revision 2/13/2017 0:00 Approved 08/27/2015, Retirement Date 9/30/2015; Palmetto LCD L34413, Effective Date 10/01/2015; Palmetto Article A53047, Effective Date 10/01/2015; Novitas LCD L32690, Effective Date 08/13/2012, Revision Date 9/11/14, Retirement Date 9/30/2015; Novitas LCD L35091, Effective Date 10/01/2015; First Coast LCD L29095, Effective Date 02/02/09, Retirement Date 9/30/2015; First Coast LCD L33808, Effective Date 10/01/2015; Cahaba LCD L30058, Effective Date 05/04/09, Retirement Date

2 Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. 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. Clinical Validation is not permitted. 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. Clinical Validation is not permitted Complex Cataract Removal Complex Inpatient Hospital MS- DRG Coding Validation Complex Inpatient Hospital MS- DRG Coding Validation Ambulatory Surgery Center (ASC); Outpatient Hospital Inpatient Hospital Inpatient Hospital CMS NCD 10.1, Effective 8/31/1992; CMS NCD 80.10; CMS NCD 80.12, Effective 5/19/1997; CGS LCD L31860, Effective Date 4/30/2011, Revision 10/17/2011, Retirement Date 9/30/2015; CGS LCD L33954, Effective Date 10/01/2015; NGS LCD L26853, Effective date 7/1/2008, Revision 11/1/2014, Retirement Date 9/30/15; NGS LCD L33558, Effective Date 10/1/2015, Revision 11/1/2016; Noridian LCD L33681, Effective Date 09/16/2013, Revision 09/1/2014, Retirement Date 9/30/2015; Noridian LCD L34203, Effective Date 10/01/2015; Palmetto LCD L32379, Effective Date 03/05/2012, Revision 08/27/2015, Retirement Date 9/30/2015; Palmetto Article A52100, Effective Date 1/14/2013, Revision 08/27/2015, Retirement Date 9/30/2015; Palmetto LCD L34413, Effective Date 10/01/2015; Palmetto Article A53047, Effective Date 10/01/2015; Novitas LCD L32690, Effective Date 08/13/2012, Revision Date 9/11/14, Retirement Date 9/30/2015; Novitas LCD L35091, Effective Date 10/01/2015; First Coast LCD L29095, Effective Date 02/02/09, Retirement Date 9/30/2015; First Coast LCD L33808, Effective Date 10/01/2015; Cahaba LCD L30058, Effective Date 05/04/09, Retirement Date Complex 2/13/2017 0:00 Approved 1. CMS Program Integrity Manual Ch A- C DRG Validation Review; 2. CMS QIO Manual Section 4130; 3. ICD-9 & 10 CM Coding Manual; 4. ICD-9 & 10 CM Addendums; 5. ICD-9 & 10 CM Official Guidelines for Coding and Reporting, and Addendums; 6. ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums; 7. Coding Clinic for ICD-10-CM and ICD-10-PCS 1. CMS Program Integrity Manual Ch A- C DRG Validation Review; 2. CMS QIO Manual Section 4130; 3. ICD-9 & 10 CM Coding Manual; 4. ICD-9 & 10 CM Addendums; 5. ICD-9 & 10 CM Official Guidelines for Coding and Reporting, and Addendums; 6. ICD-10 Procedural Coding System (PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums; 7. Coding Clinic for ICD-10-CM and ICD-10-PCS

3 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 Inpatient Psych Billed Inpatient Hospital; Inpatient are covered by the Medicare payment that the acute hospital without Source of Admission Equal to "D" Psychiatric Facility 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. OIG Report A dated May 2010; Claims Processing Manual (100-04), Chapter 3, Section ; Claims Processing Manual 2/28/2017 0:00 Approved (100-04), Chapter 3, Section 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 Inpatient Psych Billed Inpatient Hospital; Inpatient are covered by the Medicare payment that the acute hospital without Source of Admission Equal to "D" Psychiatric Facility 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. OIG Report A dated May 2010; Claims Processing Manual (100-04), Chapter 3, Section ; Claims Processing Manual 2/28/2017 0:00 Approved (100-04), Chapter 3, Section Documentation will be reviewed to determine if Sacral Neurostimulation meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Documentation will be reviewed to determine if Sacral Neurostimulation meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary Complex Medical Necessity Sacral Neurostimulation Complex Medical Necessity Sacral Neurostimulation Inpatient; Outpatient; ASC; Physician Inpatient; Outpatient; ASC; Physician 1.CMS IOM 100-3, National Coverage Determination , Effective 1/1/2002; 2.CMS IOM Medicare Claims Processing, Chapter 32, Section 40; 3.First Coast LCD L36296, Sacral Neuromodulation, Effective 10/1/2015; 4.Novitas LCD L35449, Sacral Nerve Stimulation, Effective 10/1/2015;5. Novitas LCD L34707, Sacral Nerve Stimulation, Effective 7/24/14 9/30/ CMS IOM 100-3, National Coverage Determination , Effective 1/1/2002; 2.CMS IOM Medicare Claims Processing, Chapter 32, Section 40; 3.First Coast LCD L36296, Sacral Neuromodulation, Effective 10/1/2015; 4.Novitas LCD L35449, Sacral Nerve Stimulation, Effective 10/1/2015;5. Novitas LCD L34707, Sacral Nerve Stimulation, Effective 7/24/14 9/30/2015

4 Regadenoson Regadenoson (Lexiscan), 0.4mg - Excessive Units - Outpatient (Lexiscan) Billed With Units > 4 Regadenoson (Lexiscan), 0.4mg - Excessive Units - Outpatient To identify excess units of J3489 as either excess units within a single line and/or as excess units across multiple lines/claims for the same beneficiary, the same HCPCS code and the same revenue center date. To identify excess units of J3489 as either excess units within a single line and/or as excess units across multiple lines/claims for the same beneficiary, the same HCPCS code and the same revenue center date Regadenoson (Lexiscan) Billed With Units > Zoledronic Acid Units > [greater than or equal to] Zoledronic Acid Units > [greater than or equal to] 5 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 comorbidity related to obesity and have been previously Complex Medical Necessity unsuccessful with the medical treatment of obesity. Claims Bariatric Surgery reporting surgical services for beneficiaries that do not meet all the Medicare coverage guidelines will be denied as not medically necessary. 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 comorbidity related to obesity and have been previously Complex Medical Necessity unsuccessful with the medical treatment of obesity. Claims Bariatric Surgery reporting surgical services for beneficiaries that do not meet all the Medicare coverage guidelines will be denied as not medically necessary. Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital Outpatient Hospital 1. Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, ;2.Medicare Claims Processing Manual: CMS Publication ; Chapter 17, 10, 40 and 90.2;3.Lexiscan (Regadenoson) package insert. Astellas Pharma US, FDA Website 1/30/2017 0:00 Approved 1. Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, ;2.Medicare Claims Processing Manual: CMS Publication ; Chapter 1/30/2017 0:00 Approved 17, 10, 40 and 90.2;3.Lexiscan (Regadenoson) package insert. Astellas Pharma US, FDA Website 1) Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, and , 2009; 2) HCPCS Level II Manual; 3) Use HCPC Manual that applies to the DOS 1/30/2017 0:00 Approved on the claim; 4) FDA website, Zometa package insert; 5) FDA website, Reclast package insert 1) Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, and , 2009; 2) HCPCS Level II Manual; 3) Use HCPC Manual that applies to the DOS 1/30/2017 0:00 Approved on the claim; 4) FDA website, Zometa package insert; 5) FDA website, Reclast package insert 1) Title XVIII of the Social Security Act (SSA): Section 1833(e); 2) Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A); 3) CMS Publication , National Coverage Determinations Manual, Chapter 1, Section 100.1, Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity; 4) CMS Publication , Medicare Claims Processing Manual, Chapter 32, Section 150, Billing Requirements for Bariatric Surgery for Morbid Obesity 1) Title XVIII of the Social Security Act (SSA): Section 1833(e); 2) Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A); 3) CMS Publication , National Coverage Determinations Manual, Chapter 1, Section 100.1, Bariatric Surgery for Treatment of Co-morbid Conditions Related to Morbid Obesity; 4) CMS Publication , Medicare Claims Processing Manual, Chapter 32, Section 150, Billing Requirements for Bariatric Surgery for Morbid Obesity

5 When providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or profession (modifier 26) components for the same service Global vs. TC/PC Split Reimbursements Outpatient Hospital (OPH), Physician/Non-physician 3 years from demand date (automated) 2 - all applicable states 1. Title XVIII of the Social Security Act (SSA), 1833(e); 2. Medicare Fee-for-Service Payment/Physician Fee Schedule PFS Relative Value Files; 3. CMS Publication , Medicare Claims Processing Manual, Chapter 1(General Billing Requirements), 120 (Detection of Duplicate Claims); 4. CMS Publication , Medicare Claims Processing Manual, Chapter 12 (Physician/Non-physician Practitioners), 20.2 (Relative Value Units); 5. CMS Publication , Medicare Claims Processing Manual, Chapter 13 (Radiology and Other Diagnostic Procedures), 20.1 (Professional Component [PC]), 20.2 (Technical Component [TC]), and ( Furnished in Leased Departments); 6. CMS Publication , Medicare Claims Processing Manual, Chapter 16 (Laboratory ), (Technical Component [TC] of Physician Pathology to Hospital Patients) 4/26/2017 0:00 Approved When providers are reimbursed for global procedures and then receive additional reimbursement for technical (modifier TC) and/or profession (modifier 26) components for the same service Global vs. TC/PC Split Reimbursements Outpatient Hospital (OPH), Physician/Non-physician 3 years from demand date (automated) 3- all applicable states 1. Title XVIII of the Social Security Act (SSA), 1833(e); 2. Medicare Fee-for-Service Payment/Physician Fee Schedule PFS Relative Value Files; 3. CMS Publication , Medicare Claims Processing Manual, Chapter 1(General Billing Requirements), 120 (Detection of Duplicate Claims); 4. CMS Publication , Medicare Claims Processing Manual, Chapter 12 (Physician/Non-physician Practitioners), 20.2 (Relative Value Units); 5. CMS Publication , Medicare Claims Processing Manual, Chapter 13 (Radiology and Other Diagnostic Procedures), 20.1 (Professional Component [PC]), 20.2 (Technical Component [TC]), and ( Furnished in Leased Departments); 6. CMS Publication , Medicare Claims Processing Manual, Chapter 16 (Laboratory ), (Technical Component [TC] of Physician Pathology to Hospital Patients) 4/26/2017 0:00 Approved

6 Potential incorrect billing occurred when Panretinal (Scatter) Laser Photocoagulation (CPT code 67228) is paid more than once, per eye, within the global surgery period Panretinal (Scatter) Laser Photocoagulation - Excess Frequency Outpatient Hospital (OPH), Physician/Non-physician 3 years from demand date (automated) 2 - NGS states only: IL, MN, WI 1. Title XVIII of the Social Security Act (SSA): 1833(e); 2. Title XVIII of the Social Security Act (SSA): 1862(a)(1)(A); 3. CMS Publication , Program Integrity Manual, Chapter 3 (Verifying Potential Errors and Taking Corrective Actions), (Re-opening Claims) and 3.6 (Determinations Made During Review); 4. CGS Administrators, LLC (CGS) Local Coverage Determination (LCD) L31888 (Retired 9/30/2015); 5. CGS LCD L34064 (Revised 10/1/2016); 6. National Government (NGS) LCD L28497 (Retired 9/30/2015); 7. NGS LCD L33628 (Revised 10/1/2016) 4/26/2017 0:00 Approved Cataract removal can only occur once per eye during a lifetime. This issue identifies overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye in the look back period. Cataract removal can only occur once per eye during a lifetime. This issue identifies overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye in the look back period. To identify claims where modifier -59 has been inappropriately appended when Endomyocardial Biopsies and Right Heart Catheterizations are billed together. To identify claims where modifier -59 has been inappropriately appended when Endomyocardial Biopsies and Right Heart Catheterizations are billed together. Documentation will be reviewed to determine if Cardiac PET Scans meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary. Documentation will be reviewed to determine if Cardiac PET Scans meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary Cataract Surgery Once in a Lifetime Cataract Surgery Once in a Lifetime Improper payments for Endomyocardial Biopsies and Right Heart Outpatient Hospital; Catheterizations that were Not Distinct Physician Improper payments for Endomyocardial Biopsies and Right Heart Catheterizations that were Not Distinct Complex Medical Necessity Cardiac PET Scans Complex Medical Necessity Cardiac PET Scans Outpatient Hospital, ASC Outpatient Hospital, ASC Outpatient Hospital; Physician Outpatient Hospital; Physician Outpatient Hospital; Physician 3 years from initial determination date (complex) 3 - all applicable states 1. CMS Pub , Ch. 3, MLN Medicare Vision ICN September Downloaded December 8, Available at: Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/VisionServic es_factsheet_icn pdf 1/24/2017 0:00 Approved 1. CMS Pub , Ch. 3, MLN Medicare Vision ICN September Downloaded December 8, Available at: 1/24/2017 0:00 Approved Education/Medicare-Learning-Network- MLN/MLNProducts/downloads/VisionServic es_factsheet_icn pdf 1. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A); 2. OIG Report (A ) DRAFT; 3. NCCI Manuals, 2015 Complex 4/4/2017 0:00 Approved and 2016, Chapter 11; 4. CPT Manual 1. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A); 2. OIG Report (A ) DRAFT; 3. NCCI Manuals, 2015 Complex 4/4/2017 0:00 Approved and 2016, Chapter 11; 4. CPT Manual 1. CMS NCD ; 2. CMS NCD ; 3. CMS IOM , chapter 13, 60; 4. Annual American Medical Association: CPT Manual, Coding Guidelines; 5. Annual ICD-9-CM Manual, Coding Guidelines; 6. Annual HCPCS Manual, Coding Guidelines 1. CMS NCD ; 2. CMS NCD ; 3. CMS IOM , chapter 13, 60; 4. Annual American Medical Association: CPT Manual, Coding Guidelines; 5. Annual ICD-9-CM Manual, Coding Guidelines; 6. Annual HCPCS Manual, Coding Guidelines

7 Identification of overpayments associated to minor and major surgical services. 1) E/M services (as specifically defined in the IOM) billed the day prior to, day of, or during the 90-day global period of a major (90-day) surgical service without modifiers as specifically defined in the IOM; 2) E/M services (as specifically defined in the IOM) billed the day of or during the 10-day global period of a minor (10-day) surgical service without modifiers as specifically defined in the IOM; and 3) E/M services (as specifically defined in the IOM) billed the day of a minor (0-day) surgical service without modifiers as specifically defined in the IOM Global Surgery - Pre- and Postoperative Visits Physician/NPP 1. CFR, title 42, Part 405 Subpart l, Subpart ; 2. IOM, CMS Pub , Medicare Claims Processing Manual, Chapter 12, 40, 40.1, 40.2, 40.3 and 40.4; 3. IOM, CMS Pub , Program Integrity Manual, Chapter 3, 3.5, Subsections 3.5.1, 3.6.A and Subsection /4/2017 0:00 Approved Identification of overpayments associated to minor and major surgical services. 1) E/M services (as specifically defined in the IOM) billed the day prior to, day of, or during the 90-day global period of a major (90-day) surgical service without modifiers as specifically defined in the IOM; 2) E/M services (as specifically defined in the IOM) billed the day of or during the 10-day global period of a minor (10-day) surgical service without modifiers as specifically defined in the IOM; and 3) E/M services (as specifically defined in the IOM) billed the day of a minor (0-day) surgical service without modifiers as specifically defined in the IOM Global Surgery - Pre- and Postoperative Visits Physician/NPP 1. CFR, title 42, Part 405 Subpart l, Subpart ; 2. IOM, CMS Pub , Medicare Claims Processing Manual, Chapter 12, 40, 40.1, 40.2, 40.3 and 40.4; 3. IOM, CMS Pub , Program Integrity Manual, Chapter 3, 3.5, Subsections 3.5.1, 3.6.A and Subsection /4/2017 0:00 Approved Multi-use vials are not subject to payment for discarded Trastuzumab amounts of drug or biological. Claim lines billed with modifier (Herceptin), J Multi-Dose Vial JW indicate billing of medication wastage. Wastage Billed with JW Modifier Multi-use vials are not subject to payment for discarded Trastuzumab amounts of drug or biological. Claim lines billed with modifier (Herceptin), J Multi-Dose Vial JW indicate billing of medication wastage. Wastage Billed with JW Modifier Documentation will be reviewed to determine if the billed amount of trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines. Documentation will be reviewed to determine if the billed amount of trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines Trastuzumab (Herceptin), J Multi-Dose Vial Wastage, Dose vs. Units Billed Trastuzumab (Herceptin), J Multi-Dose Vial Wastage, Dose vs. Units Billed Social Security Act, Section [42 U.S.C. 1395l] (e); Medicare Claims Processing Manual, , Chapter 17, Section 40: ; CDC: Questions about Multi-dose vials; Package label (manufacturer website): Herceptin Social Security Act, Section [42 U.S.C. 1395l] (e); Medicare Claims Processing Manual, , Chapter 17, Section 40: ; CDC: Questions about Multi-dose vials; Package label (manufacturer website): Herceptin Social Security Act, Section [42 U.S.C. 1395l] (e); Medicare Claims Processing Manual, , Chapter 17, Section 40; CDC: Questions about Multi-dose vials; Package label (manufacturer website): Herceptin Social Security Act, Section [42 U.S.C. 1395l] (e); Medicare Claims Processing Manual, , Chapter 17, Section 40; CDC: Questions about Multi-dose vials; Package label (manufacturer website): Herceptin 2/28/2017 0:00 Approved 2/28/2017 0:00 Approved Complex 2/28/2017 0:00 Approved Complex 2/28/2017 0:00 Approved

8 Ibandronate sodium (Boniva) injection approved dosage is 3 mg administered once every 3 months. Ibandronate sodium (Boniva) should not be dosed more frequently than once every 3 months. Ibandronate sodium (Boniva) injection approved dosage is 3 mg administered once every 3 months. Ibandronate sodium (Boniva) should not be dosed more frequently than once every 3 months Ibandronate sodium (Boniva), 1 mg - Excessive Frequency Ibandronate sodium (Boniva), 1 mg - Excessive Frequency U.S.C. 1395l] (e); 2. Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, ; 3. Medicare Claims Processing Manual: CMS Publication ; Chapter 17, 10, 40 and 90.2; 4. Boniva (ibandronate) package insert. Roche, FDA Website U.S.C. 1395l] (e); 2. Medicare Benefit Policy Manual: CMS Publication ; Chapter 15, ; 3. Medicare Claims Processing Manual: CMS Publication ; Chapter 17, 10, 40 and 90.2; 4. Boniva (ibandronate) package insert. Roche, FDA Website 4/4/2017 0:00 Approved 4/4/2017 0:00 Approved 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 Primary Code and/or denied Primary Code 3 years from demand date (automated) 2 - all applicable states Chapter 12, 30 D; 3. Medicare Claims Chapter 01, 70; 4. Medicare Claims Chapter 16, 40.8; 5. Medicare Claims Chapter 29, 240 (revised 7/23/2013) 4/26/2017 0:00 Approved 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 Primary Code and/or denied Primary Code 3 years from demand date (automated) 3 - all applicable states Chapter 12, 30 D; 3. Medicare Claims Chapter 01, 70; 4. Medicare Claims Chapter 16, 40.8; 5. Medicare Claims Chapter 29, 240 (revised 7/23/2013) 4/26/2017 0:00 Approved 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. 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 Visits to Patients in Swing Beds Visits to Patients in Swing Beds 3/24/2017 0:00 Approved Chapter 12, /24/2017 0:00 Approved Chapter 12,

9 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 Not a New Patient 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. 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 Not a New Patient 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. Only one hospital discharge day management service is payable per patient per hospital stay. Only the attending Hospital Discharge Day physician of record reports the discharge day management Management Service service. Chapter 12, (A) Chapter 12, (A) Chapter 12, Only one hospital discharge day management service is payable per patient per hospital stay. Only the attending physician of record reports the discharge day management service Hospital Discharge Day Management Service Chapter 12, Clinical profile of drugs and biologicals that support only one possible dose given. Clinical profile of drugs and biologicals that support only one possible dose given Drugs & Biologicals - Units exceed the only FDA approved dose Drugs & Biologicals - Units exceed the only FDA approved dose ; ASC ; ASC Chapter 17, 10, 40 and 90.2; 3. Fosaprepitant (Emend) package insert, FDA website; 4. Ibandronate sodium (Boniva) package insert, FDA website; 5. Palonosetron (Aloxi) package insert, FDA website; 6. Pegfilgrastim (Neulasta) package insert, FDA website; 7. Fulvestrant (Faslodex) package insert, FDA website 4/4/2017 0:00 Approved Chapter 17, 10, 40 and 90.2; 3. Fosaprepitant (Emend) package insert, FDA website; 4. Ibandronate sodium (Boniva) 4/4/2017 0:00 Approved package insert, FDA website; 5. Palonosetron (Aloxi) package insert, FDA website; 6. Pegfilgrastim (Neulasta) package insert, FDA website; 7. Fulvestrant (Faslodex) package insert, FDA website Home Billed for Hospital Inpatients - Home CPT Codes may not be used for billing services provided in settings other than in the private residence of a beneficiary Inappropriate billing of Home Health E&M codes during Inpatient Professional 1) Medicare Claims Processing Manual: CMS Publication ; Chapter 12, ; 2) CPT Manual 2013-present 1/30/2017 0:00 Approved - Cotiviti Not Pursuing

10 Both Initial Hospital Care codes (CPT codes 99221â 99223) and Subsequent Hospital Care codes (CPT Codes ) are â œper diemâ services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. Both Initial Hospital Care codes (CPT codes 99221â 99223) and Subsequent Hospital Care codes (CPT Codes ) are â œper diemâ services and may be reported only once per day by the same physician(s) of the same specialty from the same group practice. If evaluation and management service are being rendered to patients admitted to an inpatient hospital setting, then CPT Codes , and are to be used. CPT codes are to be used for evaluation and management service provided in the physician's office, in an outpatient or other ambulatory facility If evaluation and management service are being rendered to patients admitted to an inpatient hospital setting, then CPT Codes , and are to be used. CPT codes are to be used for evaluation and management service provided in the physician's office, in an outpatient or other ambulatory facility Identification of overpayments made when providers report visits with new-patient Evaluation and Management (E/M) codes for patients who do not meet the definition of a new patient. Claims are recouped when a provider bills a newpatient visit code and the same provider or a provider from the same group practice and with the same specialty has performed any other E/M services within a 3-year period of time Excessive Units of Hospital Excessive Units of Hospital Office Visits Billed for Hospital Inpatients Office Visits Billed for Hospital Inpatients New Patient Visits Professional Professional Professional Professional Professional U.S.C. 1395l](e); 2. Medicare Claims Processing Manual: Publication ; Chapter 12, (A) ; 3. American Medical 3/24/2017 0:00 Approved Association (AMA), Current Procedure Terminology 2007 to present U.S.C. 1395l](e); 2. Medicare Claims Processing Manual: Publication ; Chapter 12, (A) ; 3. American Medical 3/24/2017 0:00 Approved Association (AMA), Current Procedure Terminology 2007 to present Chapter 12, , and Chapter 12, , and Medicare Claims Processing Manual: CMS Publication ; Chapter 12, A, and ; 2. AMA CPT Manual, Evaluation and Management Guidelines (1999 through present)

11 Identification of overpayments made when providers report visits with new-patient Evaluation and Management (E/M) codes for patients who do not meet the definition of a new patient. Claims are recouped when a provider bills a newpatient visit code and the same provider or a provider from the same group practice and with the same specialty has performed any other E/M services within a 3-year period of time New Patient Visits Professional 1. Medicare Claims Processing Manual: CMS Publication ; Chapter 12, A, and ; 2. AMA CPT Manual, Evaluation and Management Guidelines (1999 through present) Home Billed for Hospital Inpatients - Home CPT Codes may not be used for billing services provided in settings other than in the private residence of a beneficiary Inappropriate billing of Home Health E&M codes during Inpatient Professional 1) Medicare Claims Processing Manual: CMS Publication ; Chapter 12, ; 2) CPT Manual 2013-present 1/30/2017 0:00 Approved - Cotiviti Not Pursuing