HMS Skip Navigation Links
Home
Region 4 Info
Provider Info
New Issues
FAQ
Contact Us
Login

New Issues Approved by CMS

All new issues that are identified by HMS must first be approved by CMS.

Number of Records per Page
Next PageLast Page
NameDescriptionNumberProvider TypeReview TypeDate ApprovedPosted OnRegion 4 StatesRegion 4 MACSDates of ServiceAdditional Information
Complex 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. CMS Program Integrity Manual Ch. 6.5.3 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.
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.0008Outpatient HospitalComplex11/23/201604/13/2017All Region 4 StatesAB MACsClaims having a claim paid date with three years of the ADR date1) 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 100-03.National Coverage Determinations Manual, Chapter 1, Section 100, Gastrointestinal System 4) CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 32, Section 150, Billing Requirements for Bariatric Surgery for Morbid Obesity
Complex Medical Necessity Sacral NeurostimulationSacral 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. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A) 2. 42 CFR §405.980(b) and (c) 3. 42 CFR §405.986 4. CMS IOM 100-3, National Coverage Determination 230.18, Effective 1/1/2002 5. CMS IOM 100-04 Medicare Claims Processing, Chapter 32, Section 40 6. First Coast LCD L36296, Sacral Neuromodulation, Effective 10/1/2015 7. Novitas LCD L35449, Sacral Nerve Stimulation, Effective 10/1/2015 8. Novitas LCD L34707, Sacral Nerve Stimulation, Effective 7/24/14 – 9/30/2015 9. Noridian LCA A53016, Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/1/2015 10. Noridian LCA A51767, Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 4/20/2012-9/30/2015
Complex Comprehensive Cataract RemovalMedicare 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.0002Outpatient Hospital; Ambulatory Surgical CenterComplex11/23/201604/13/2017All Region 4 StatesAB MACsClaims having a claim paid date with three years of the ADR date1. Medicare Internet Only Manual (IOM) Pub 100-03, Chapter 10, Section 10.1 2. Medicare Internet Only Manual (IOM) Pub 100-03, Chapter 80, Section 80.12 and 80.13 3. Noridian LCD L34203, Effective Date 10/01/2015 4. Noridian LCD L33681, Effective Date 09/16/2013, Revision 09/1/2014, Retirement Date 9/30/2015 5. Novitas LCD L32690, Effective Date 08/13/2012, Revision Date 9/11/14, Retirement Date 9/30/2015 6. Novitas LCD L35091, Effective Date 10/01/2015
Automated Cataract Surgery Once in a LifetimeCataract removal can only occur once per eye for the same date of service. This issue identifies overpayments associated to outpatient hospital providers billing more than one unit of cataract removal for the same eye.0009Outpatient HospitalAutomated Review01/06/201704/13/2017All 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: Section 1833(e) 2. Title XVIII of the Social Security Act: Section 1862(a)(1)(A) 3. CMS Pub 100-08, Ch. 3, §3.6 4. National Correct Coding Initiative (NCCI) Policy Manual (Chapter 8, Section D
Home Services Billed for Hospital InpatientsHome 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
Trastuzumab (Herceptin), J9355 - Multi-Dose Vial Dose vs. Units BilledDocumentation will be reviewed to determine if the billed amount of trastuzumab (Herceptin) meets Medicare coverage criteria and applicable coding guidelines. 0036Outpatient Hospital; Professional Services (Physician/Non-Physician Practitioner)Complex02/10/201704/13/2017All Region 4 states AB MACsclaims that have a "claim paid date" which is less than 3 years prior to the Additional Documentation Request Letter date.1. Social Security Act, Section 1833. [42 U.S.C. 1395l] (e) 2. Medicare Claims Processing Manual, 100-04, Chapter 17, Section 40 3. CDC: Questions about Multi-dose vials 4. Package label (manufacturer website): Herceptin
Add-on codes paid without required Primary Code – by Physician/ASC/Lab and Outpatient claimsCPT 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.0050Outpatient Hospital; Professional Services (Physician/Non-Physician Practitioner)Automated Review02/14/201706/19/2017All 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 D. 3. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 01, § 70 4. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 16, § 40.8 5. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 29, § 240 (revised 7/23/2013) 6. Medicare Claims Processing: Pub 100-04; Change Request CR9844 (effective 01/01/2017), I. b.
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
Excessive Units of Hospital ServicesBoth 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.
Disclaimer: This website contains proprietary, confidential and privileged information and data that may not be copied, reproduced or disseminated, in whole or part, without the prior written consent of HMS.

Version: 1.0.22 User: Browser: Unknown v.00