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Confidential or unpublished investigations are outside coverage.", "sources": [ { "id": "cms-rac-approved", "name": "CMS approved RAC topics", "url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics", "mode": "active", "kind": "Approved", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 163, "pages_checked": 7, "verified_detail_count": 163, "note": "Full index and listed issue details checked successfully." }, { "id": "cms-rac-proposed", "name": "CMS proposed RAC topics", "url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics", "mode": "active", "kind": "Proposed", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 0, "pages_checked": 1, "verified_detail_count": 0, "note": "Full index and listed issue details checked successfully." }, { "id": "novitas-jh", "name": "Novitas JH Targeted Probe and Educate", "url": "https://www.novitas-solutions.com/webcenter/portal/MedicareJH/SearchJH?query=TPE", "family": "Novitas JH / TPE", "mode": "active", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 11, "verified_detail_count": 11, "note": "Source collection completed and records were normalized." }, { "id": "cms-smrc", "name": "SMRC current projects (Noridian)", "url": "https://noridiansmrc.com/current-projects/", "family": "SMRC", "mode": "active", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 15, "verified_detail_count": 15, "note": "Source collection completed and records were normalized." }, { "id": "oig-medicare", "name": "HHS OIG Medicare A/B reports", "url": "https://oig.hhs.gov/reports/all/?financial-group=medicare-a&financial-group=medicare-b&hhs-agency=all&issue-date=all", "family": "OIG", "mode": "active", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 18, "verified_detail_count": 18, "note": "Source collection completed and records were normalized." }, { "id": "cert", "name": "CMS CERT reports", "url": "https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports", "family": "CERT", "mode": "active", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 1, "verified_detail_count": 1, "note": "Source collection completed and records were normalized." }, { "id": "cms-program", "name": "CMS medical-review and program-integrity transmittals", "url": "https://www.cms.gov/medicare/regulations-guidance/transmittals/2026-transmittals", "family": "CMS Program Integrity", "mode": "active", "status": "ok", "last_attempt_at": "2026-09-15T05:59:49Z", "last_success_at": "2026-09-15T05:59:49Z", "index_count": 13, "verified_detail_count": 13, "note": "Source collection completed and records were normalized." } ], "records": [ { "id": "rac-0229", "issue_number": "0229", "title": "0229-Anesthesia During Spine Pain Management Procedures", "review_type": "Automated", "provider_type": "Physicians/Anesthesiologist Services", "jurisdiction": "All A/B MACs", "source_date": "2026-07-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics/0229-anesthesia-during-spine-pain-management-procedures", "source_id": "cms-rac-approved", "description": "Claims for anesthesia services billed under HCPCS code 01992 will be denied when reported on the same date of service for the same beneficiary as spinal pain management procedures, including facet joint injections, facet joint denervation, and epidural steroid injections, in accordance with MAC policies and FPS83 guidelines.", "codes_text": "01992", "policy_text": "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 - Establishing Good Cause for Reopening 7. 42 CFR §414.40 - Coding and ancillary policies 8. 42 CFR §414.46 - Additional rules for payment of anesthesia services. 9. 42 CFR §415.110 - Conditions for payment: Medically directed anesthesia services. 10. 42 CFR §415.170 - Conditions for payment on a fee schedule basis for physician services in a teaching setting. 11. 42 CFR §415.178 - Anesthesia services. 12. 42 CFR §482.52 - Condition of participation: Anesthesia services. 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6 14. Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners, §20.3- Bundled Services/Supplies, §30- Correct Coding Policy, §40- Surgeons and Global Surgery, §50- Payment for Anesthesiology Services, §140.3 - Anesthesia Fee Schedule Payment for Qualified Nonphysician Anesthetists, §140.4 - Qualified Nonphysician Anesthetist Special Billing and Payment Situations 15. Medicare NCCI Coding Policy Manual- Chapter 1; General Correct Coding Policies; G. Anesthesia Services Included in the Surgical Procedure 16. Medicare NCCI Coding Policy Manual – Chapter 2; Anesthesia Services; CPT Codes 00000-01999; B. Standard Anesthesia Coding 17. Medicare NCCI Coding Policy Manual- Chapter 4; Surgery: Musculoskeletal System; C. Anesthesia 18. Medicare NCCI Coding Policy Manual- Chapter 8; Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems; C. Nervous System 19. CMS Anesthesia Conversion Factors and Base units are available at: Anesthesiologists Center | CMS 20. CGS Administrators, LLC, Local Coverage Determination (LCD) L39383- Sacroiliac Joint Injections and Procedures; Effective: 3/19/2023 21. CGS Administrators, LLC, Local Coverage Article (LCA) A59154- Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective 3/19/2023 22. National Government Services, Inc., Local Coverage Determination (LCD) L39455- Sacroiliac Joint Injections and Procedures; Effective 3/19/2023; Revised 08/10/2023 23. National Government Services, Inc., Local Coverage Article (LCA) A59233- Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective 3/19/2023; Revised 01/25/2024 24. Wisconsin Physicians Service Insurance Corporation, Local Coverage Determination (LCD) L39475- Sacroiliac Joint Injections and Procedures; Effective 3/19/2023; Revised: 12/26/2024 25. Wisconsin Physicians Service Insurance Corporation, Local Coverage Article (LCA) A59257- Billing and Coding Sacroiliac Joint Injections and Procedures 03/19/2023; Revised 12/26/2024 26. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39462- Sacroiliac Joint Injections and Procedures; Effective 03/19/2023 27. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A59244- Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective 03/19/2023; Revised: 06/01/2024 28. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39464- Sacroiliac Joint Injections and Procedures; Effective: 03/19/2023 29. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A59246- Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective: 03/19/2023; Revised: 06/01/2024 30. Palmetto GBA, Local Coverage Determination (LCD) L39402- Sacroiliac Joint Injections and Procedures; Effective: 03/19/2023; Revised: 11/28/2024 31. Palmetto GBA, Local Coverage Article (LCA) A59192- Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective: 03/19/2023; Revised: 10/18/2024 32. CGS Administrators, LLC, Local Coverage Determination (LCD) L39015- Epidural Steroid Injection for Pain Management; Effective: 12/05/2021; Revised 11/09/2023 33. CGS Administrators, LLC, Local Coverage Article (LCA) A58731- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 12/05/2021 34. National Government Services, Inc., Local Coverage Determination (LCD) L39036- Epidural Steroid Injections for Pain Management; Effective: 12/05/2021; Revised: 11/23/2023 35. National Government Services, Inc., Local Coverage Article (LCA) A58745- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 12/05/2021; Revised: 11/23/2023 36. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39240- Epidural Steroid Injections for Pain Management; Effective: 06/19/2022 37. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58993- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 06/19/2022; Revised: 11/15/2023 38. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39242- Epidural Steroid Injections for Pain Management; Effective: 06/19/2022 39. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58995- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 06/19/2022; Revised: 11/15/2023 40. Palmetto GBA, Local Coverage Determination (LCD) L38994- Epidural Steroid Injections for Pain Management; Effective: 12/05/2021; Revised: 11/16/2023 41. Palmetto GBA, Local Coverage Article (LCA) A58695- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 12/05/2021; Revised: 11/16/2023 42. Wisconsin Physicians Service Insurance Corporation, Local Coverage Determination (LCD) L39054- Epidural Steroid Injections for Pain Management; Effective: 12/05/2021; Revised: 02/01/2024 43. Wisconsin Physicians Service Insurance Corporation, Local Coverage Article (LCA) A58777- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective:12/05/2021; Revised: 11/30/2023 44. First Coast Service Options, Inc., Local Coverage Determination (LCD) L33906- Epidural Steroid Injections for Pain Management; Effective: 10/01/2015; Revised: 12/12/2021 45. First Coast Service Options, Inc., Local Coverage Article (LCA) A56651- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 10/03/2018; Revised: 11/16/2023 46. Novitas Solutions, Inc., Local Coverage Determination (LCD) L36920- Epidural Steroid Injections for Pain Management; Effective: 05/04/2017; Revised: 12/12/2021 47. Novitas Solutions, Inc., Local Coverage Article (LCA) A56681- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective: 07/11/2019; Revised: 11/16/2023 48. CGS Administrators, LLC, Local Coverage Determination (LCD) L38773- Facet Joint Interventions for Pain Management; Effective: 05/02/2021; Revised: 07/07/2024 49. CGS Administrators, LLC, Local Coverage Article (LCA) A58364- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 05/02/2021; Revised: 07/07/2024 50. First Coast Service Options, Inc., Local Coverage Determination (LCD) L33930- Facet Joint Interventions for Pain Management; Effective: 10/01/2015; Revised: 08/11/2024 51. First Coast Service Options, Inc., Local Coverage Article (LCA) A57787- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 10/03/2018; Revised: 09/19/2024 52. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38801- Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/07/2024 53. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58403- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/07/2024 54. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38803- Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/07/2024 55. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58405- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/07/2024 56. Novitas Solutions, Inc., Local Coverage Determination (LCD) L34892- Facet Joint Interventions for Pain Management; Effective: 10/01/2015; Revised: 08/11/2024 57. Novitas Solutions, Inc., Local Coverage Article (LCA) A56670- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 07/11/2019; Revised: 09/19/2024 58. Palmetto GBA, Local Coverage Determination (LCD) L38765- Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 05/18/2023 59. Palmetto GBA, Local Coverage Article (LCA) A58350- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/07/2024 60. Wisconsin Physicians Service Insurance Corporation, Local Coverage Determination (LCD) L38841- Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/14/2024 61. Wisconsin Physicians Service Insurance Corporation, Local Coverage Article (LCA) A58477- Billing and Coding: Facet Joint Interventions for Pain Management; Effective: 04/25/2021; Revised: 07/14/2024 62. AMA CPT Codebook", "codes": [ "01992" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "f961e5f1a9a62017347b9d98a9c7acd3e120a07d29840f01432248f0006a2b67", "raw_sha256": "1c38219c0b5c7c165f11867bcb031459cdf5713aff62700f849b0a569a06ba11", "texas": "national", "specialties": [ "Anesthesia & pain" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Review the anesthesia and underlying procedure codes together, including same-date billing and the applicable coverage and documentation requirements.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0228", "issue_number": "0228", "title": "0228-Therapy Claims Billed with KX Modifier, Medical Necessity, and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MAC's", "source_date": "2026-04-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0228-therapy-claims-billed-kx-modifier-medical-necessity-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if therapy meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Appropriate use of modifier KX will be evaluated. Use of modifier KX indicates that the clinician attests that services at, and above, the therapy threshold are medically necessary and reasonable, with justification for continued therapy documented in the patient’s medical record.", "codes_text": "Physical Therapy 97012, 97035, 97110, 97112, 97116, 97124, 97140, 97150, 97530, 97535, 97161, 97162, 97163, 97164 Occupational Therapy 29200, 29240, 29260, 29280, 29520, 29530, 29540, 29550, 29799, 90901, , 97014, 97032, 97110, 97112, 97165, 97166, 97167, 97168, 97530, 97535, 97542, 97750, 97760, 97761, G0281, G0282, G0283 Speech Therapy 92507, 92520, 92521, 92522, 92523, 92524, 92526, 92606, 92609, 92610, 92630, 92633, 96125, 97129, 97130", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1833(e)- Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled 1835(a)(2)- Procedure for Payment of Claims of Providers of Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(g)- Outpatient Occupational Therapy Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(p)- Outpatient Physical Therapy Services 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(ll)- Speech-Language Pathology Services; Audiology Services 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1862(a)(1)(A)-Exclusions from Coverage and Medicare as a Secondary Payer 7. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review 8. 42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request 9. 42 Code of Federal Regulations (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 10. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 11. 42 Code of Federal Regulations 42 CFR §409.44 (c)(2)- Physical therapy, speech-language pathology services, and occupational therapy 12. 42 Code of Federal Regulations (CFR) §410.105 Requirements for coverage of CORF services 13. 42 Code of Federal Regulations (CFR) §410.59 Outpatient occupational therapy services: Conditions 14. 42 Code of Federal Regulations (CFR) §410.60 Outpatient physical therapy services: Conditions 15. 42 Code of Federal Regulations (CFR) §410.61 Plan of treatment requirements for outpatient rehabilitation services 16. 42 Code of Federal Regulations (CFR) §424.10 Purpose and scope 17. 42 Code of Federal Regulations (CFR) §424.11 General procedures 18. 42 Code of Federal Regulations (CFR) §424.24 Requirements for medical and other health services furnished by providers under Medicare Part B 19. Medicare Benefit Policy Manual Chapter 15 §220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, or Speech-Language Pathology Service) Under Medical Insurance 20. Medicare Benefit Policy Manual Chapter 15 §230- Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology 21. Medicare Claims Processing Manual, Chapter 5 §10- Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services- General 22. Medicare Claims Processing Manual (MCPM), Chapter 5 §20.2 – Reporting of Service Units with HCPCS 23. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 24. American Medical Association Current Procedural Terminology Codebook 25. HCPCS Level II Codebook", "codes": [ "29200", "29240", "29260", "29280", "29520", "29530", "29540", "29550", "29799", "90901", "92507", "92520", "92521", "92522", "92523", "92524", "92526", "92606", "92609", "92610", "92630", "92633", "96125", "97012", "97014", "97032", "97035", "97110", "97112", "97116", "97124", "97129", "97130", "97140", "97150", "97161", "97162", "97163", "97164", "97165", "97166", "97167", "97168", "97530", "97535", "97542", "97750", "97760", "97761", "G0281", "G0282", "G0283" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "5131e5469e55704909e3a539e16eac592f9e0121843f46b6c50390e321ed9637", "raw_sha256": "60c9a63e51711be3880ef2e6105c6318e9ef4bc9cc3317d4f6e2a665474fd3da", "texas": "national", "specialties": [ "Therapy & rehabilitation" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Identify affected therapy claims carrying KX and verify that the record supports the continued skilled therapy and medical necessity represented by that modifier.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0227", "issue_number": "0227", "title": "0227-Wireless Capsule Endoscopy: Medical Necessity and Documentation Review.", "review_type": "Complex", "provider_type": "Outpatient Hospital (OP), Professional Services", "jurisdiction": "JN, JJ, JM, JH, JL, J15", "source_date": "2026-03-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics/0227-wireless-capsule-endoscopy-medical-necessity-documentation-review", "source_id": "cms-rac-approved", "description": "Wireless capsule endoscopic (WCE) imaging is intended as an adjunctive tool in the detection of certain gastrointestinal (GI) conditions. This procedure requires that a patient ingest a small capsule containing a disposable light source, miniature color video camera, battery, antenna, and a data transmitter. The self-contained capsule is made of specially sealed biocompatible material that is resistant to the digestive fluids throughout the GI tract. Following ingestion of the capsule, natural contraction and relaxation of the GI tract propels the camera forward. The camera contained in the capsule records images of the intestinal mucosa as it travels the length of the digestive system. During the entire procedure, which normally takes approximately 8 hours, the patient wears a data recorder around the waist, which captures and stores the images transmitted by the capsule's camera. After completion of the procedure, the patient data recorder is connected to a computer workstation where the images are downloaded, reviewed, and interpreted by the physician. The capsule is designed to be disposable and is excreted naturally from the body. Documentation will be reviewed to determine whether capsule endoscopy services met Medicare coverage criteria and were reasonable and necessary.", "codes_text": "91110, 91111", "policy_text": "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 1862(a)(7)-Exclusions from Coverage and Medicare as a Secondary Payer (This section excludes routine physical examinations) 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 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 CFR §410.32(d)(3)- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 9. 42 CFR §410.33- Independent diagnostic testing facility 10. 42 CFR §414.40 – Coding and Ancillary Policies 11. 42 CFR §414.50- Physician or other supplier billing for diagnostic tests performed or interpreted by a physician who does not share a practice with the billing physician or other supplier 12. 42 CFR §414.510- Laboratory date of service for clinical laboratory and pathology specimens 13. Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §210.3 Colorectal Cancer Screening Tests 14. Medicare Benefit Policy Manual, Chapter 14, §10- Coverage of Medical Devices 15. Medicare Claims Processing Manual, Chapter 12, §40.2 – Billing Requirements for Global Surgeries; Chapter 23, §20.3 – Use and Acceptance of HCPCS Codes and Modifiers, §20.9 – National Correct Coding Initiative (NCCI), §30- Services paid under the Medicare Physicians Fee Schedule 16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 17. Medicare Program Integrity Manual, Chapter 13, §13.5.4 - Reasonable and necessary provisions in LCDs 18. CGS, Local Coverage Determination L34081- Endoscopy by Capsule; Effective 10/01/2015; Revised 03/06/2025 19. CGS, Local Coverage Article A56461- Billing and Coding: Endoscopy by Capsule; Effective 10/01/2017; Revised 10/01/2025 20. FCSO Inc., Local Coverage Determination L33774 – Wireless Capsule Endoscopy; Effective 10/01/2015; Revised 07/11/2019 21. FCSO Inc., Local Coverage Article A56704 – Billing and Coding: Wireless Capsule Endoscopy; Effective 10/03/2018; Revised 03/10/2022 22. Palmetto GBA, Local Coverage Determination L36427 – Wireless Capsule Endoscopy; Effective 01/25/2016; Revised 10/28/2021 23. Palmetto GBA, Local Coverage Article A56727 – Billing and Coding: Wireless Capsule Endoscopy; Effective 07/25/2019; Revised 10/01/2025 24. Novitas Solutions, Inc., Local Coverage Determination L35089 – Wireless Capsule Endoscopy; Effective 10/01/2015; Revised 11/21/2019 25. Novitas Solutions, Inc., Local Coverage Article A57753 - Billing and Coding: Wireless Capsule Endoscopy; Effective 11/21/2019; Revised 01/01/2022 26. AMA CPT Codebook 27. American Medical Association (AMA), Current Procedure Terminology (CPT), Coding and Payment, APC Payment Book, APCs for Procedure or Service, Multiple Procedure Reduction Applies (Payment Status Indicator = T) 28. American Medical Association (AMA) Current Procedural Terminology (CPT) Assistant 29. National Correct Coding Initiative (NCCI) Policy Manual, Section E – Modifiers and Modifier Indicators", "codes": [ "91110", "91111" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0424c288c670cbd57c915cee2ffe6cf66ac2b9e32472cb6b59c898db932b5790", "raw_sha256": "aaebe50d78b31578479a620c101d9b263b525dc82c2e6febc94d1d1112191002", "texas": "texas", "specialties": [ "Gastroenterology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0226", "issue_number": "0226", "title": "0226-External Counterpulsation (ECP) Therapy for Severe Angina: Coverage Determination and Documentation Requirements", "review_type": "Complex", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2026-03-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics/0226-external-counterpulsation-ecp-therapy-severe-angina-coverage-determination-documentation", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if External Counterpulsation (ECP) Therapy meets Medicare coverage criteria and documentation requirements.", "codes_text": "G0166", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 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, §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- Establishing Good Cause for Reopening 7. 42 CFR §410.26- Services and supplies incident to a physician's professional services: Conditions 8. 42 CFR §410.32(b)(ii) – Levels of Supervision 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Medicare National Coverage Determination (NCD) Manual, Chapter 1- Coverage Determinations, §20.20 – External Counterpulsation (ECP) Therapy for Severe Angina 11. Medicare Benefit Policy Manual, Chapter 6, §20.5.3 – Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service Furnished on or After January 1, 2020 – Changes to Supervision Requirements 12. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §130 – External Counterpulsation (ECP) Therapy 13. AMA CPT Codebook", "codes": [ "G0166" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8ab8b822a2ca61fa61f78918cd2bbf47aa7cb5748a0c0394ee6b7b026623baee", "raw_sha256": "46823812b36ae16dfd1aa7f52d9d3288f0bea6ad5b4b79d3aef2cf0265cc6913", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0207", "issue_number": "0207", "title": "0207-Spinal Cord Neurostimulation: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0207-spinal-cord-neurostimulation-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Dorsal Column (Spinal cord) stimulation involves surgical implantation of neurostimulator electrodes within the dura mater (endodural) or percutaneous insertion of electrodes in the epidural space. The implantation consists of two stages: the first stage contains an implantation of neurostimulator electrode(s) and a connection of an external neurostimulator. In some cases, temporary electrodes are used. It is a short trial to assess the patient’s suitability for ongoing treatment with a permanent surgically implanted nerve stimulator. If pain relief is achieved, the temporary system may be transitioned to a permanent system. The second stage involves subcutaneous insertion of a permanent neurostimulator with connection of the implanted electrode(s). Spinal cord neurostimulators (SCS) may be covered as therapies for the relief of chronic intractable pain, and medical records will be reviewed to determine if the implantation of SCS meets Medicare coverage criteria and documentation requirements.", "codes_text": "63685", "policy_text": "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 Benefit 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 §424.5- Basic Conditions, (a)(6)- Sufficient Information 8. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)- Any Services Not Reasonable and Necessary 9. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation and §160.7 Electrical Nerve Stimulators, (B) Central Nervous System Stimulators (Dorsal Column and Depth Brain Stimulators) 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. Medicare Program Integrity Manual, Chapter 13 – Local Coverage Determinations, §13.5.4 Reasonable and Necessary Provision in LCDs 12. First Coast Local Coverage Determination L36035- Spinal Cord Stimulation for Chronic Pain; Effective 10/01/2015; Revised 11/28/2019 13. First Coast Local Coverage Article A57709- Billing and Coding: Spinal Cord Stimulation for Chronic Pain; Effective 10/03/2018 14. Novitas Local Coverage Determination L35450- Spinal Cord Stimulation (Dorsal Column Stimulation); Effective 10/01/2015; Revised 09/26/2019 15. Novitas Local Coverage Article A57023- Billing and Coding: Spinal Cord Stimulation (Dorsal Column Stimulation); Effective 09/26/2019; Revised 09/26/2019 16. Palmetto Local Coverage Determination L37632- Spinal Cord Stimulators for Chronic Pain; Effective 01/29/2018; Revised 05/13/21 17. Palmetto Local Coverage Article A56876- Billing and Coding: Spinal Cord Stimulators for Chronic Pain; Effective 08/22/2019; Revised 05/13/21 18. Noridian Local Coverage Determination L36204- Spinal Cord Stimulators for Chronic Pain; Effective 06/01/2016; Revised 12/01/2019 19. Noridian Local Coverage Determination L35136 – Spinal Cord Stimulators for Chronic Pain; Effective 10/01/2015; Revised 12/01/2019 20. Noridian Local Coverage Article A57791 – Billing and Coding: Spinal Cord Stimulators for Chronic Pain; Effective 12/01/2019, Revised 01/01/2022 21. Noridian Local Coverage Article A57792 – Billing and Coding: Spinal Cord Stimulation for Chronic Pain; Effective 12/01/19, Revised 01/01/2022 22. American Hospital Association (AHA) Coding Clinic for HCPCS 23. American Medical Association (AMA) Current Procedure Terminology Assistant 24. National Correct Coding Initiative Policy Manual for Medicare Services, Chapter VIII – Surgery: Endocrine, Nervous, Eye and Ocular Adnexa, and Auditory Systems, CPT Codes 60000 – 69999 25. American Medical Association (AMA) Current Procedural Terminology (CPT) Manual", "codes": [ "63685" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "9a04a5b71c8fb1d6abff2a071299fcf892ec283568ef224c597583135a14316f", "raw_sha256": "a7cdb0102c9bee5ecb182edc63111e0f4d64624c67cbec642e584186e06a66e3", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:41:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0197", "issue_number": "0197", "title": "0197-Immunosuppressive Drugs: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0197-immunosuppressive-drugs-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if the submitted documentation supports Medicare’s coverage criteria and reasonable and necessary requirements.", "codes_text": "J7507", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.30- Prescription Drugs Used in Immunosuppressive Therapy 10. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 11. 42 CFR §410.78- Telehealth Services 12. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 13. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 14. 42 CFR §414.65- Payment for Telehealth Services 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 21. Medicare Program Integrity Manual, Ch. 5- Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, Prosthetics, Orthotics, and Supplies (DMEPOS);§5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; (*Historical, for claims with Dates of Service prior to 01/01/2020) 22. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 23. Medicare Claims Processing Manual, Chapter 17- Drugs and Biological, §80.3- Billing for Immunosuppressive Drugs 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33824- Immunosuppressive Drugs; Effective 10/01/2015; Revised 01/01/2020 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Coverage Article A52474- Immunosuppressive Drugs- Policy Article; Effective 10/01/2015; Revised 01/01/2023 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 27. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023", "codes": [ "J7507" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0f41d3ce5c4a43060070f74e31826527fc533619aa8b03bbf44fd87c1fc2f3fc", "raw_sha256": "02696f4b8eb87c02b385dcdd6a46ce47a00fb9810fe254196384e70214afa30e", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0176", "issue_number": "0176", "title": "0176-Annual Wellness Visit: Incorrect Coding", "review_type": "Complex", "provider_type": "Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0176-annual-wellness-visit-incorrect-coding", "source_id": "cms-rac-approved", "description": "Claims for HCPCS code G0402- Initial Preventative Physical Examination (IPPE), may not be billed more than 12 months after the effective date of the beneficiary’s first part B coverage, or more than once in a lifetime. Claims for HCPCS code G0438- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); initial, may not be billed more than once in a lifetime. Claims for HCPCS code G0439- Annual Wellness Visit (AWV); Includes a personalized prevention plan (PPPS); subsequent, may not be billed within 12 months of G0438 or G0439.", "codes_text": "G0402, G0438, G0439", "policy_text": "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 1861 (s)(2)(W)- an initial preventive physical exam 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 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (ww)- Initial Preventive Physical Examination 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861 (hhh)-Annual Wellness Visit 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 7. 42 CFR §405.929- Post-Payment Review 8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 9. 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 10. 42 CFR §405.986- Good Cause for Reopening 11. 42 CFR §410.15 - Annual Wellness Visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage 12. 42 CFR §410.16-Initial Preventative Physical Examination: Conditions for and limitations on coverage 13. Medicare Benefit Policy Manual- Chapter 15- Covered Medical and Other Health Services, §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) 14. Medicare Claims Processing Manual- Chapter 12- Physicians/Nonphysician Practitioners, §30.6.1.1 Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] 15. Medicare Claims Processing Manual- Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit 16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 17. AMA HCPCS/CPT Codebook", "codes": [ "G0402", "G0438", "G0439" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "43f0e4cb364191a6a22a6b2c7440a07440abd6184cefc356cad494d896930df8", "raw_sha256": "01fcc9745efc17bb10ebae2c1a85d6d619d8c2ac6aecfa8b65c48fd1d60e8d18", "texas": "national", "specialties": [ "Primary care" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Check beneficiary eligibility, prior IPPE/AWV history, and the earliest eligible date. Do not substitute a blanket 365-day scheduling rule for Medicare eligibility verification.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0162", "issue_number": "0162", "title": "0162-Computerized Tomography Coronary Angiography: Medical Necessity and Documentation Requirements", "review_type": "Not specified", "provider_type": "Outpatient Hospital", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0162-computerized-tomography-coronary-angiography-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Computed Tomography (CT) Coronary Angiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.", "codes_text": "CPT 75574", "policy_text": "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 1862(a)(7)- Routine physical checkups 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 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 CFR §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 9. 42 CFR §411.15(a)(1)- Particular services excluded from coverage; Routine physical checkups 10. Medicare National Coverage Determinations Manual, Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations §220.1- Computed Tomography (CT) §A- General, and §F- Computed Tomographic Angiography (CTA) 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions. 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 13. CGS Local Coverage Determination LCD L33947- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 10/05/2023 14. CGS Local Coverage Article LCA A56451- Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2016; Revised 11/16/2023 15. First Coast Local Coverage Determination LCD L33282- Computed Tomographic Angiography of the Chest, Heart and Coronary Arteries; Effective 10/01/2015; Revised 10/01/2019; Retired 2/23/2023 16. First Coast Local Coverage Article LCA A57061- Billing and Coding: Computed Tomographic Angiography of the Chest, Heart, and Coronary Arteries; Effective 10/03/2018; Revised 10/01/2022; Retired 2/23/2023 17. NGS Local Coverage Determination LCD L33559- Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 4/01/2022 18. NGS Local Coverage Article LCA A56737- Billing and Coding: Cardiac Computed Tomography (CCT) and Coronary Computed Tomography Angiography (CCTA); Effective 08/01/2019; Revised 10/01/2023 19. Palmetto Local Coverage Determination LCD L33423- Cardiac Computed Tomography and Angiography (CCTA); Effective 10/01/2015; Revised 4/06/2023 20. Palmetto Local Coverage Article LCA A56691- Billing and Coding: Cardiac Computed Tomography and Angiography (CCTA); Effective 07/11/2019; Revised 10/01/2023 21. WPS Local Coverage Determination LCD L35121- Coronary Computed Tomography Angiography (CCTA); Effective 10/01/2015; Revised 11/30/2023 22. WPS Local Coverage Article LCA A57552- Billing and Coding: Coronary Computed Tomography Angiography (CCTA); Effective 11/28/2019; Revised 10/01/2023 23. AMA CPT Codebook", "codes": [ "75574" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "4848ece94ac5a320bc1be9b9498f5cfdb56617956e60163f45c2b8fbb98edbd0", "raw_sha256": "40da1b2b44f236c0c93ab962e28c4f606817906e4695e3312bbfd75170c9de1c", "texas": "national", "specialties": [ "Cardiology", "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:41:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0143", "issue_number": "0143", "title": "0143-Vitamin D Assay Testing: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital; Outpatient Hospital", "jurisdiction": "JE, JF", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0143-vitamin-d-assay-testing-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Vitamin D lab assay is only reimbursable under Medicare when it meets the indications under the applicable LCDs and not as a routine screening according to 42 CFR 410.32(a). Claim lines that do not meet the coverage requirements will be denied.", "codes_text": "82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED 82652 VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED", "policy_text": "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. 42 CFR §410.32(a) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 8. 42 CFR §411.15(k)(1)- Particular services excluded from coverage 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1- 3.6.6 10. Medicare Program Integrity Manual, Chapter 13, §13.5.4 Reasonable and Necessary Provision in an LCD 11. Medicare Benefit Policy Manual, Chapter 6- Hospital Services Covered Under Part B, Section 20.4.4- Coverage of Outpatient Diagnostic Services Furnished on or After January 1, 2010 12. Noridian, LCD L36692 (JE) Vitamin D Assay Testing, Effective 02/03/2017, Revised 12/01/2019 13. Noridian LCA A57718 (JE) Vitamin D Assay Testing, Effective 12/01/2019 Revised Date 10/01/2023 14. Noridian, LCD L34051 (JF) Vitamin D Assay Testing, Effective 10/01/2015, Revised 12/01/2019 15. Noridian LCA A57719 (JF) Vitamin D Assay Testing, Effective 12/01/2019, Revised Date 10/01/2023 16. AMA CPT Codebook", "codes": [ "82306", "82652" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d30b9674630ffc4c1636e046262e24b9bd12e7f6398d5846831ebe4b53c83609", "raw_sha256": "b4053352a7c92ed79f4f2b0c343531cd13978b9b61422f748d3aff542f23da71", "texas": "not-listed", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0132", "issue_number": "0132", "title": "0132-Evaluation and Management Same Day as Admission to a Nursing Facility: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0132-evaluation-and-management-same-day-admission-nursing-facility-unbundling", "source_id": "cms-rac-approved", "description": "CMS will not pay for an emergency department visit or an office visit E&M service on the same day as a comprehensive nursing facility assessment when both the E&M service and the comprehensive nursing facility assessment are performed by the same physician, at a site other than the nursing facility. The E&M service is bundled into the comprehensive nursing facility assessment code. The E&M service is not separately payable.", "codes_text": "CPT 99201 -99215, 99281 – 99285", "policy_text": "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 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, §30.6.7 Payment for Office or Other Outpatient Evaluation and Management (E/M) Visits (Codes 99201 - 99215), (C) Office/Outpatient or Emergency Department E/M Visit on Day of Admission to Nursing Facility 9. Medicare Claims Processing Manual: Chapter 12- Physicians/Nonphysician Practitioners, §30.6.11 Emergency Department Visits (Codes 99281 - 99288), (D) Emergency Department or Office/Outpatient Visits on Same Day As Nursing Facility Admission 10. Medicare Claims Processing Manual: Chapter 12 -Physicians/Nonphysician Practitioners, §30.6.13 Nursing Facility Services, (A) Visits to Perform the Initial Comprehensive Assessment and Annual Assessments", "codes": [ "99201", "99215", "99281", "99285" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "f384fdb4d1ee8cb42defe28cdbf2f945f40063c82d88f7425ec86cae06845179", "raw_sha256": "a72c6db557c3afda85650b3f1f7dd86ec509b086afc8c1898e81b88c066f0e42", "texas": "national", "specialties": [ "Primary care", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0121", "issue_number": "0121", "title": "0121-Destruction of Premalignant Lesions: Excessive Units", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0121-destruction-premalignant-lesions-excessive-units", "source_id": "cms-rac-approved", "description": "Based on CPT Code descriptions, CPT Code 17000 may only be billed once per date of service; CPT Code 17003 may only be billed thirteen times per date of service, and CPT Code 17004 may only be billed once per date of service. If billed in excess of these limits, excess units of CPT codes 17000, 17003 and/or 17004 will be recovered.", "codes_text": "17000, 17003, 17004", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. American Medical Association (AMA), Current Procedural Terminology (CPT) 2015 –current (Destruction, Benign or Premalignant Lesions) 9. Palmetto GBA LCA A56346- Billing and Coding: Removal of Benign and Malignant Skin Lesions; Effective 01/01/2019; Revised 5/12/2022 10. CGS Administrators, LLC, LCA A57044- Billing and Coding: Removal of Benign Skin Lesions; Effective 09/26/2019; Revised 7/29/2021 11. NGS LCA A54602- Billing and Coding: Removal of Benign Skin Lesions; Effective 10/01/15; Revised 5/07/2020 12. Novitas LCA A57113- Billing and Coding: Removal of Benign Skin Lesions; Effective 09/26/19; Revised 01/12/2022 13. WPS, Local Coverage Article (LCA) A57482- Billing and Coding: Removal of Benign Skin Lesions; Effective 10/31/2019; Revised 10/28/2021", "codes": [ "17000", "17003", "17004" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "769a0bb5cdeb7c4da7e04dd3db555ec5062d3c5295a6063e134f420faa016500", "raw_sha256": "732bf543c9abdbb6e8c956e0db7724f54c205dab19a13715fd5f98f4b81aa47c", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0112", "issue_number": "0112", "title": "0112-Monthly Capitation Payment for End-stage Renal Disease: 4 or More Visits per Month", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-28", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0112-monthly-capitation-payment-end-stage-renal-disease-4-or-more-visits-month", "source_id": "cms-rac-approved", "description": "A Monthly Capitation Payment (MCP) is a payment made to physicians for most dialysis-related physician services furnished to Medicare End Stage Renal Disease (ESRD) patients on a monthly basis. The same monthly amount is paid to the physician for each patient supervised regardless of whether the patient dialyzes at home or as an outpatient in an approved ESRD facility. The claim/claim line with a single paid unit of 90957 or 90960 is the covered service. All additional claim(s)/claim line(s) of 90957-90962, are the overpayments and will be recovered in full.", "codes_text": "90957, 90958, 90959, 90960, 90961, 90962", "policy_text": "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 §405.929- Post-Payment Review 5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 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 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §140- Monthly Capitation Payment Method for Physicians’ Services Furnished to Patients on Maintenance Dialysis; §140.1- Payment for ESRD-Related Services Under the Monthly Capitation Payment (Center Based Patients); and §140.4- Controlling Claims Paid Under the Monthly Capitation Payment Method 9. AMA CPT Codebook", "codes": [ "90957", "90958", "90959", "90960", "90961", "90962" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d2644fc803a98123fae595d4bc321e1120abd837bdd8adb05afe7dfc03c6e6fd", "raw_sha256": "44d77ee6989ea125837e956a2273978ad63ebc9c1816bb96888d8f7efade8df9", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0116", "issue_number": "0116", "title": "0116-Modifiers TC and PC: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-27", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0116-modifiers-tc-and-pc-incorrect-coding", "source_id": "cms-rac-approved", "description": "HCPCS Codes with a PC/TC Indicator of \"1\" and billed with either 26 or TC in any modifier field should be paid at either the technical component or the professional component rate based on the modifier billed. Overpayments occur when the applicable Medicare Physician Fee Schedule amount for Modifier TC and/or 26 are not applied. Findings will be the difference between the original Provider Paid Amount and the Re-Calculated Provider Paid Amount.", "codes_text": "HCPCS Codes with a PC/TC Indicator of \"1\" as identified in the CMS MPFSDB", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6- Physician Fee Schedule Payment Policy Indicator File Record Layout 9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layouts 20 - Professional Component (PC)/Technical Component (TC) Indicator 10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum - MPFSDB Record Layout and Field Descriptions; MPFSDB File Record Layout for 2018 and prior may be found on the CMS website: https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched 11. AMA CPT Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "baf3c27f977c8099f42e739998a3eb52d5835e4e5c40eab63ee12c3e4d051fd5", "raw_sha256": "fd89665da9539c668d1adfbc53582b4b4498b038ed6fa0eaf12543bea8d6be96", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0102", "issue_number": "0102", "title": "0102-Home Use of Oxygen: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2025-08-27", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0102-home-use-oxygen-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Home Oxygen meets coverage criteria and is medically reasonable and necessary.", "codes_text": "E1390, E0431", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(5) - Payment for oxygen and oxygen equipment; §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 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 §410.38- Durable Medical Equipment: Scope and Conditions 8. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 9. 42 CFR §414.65- Payment for Telehealth Services 10. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 11. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 12. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies; §100.2.3- Evidence of Medical Necessity for Oxygen 13. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 14. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements 15. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, §5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; §5.9.1- evidence of medical Necessity for the Oxygen Claims (*Historical, for claims with Dates of Service Prior to 01/01/2020) 16. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; §5.11- Evidence of Medical Necessity; §5.11.1- Evidence of Medical Necessity for the Oxygen Claims 17. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.2- Home Use of Oxygen 18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination L33797: Oxygen and Oxygen Equipment; Effective 10/01/2015; Revised 08/02/2020 19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52514: Oxygen and Oxygen Equipment- Policy Article; Effective 10/01/2015; Revised 8/02/2020 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020", "codes": [ "E0431", "E1390" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d6572c8ade36068c08702a9957e6c40620383ffa9d9b240195293a342913a0ca", "raw_sha256": "82ef42820a4d8958c5083969d197a7e419c719e7f417a7c1149e2bbe6fa4d468", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0079", "issue_number": "0079", "title": "0079-Ventilators: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2025-08-26", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0079-ventilators-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Ventilators meet coverage criteria and/or are medically reasonable and necessary.", "codes_text": "E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube) E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33800: Respiratory Assist Devices, Effective 10/01/2015; Revised 01/01/2024 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52517: Respiratory Assist Devices- Policy Article, Effective 10/01/2015; Revised 08/08/2021 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 26. HCPCS Level II Codebook 27. ICD-10-CM Diagnosis Codebook", "codes": [ "E0465", "E0466" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "71ce0ec0134dc59ed8543f474ad66cb6de569297514342fe1cd148a96d334106", "raw_sha256": "70915a3bc25cb8b116fd8a2c75692e363ba9bde585e1dbe6b806e3714ec7861e", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0078", "issue_number": "0078", "title": "0078-Cardiac Pacemaker: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital", "jurisdiction": "ALL A/B MACs", "source_date": "2025-08-26", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0078-cardiac-pacemaker-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Cardiac Pacemakers meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.", "codes_text": "33206, 33207, 33208", "policy_text": "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 §405.929- Post-Payment Review 5. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 6. 42 CFR §405.986- Good Cause for Reopening 7. Medicare National Coverage Determinations (NCD), Chapter 1, Part 1, §20.8.3- Cardiac Pacemakers: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. CGS Local Coverage Article A54961- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 05/01/2016; Revised 03/24/2022 10. First Coast Local Coverage Article A54926- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019 11. NGS Local Coverage Article A54909- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 4/15/2016; Revised 5/7/2020 12. Noridian Local Coverage Article A54929- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers- Coding and Billing; Effective 4/15/2016; Revised 10/01/2019 13. Noridian Local Coverage Article A54931- Single Chamber and Dual Chamber Permanent Cardiac Pacemakers- Coding and Billing; Effective 4/15/2016, Revised 10/01/2019 14. Novitas Local Coverage Article A54982- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/1/2016; Revised 10/01/2019 15. Palmetto Local Coverage Article A54831- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 01/13/2016; Revised 05/06/2021 16. WPS Local Coverage Article A54958- Billing and Coding: Single Chamber and Dual Chamber Permanent Cardiac Pacemakers; Effective 5/15/2016; Revised 08/26/2021 17. Annual American Medical Association CPT Manual, Coding Guidelines", "codes": [ "33206", "33207", "33208" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "33bf03563e3699fa4c9870eb75bd33eb0ad39f04b69a5efd59f2a8c0dc361ff5", "raw_sha256": "f3c48660a7043dc7590d9f15a987fbf3112b6716abbab40ea0146151f507d4c1", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0066", "issue_number": "0066", "title": "0066-Positive Airway Pressure Devices for Treatment of Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2025-08-26", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0066-positive-airway-pressure-devices-treatment-obstructive-sleep-apnea-medical-necessity", "source_id": "cms-rac-approved", "description": "This review will determine if a Positive Airway Pressure Device is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "HCPCS E0601 and E0470", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 12. 42 CFR §414.65- Payment for Telehealth Services 13. Medicare National Coverage Determination Manual, NCD §240.4- Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea (OSA) 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service Prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, Prosthetics, Orthotics, and Supplies (DMEPOS);§5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; (*Historical, for claims with Dates of Service Prior to 01/01/2020) 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. CGS and Noridian Healthcare Solutions LCD L33718- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea; Effective 10/01/2015; Revised 09/27/2021 23. CGS and Noridian Healthcare Solutions LCA A52467- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea- Policy Article; Effective 10/01/2015; Revised 08/08/2021 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023 25. HCPCS Level II Codebook", "codes": [ "E0470", "E0601" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "fcdec02191c0533b8280933e99aaa79cb753df06a5db6a973e619946ce5e61e3", "raw_sha256": "3808cf3c9ec9f056110aafe144aded68afdd85b554e1b22b43412aff8584aefe", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0046", "issue_number": "0046", "title": "0046-Durable Medical Equipment Rentals- Multiple Billing within the Same Month", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2025-08-26", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0046-durable-medical-equipment-rentals-multiple-billing-within-same-month-0", "source_id": "cms-rac-approved", "description": "Overpayments associated to DMEPOS suppliers billing multiple rentals for the same equipment within the same month (27 days) will be recovered.", "codes_text": "A4639, A7025, E0117, E0140, E0144, E0149, E0165, E0170, E0171, E0181, E0182, E0186, E0187, E0193, E0194, E0196, E0197, E0198, E0202, E0235, E0236, E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0277, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0305, E0316, E0371, E0372, E0373, E0424, E0431, E0433, E0434, E0439, E0462, E0470, E0471, E0472, E0480, E0482, E0483, E0500, E0550, E0565, E0570, E0572, E0574, E0575, E0585, E0600, E0601, E0606, E0617, E0618, E0619, E0620, E0630, E0635, E0636, E0639, E0640, E0656, E0657, E0675, E0740, E0744, E0745, E0749, E0762, E0764, E0776, E0779, E0781, E0784, E0791, E0849, E0855, E0856, E0910, E0911, E0912, E0920, E0930, E0940, E0941, E0946, E0955, E0958, E0968, E0983, E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1010, E1012, E1014, E1020, E1028, E1029, E1030, E1031, E1035, E1036, E1037, E1038, E1039, E1050, E1060, E1070, E1083, E1084, E1087, E1088, E1092, E1093, E1100, E1110, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1221, E1222, E1223, E1224, E1225, E1228, E1232, E1233, E1234, E1235, E1236, E1237, E1240, E1270, E1280, E1295, E1390, E1391, E1392, E1405, E1406, E1700, E1800, E1801, E1802, E1805, E1806, E1811, E1812, E1815, E1816, E1818, E1840, E1841, E2000, E2120, E2310, E2311, E2312, E2313, E2321, E2322, E2325, E2326, E2327, E2328, E2329, E2330, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2378, E2402, K0001, K0002, K0003, K0004, K0006, K0007, K0009, K0010, K0011, K0012, K0195, K0455, K0606, K0730, K0738, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K1002, K1016, K1018, K1020, K1024, K1025, K1031, K1032, K1033, B9002, B9004, B9006", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 § 405.929- Post-Payment Review 7. 42 CFR § 405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 11. National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List 12. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 13. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 14. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests; §3.3- Policies and Guidelines Applied During Review; §3.3.1.3- Automated Review 15. Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule 16. HCPCS Level II Codebook", "codes": [ "A4639", "A7025", "B9002", "B9004", "B9006", "E0117", "E0140", "E0144", "E0149", "E0165", "E0170", "E0171", "E0181", "E0182", "E0186", "E0187", "E0193", "E0194", "E0196", "E0197", "E0198", "E0202", "E0235", "E0236", "E0250", "E0251", "E0255", "E0256", "E0260", "E0261", "E0265", "E0266", "E0277", "E0290", "E0291", "E0292", "E0293", "E0294", "E0295", "E0296", "E0297", "E0300", "E0301", "E0302", "E0303", "E0304", "E0305", "E0316", "E0371", "E0372", "E0373", "E0424", "E0431", "E0433", "E0434", "E0439", "E0462", "E0470", "E0471", "E0472", "E0480", "E0482", "E0483", "E0500", "E0550", "E0565", "E0570", "E0572", "E0574", "E0575", "E0585", "E0600", "E0601", "E0606", "E0617", "E0618", "E0619", "E0620", "E0630", "E0635", "E0636", "E0639", "E0640", "E0656", "E0657", "E0675", "E0740", "E0744", "E0745", "E0749", "E0762", "E0764", "E0776", "E0779", "E0781", "E0784", "E0791", "E0849", "E0855", "E0856", "E0910", "E0911", "E0912", "E0920", "E0930", "E0940", "E0941", "E0946", "E0955", "E0958", "E0968", "E0983", "E0988", "E1002", "E1003", "E1004", "E1005", "E1006", "E1007", "E1008", "E1010", "E1012", "E1014", "E1020", "E1028", "E1029", "E1030", "E1031", "E1035", "E1036", "E1037", "E1038", "E1039", "E1050", "E1060", "E1070", "E1083", "E1084", "E1087", "E1088", "E1092", "E1093", "E1100", "E1110", "E1150", "E1160", "E1161", "E1170", "E1171", "E1172", "E1180", "E1190", "E1195", "E1200", "E1221", "E1222", "E1223", "E1224", "E1225", "E1228", "E1232", "E1233", "E1234", "E1235", "E1236", "E1237", "E1240", "E1270", "E1280", "E1295", "E1390", "E1391", "E1392", "E1405", "E1406", "E1700", "E1800", "E1801", "E1802", "E1805", "E1806", "E1811", "E1812", "E1815", "E1816", "E1818", "E1840", "E1841", "E2000", "E2120", "E2310", "E2311", "E2312", "E2313", "E2321", "E2322", "E2325", "E2326", "E2327", "E2328", "E2329", "E2330", "E2368", "E2369", "E2370", "E2373", "E2374", "E2375", "E2376", "E2377", "E2378", "E2402", "K0001", "K0002", "K0003", "K0004", "K0006", "K0007", "K0009", "K0010", "K0011", "K0012", "K0195", "K0455", "K0606", "K0730", "K0738", "K0813", "K0814", "K0815", "K0816", "K0820", "K0821", "K0822", "K0823", "K0824", "K0825", "K0826", "K0827", "K0828", "K0829", "K0835", "K0836", "K0837", "K0838", "K0839", "K0840", "K0841", "K0842", "K0843", "K0848", "K0849", "K0850", "K0851", "K0852", "K0853", "K0854", "K0855", "K0856", "K0857", "K0858", "K0859", "K0860", "K0861", "K0862", "K0863", "K0864", "K1002", "K1016", "K1018", "K1020", "K1024", "K1025", "K1031", "K1032", "K1033" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0532d9a904d02a038660da998c3a33ee537b828535883646b9fbcaf4f949d6ec", "raw_sha256": "70e5197b08e18d5cbf513bc774f50e667d384e0e62227aeeb70a36ba278abee3", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0225", "issue_number": "0225", "title": "0225-Transitional Care Management: Excessive Units", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2025-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0225-transitional-care-management-excessive-units", "source_id": "cms-rac-approved", "description": "Medicare may cover transitional care services during the 30-day period that begins when a physician discharges a Medicare patient from a healthcare facility and continues for the next 29 days. Only one of the Transitional Care Management (TCM) service CPT codes (99495 or 99496) may be billed once during the transitional care period, and TCM services may be reported by only one physician or non-physician practitioner (NPP).", "codes_text": "99495, 99496", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1175 9. AMA CPT Codebook", "codes": [ "99495", "99496" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "43066b318c1cb687e5f88a5792393b01bc97959678f1925c31214b08a2269217", "raw_sha256": "75ec37fdceee50a7f09799696423d68bb4f867af0cea1e647e47ae9b412a3750", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0224", "issue_number": "0224", "title": "0224-Transitional Care Management: Unbundling", "review_type": "Automated", "provider_type": "Professional Services (Physician/non-physician practitioner)", "jurisdiction": "All A/B MACs", "source_date": "2025-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0224-transitional-care-management-unbundling-0", "source_id": "cms-rac-approved", "description": "A physician or other qualified health care professional who reports Transitional Care Management CPT codes 99495 or 99496 may not report telephone service CPT codes 99441–99443 for the same beneficiary during the timeframe covered by the Transitional Care Management codes. Reporting both constitutes unbundling of services, and any payments will be recouped.", "codes_text": "99441, 99442, 99443", "policy_text": "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 12 - §30.A – Correct Coding Policy, Coding Based on Standards of Medical/Surgical Practice 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. Federal Register / Vol. 77, No. 222 / Friday, November 16, 2012 / Rules and Regulations, PFS proposed rule (76 FR 42917 through 42920) https://www.federalregister.gov/d/2012-26900/p-1176 10. AMA CPT Codebook", "codes": [ "99441", "99442", "99443" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d8f490815e6ffdbb65b573add079289bdb2385a7818115ab9dba1d791ed81fdb", "raw_sha256": "0bb2db3e92ae7b506d42ca9772968f38ea9c41d90708343d7088332e8123ff9d", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0223", "issue_number": "0223", "title": "0223-Drugs and Biologicals in Multi-Dose Vials: Billed with JW Modifier", "review_type": "Automated", "provider_type": "Outpatient Hospital, Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2024-12-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0223-drugs-and-biologicals-multi-dose-vials-billed-jw-modifier", "source_id": "cms-rac-approved", "description": "The JW modifier is a Healthcare Common Procedure Coding System (HCPCS) Level II modifier required to be reported on a claim to report the amount of drug that is discarded and eligible for payment under the CMS discarded drug policy. The modifier should only be used for claims that bill single-dose container drugs. The use of JW modifier is not appropriate for drugs that are from multiple-dose containers. Claims billed incorrectly will result in an overpayment.", "codes_text": "J0702, J9034, J9036, J9056 , J9058, J9059, J9267", "policy_text": "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. 42 CFR §414.904(a)(3)- Average sales price as the basis for payment; Method of payment 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 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient” 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1- Incident to Physician’s Professional Services 11. Medicare Alpha-Numeric HCPCS File- Alpha-Numeric HCPCS | CMS 12. HCPCS Level II Codebook 13. Medicare Part B Drug Average Sales Price; ASP Pricing File- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice 14. U.S. National Library of Medicine DailyMed", "codes": [ "J0702", "J9034", "J9036", "J9056", "J9058", "J9059", "J9267" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "5402d0c5a46cd2dfd2519ed83dd196e18b12a73558f4e6940e10209e89e088ee", "raw_sha256": "e6d36ddb610e75a5ce79e7fa3cbba79c7d507e4f189733592329a6840d1f423d", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0145", "issue_number": "0145", "title": "0145-Endovenous Radiofrequency Ablation and Endovenous Laser Treatment for Lower Extremity Varicose Veins: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2024-07-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0145-endovenous-radiofrequency-ablation-and-endovenous-laser-treatment-lower-extremity-varicose", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if claims for Endovenous Radiofrequency Ablation (ERFA) and Endovenous Laser Treatment (EVLT) for Lower Extremity Varicose Veins meet Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.", "codes_text": "36475, 36476, 36478, 36479, 76937", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Ch 12, §40.6 Claims for Multiple Surgeries 9. CGS Administrators, LLC, LCD L34082- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 10/03/2024 10. First Coast Service Options, Inc., LCD L38720- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 12/27/2020 11. National Government Services, Inc., LCD L33575- Varicose Veins of the Lower Extremity, Treatment of; Effective 10/01/2015; Revised 11/21/2019 12. Noridian Healthcare Solutions, LLC, LCD L34209- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019 13. Noridian Healthcare Solutions, LLC, LCD L34010- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 12/01/2019 14. Novitas Solutions, Inc., LCD L34924- Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 10/01/2015; Revised 12/27/2020 15. Palmetto GBA LCD L39121- Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 11/16/2023 16. Wisconsin Physicians Service Insurance Corp., LCD L34536- Treatment of Varicose Veins of the Lower Extremities; Effective 10/01/2015; Revised 8/31/2023 17. CGS Administrators, LLC, LCA A57305- Billing and Coding: Varicose Veins of the Lower Extremity, Treatment of; Effective 9/26/2019; Revised 10/03/2024 18. First Coast Service Options, Inc., LCA A58250- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremity; Effective 12/27/2020; Revised 3/11/2021 19. National Government Services, Inc., LCA A52870- Billing and Coding: Treatment of Varicose Veins of the Lower Extremity; Effective 10/01/2015; Revised 01/01/2025 20. Noridian Healthcare Solutions, LLC, LCA A57706- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023 21. Noridian Healthcare Solutions, LLC, LCA A57707- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 12/01/2019; Revised 01/01/2023 22. Novitas Solutions, Inc., LCA A55229- Billing and Coding: Treatment of Chronic Venous Insufficiency of the Lower Extremities; Effective 8/11/2016; Revised 3/11/2021 23. Palmetto GBA LCA A58876- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 4/03/2022; Revised 01/01/2025 24. Wisconsin Physicians Service Insurance Corp., LCA A56914- Billing and Coding: Treatment of Varicose Veins of the Lower Extremities; Effective 8/29/2019; Revised 8/31/2023 25. AMA CPT Codebook Claims Selection Criteria: 1. Provider types: Ambulatory Surgical Centers (ASC); Professional Services 2. Eligible MAC Jurisdictions: All A/B MACs 3. TOB: 083X (ASC) 4. Place of Service is limited to 24 (ASC) 5. Exclude from review claims having a “paid claim date” which is more than 3 years prior to the ADR letter date 6. Include claims billed with one of the following Category 1 CPT codes: • 36475- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency, first vein treated o +36476- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) • 36478- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser, first vein treated o +36479- Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, laser; subsequent vein(s) treated in a single extremity, each through separate access sites (List separately in addition to code for primary procedure) • 76937- Ultrasound guidance for vascular access requiring ultrasound evaluation of potential access sites, documentation of selected vessel patency, concurrent real time ultrasound visualization of vascular needle entry, with permanent recording and reporting (List separately in addition to code for primary procedure) 7. Exclude all claims identified with a valid Unique Tracking Number (UTN). 8. Exclude the following modifiers: • GA- Waiver of liability statement issued as required by payer policy, individual case, covered item • GX- Notice of Liability issued, voluntary under payer policy, non-covered item • QO-investigational clinical service provided in a clinical research study that is in an approved clinical research study • Q1-routine clinical service provided in a clinical research study that is in an approved clinical research study 9. Exclude any claims that will have an overpayment adjustment of less than $25.00 10. Exclude paid claims that will have an underpayment adjustment of less than $5.00 11. Error codes: • 1600- lack of documentation • 2100- insufficient documentation • 2500- medically unnecessary item[s] or services • 6000- unbundling • HP301- Insufficient documentation to support failure of an adequate trial of conservative treatment prior to the vein ablation. • HP302- The documentation submitted does not include history and physical findings supporting a diagnosis of symptomatic varicose veins. • HP303- Insufficient documentation to support that the beneficiary has an absence of aneurysm in target segment. • HP304- Insufficient documentation to support that the required vein diameter parameters for vein ablation were met per Medicare coverage criteria. • HP305- The documentation submitted does not note the absence of thrombosis or vein tortuosity • HP306- Insufficient documentation to support performance of test(s) to confirm the presence and location of incompetent perforating veins. • HP308- Insufficient documentation to support other causes of edema, ulceration, and/or pain in the limbs.", "codes": [ "36475", "36476", "36478", "36479", "76937" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "90e81684e2835b0c70fe8df3fae4514ea2fa6b8cd35f5d499979b6c0d9372d2f", "raw_sha256": "8782a64d07d4948121a25c17faacf0b1162f9a62dbcf02f757af8141cf740a76", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0130", "issue_number": "0130", "title": "0130-Panniculectomy: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2024-07-14", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0130-panniculectomy-medical-necessity-documentation-requirements", "source_id": "cms-rac-approved", "description": "Panniculectomy billed for cosmetic purposes will not be deemed medically necessary. In addition, panniculectomy billed at the same time as an open abdominal surgery, or if it is incidental to another procedure, is not separately coded per Coding Guidelines.", "codes_text": "15830, 15847", "policy_text": "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. 42 CFR §411.15 (h)- Particular services excluded from coverage 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §120- Cosmetic Surgery 10. CGS Administrators, LLC, LCD, L39506- Cosmetic and Reconstructive Surgery; Effective 5/21/2026 11. First Coast Service Options, Inc., LCD L38914- Cosmetic and Reconstructive Surgery; Effective 7/11/2021 12. Noridian Healthcare Solutions, LLC, LCD L35163- Plastic Surgery; Effective 10/01/2015; Revised 10/16/2025 13. Noridian Healthcare Solutions, LLC, LCD L37020- Plastic Surgery; Effective 10/10/2017; Revised 02/14/2025; Retired 10/16/2025 14. Novitas Solutions, Inc., LCD L35090- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/11/2021 15. Palmetto GBA L33428- Cosmetic and Reconstructive Surgery; Effective 10/01/2015; Revised 7/29/2021 16. Wisconsin Physician Service Corporation, LCD L39051- Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 06/25/2026 17. CGS Administrators, LLC, LCA A59299- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 5/28/2023; Revised 11/27/2025 18. First Coast Service Options, Inc., LCA A58573- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 10/01/2024, Revised 11/17/2025 19. Noridian Healthcare Solutions, LLC, LCA A57221- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 10/16/2025 20. Noridian Healthcare Solutions, LLC, LCA A57222- Billing and Coding: Plastic Surgery; Effective 10/01/2019, Revised 01/01/2025; Retired 10/16/2025 21. Novitas Solutions, Inc., LCA A56587- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 5/30/2019; Revised 11/17/2025 22. Palmetto GBA A56658- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 7/04/2019; Revised 01/01/2026 23. Wisconsin Physician Service Corporation LCA A58774- Billing and Coding: Cosmetic and Reconstructive Surgery; Effective 11/14/2021; Revised 06/25/2026 24. AMA CPT Codebook 25. Prior Authorization Demonstration for Certain Ambulatory Surgical Center ASC Services | CMS", "codes": [ "15830", "15847" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d20063df81e3bea42de3dbb64718ff2afeff71c176d190fa95d9ce78c6bb5917", "raw_sha256": "cc6fd9ffef28302c3dae6e92185b4b07d5e2a1f2a786a6e86b20d2755cbbe371", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0222", "issue_number": "0222", "title": "0222-Non-Physician Billed Without Correct Assistant at Surgery Modifier: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2024-05-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics/0222-non-physician-billed-without-correct-assistant-surgery-modifier-incorrect-coding", "source_id": "cms-rac-approved", "description": "Assistant at surgery services by non-physician providers (PA, NP, or CNS), are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the Medicare Physician Fee Schedule Data Base amount. Modifier \"AS\" is used for assistant at surgery services provided by a physician's assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). Assistant at surgery claims billed by non-physician practitioners without modifier AS, will be corrected, adding modifier AS, repricing the claim.", "codes_text": "CPT code range 10021 through 69990 with assistant at surgery indicator of “0” or “2”", "policy_text": "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, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(a)(1)(O)- Payment of Benefits 4. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review 5. 42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request 6. 42 Code of Federal Regulations (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 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 8. 42 Code of Federal Regulations (CFR) §414.4- Payment for Part B Medical and Other Medical Services 9. 42 Code of Federal Regulations (CFR) §414.40- Coding and Ancillary Policies 10. Medicare Benefit Policy Manual Chapter 15 §200 - Nurse Practitioner (NP) Services 11. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §20.4.3 12. Medicare Claims Processing Manual Chapter 12- Physician Practitioner Billing, § 100.1.7.B. 13. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §110.2 - Limitations for Assistant-at-Surgery Services Furnished by Physician Assistants 14. Medicare Claims Processing Manual, Chapter 12- Physician/ Nonphysician Practitioner, §120 - Nurse Practitioner (NP) and Clinical Nurse Specialist (CNS) Services 15. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 16. Medicare Physician Fee Schedule (MPFS) Physician Fee Schedule | CMS 17. AMA CPT Codebook 18. American Medical Association. “Modifiers Used with Surgical Procedures”, CPT Assistant, Fall 1992, page 15. 19. American Medical Association. \"A Closer Look at the Use of Surgical Modifiers\", CPT Assistant, March 1996, page 8.", "codes": [ "10021", "69990" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "96e5ea98efca831b7efc25b5356c58c235ccbb862a43725cea20e7df8e74b1ab", "raw_sha256": "37edc69b6d7e89f8c7d9720c496a8d5b5246ce85e55b695abaefb3e2681c233c", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0221", "issue_number": "0221", "title": "0221- Hospice Care- Extended Length of Stay: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Hospice", "jurisdiction": "HH/Hospice MACs", "source_date": "2023-10-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/proposed-rac-topics/0221-hospice-care-extended-length-stay-medical-necessity-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if billed Hospice Care with Extended Lengths of Stay was reasonable and necessary. Claims that do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment.", "codes_text": "REV Codes 0651- Routine Home Care 0652- Continuous Home Care 0655- Inpatient Respite Care 0656- General Inpatient Care", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1812(a)(4), (a)(5), and (d)- Scope of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1813(a)(4)(A)- Deductibles and Coinsurance 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(a)(7)- Conditions of and Limitations on Payment for Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(i)(1)(A)- Payment for Hospice Care 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1815(a) and (e)(2)(D)- Payment to Providers of Services 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1862(a)(1)(A), (a)(1)(C), (a)(6), and (a)(9)- Exclusions from Coverage and Medicare as Secondary Payer 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1879 (g)(2)- Limitation of Liability of Beneficiary Where Medicare Claims are Disallowed 10. 42 CFR §405.929- Post-Payment Review 11. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 12. 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 13. 42 CFR §405.986 - Federal Health Insurance for The Aged and Disabled, Good Cause for Reopening 14. 42 CFR, §411.15(k)(2) - Exclusions from Medicare and Limitations on Medicare Payment, Particular Services Excluded from Coverage 15. 42 CFR §418– Hospice Care 16. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10- General program Benefits, §10.1- Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description 17. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60- Certification and Recertification by Physicians for Hospice Care 18. Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, §60 - Hospice Defined 19. Medicare Benefit Policy Manual, Chapter 9, §§10- Requirements—General; 20- Certification and Election Requirements; 30.2- Respite Care Coinsurance; 40- Benefit Coverage; 50- Limitation on Liability for Certain Hospice Coverage Denials; 80- Hospice Pre-election evaluation and counseling services; 90- Caps and Limitations on Hospice Payments 20. Medicare Claims Processing Manual Chapter 11, §30- Billing and Payment for General Hospice Services 21. Medicare Claims Processing Manual Chapter 11, §100- Billing for Hospice Denials 22. Medicare Claims Processing Manual, Chapter 30, §50- Advance Beneficiary Notice of Non-coverage (ABN) 23. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 24. CGS Administrators, LLC, LCD L34538- Hospice Determining Terminal Status; Effective 10/01/2015; Revised 08/07/2025 25. National Government Services, Inc., LCD L33393 Hospice Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019 26. National Government Services, Inc., LCA A52830 Billing and coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019 27. CMS Transmittal 13664, Change Request (CR) 14384 (effective 10/01/2025): Manual Updates Adding language to the Timing and Content of Certification, Revocation and Discharge Guidance, and Hospice Election 28. CMS, Hospice: CMS Flexibilities to Fight Covid-19, Revised 05/10/2023. Hospice: CMS Flexibilities to Fight COVID-19", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d290e6d060190d436375881beebc262699bb1da8869d58a62c254aa193901557", "raw_sha256": "96bfbe5a40cb05a1db19bda702388cff530130caae8c317938f5d89d617e2945", "texas": "unresolved", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0220", "issue_number": "0220", "title": "0220-Hip Orthoses within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Supplier, DME Physician", "jurisdiction": "All DME MACs", "source_date": "2023-09-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0220-hip-orthoses-within-reasonable-useful-lifetime-excessive-units", "source_id": "cms-rac-approved", "description": "Claims for Hip Orthoses with dates of service within the reasonable useful lifetime of a previously paid identical HCPCS Hip Orthoses, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "L1600, L1610, L1620, L1650, L1652, L1660, L1681, L1686, L1690, L1630, L1640, L1680, L1685, L1700, L1710, L1730, L1755", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 42 Code of Federal Regulations (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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 110.2 – Repairs, Maintenance, Replacement, and Delivery (C) – Replacement 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 16. HCPCS Level II Codebook", "codes": [ "L1600", "L1610", "L1620", "L1630", "L1640", "L1650", "L1652", "L1660", "L1680", "L1681", "L1685", "L1686", "L1690", "L1700", "L1710", "L1730", "L1755" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "32b96056fac220ede13d344b45860016570ca9856b0ff9c564af9614ade442bf", "raw_sha256": "3e292ac95b13c2ddf2f9f2f4cee2d7a4a50185e4516b5f78fbed664042f40633", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0219", "issue_number": "0219", "title": "0219-Minimally-Invasive Surgical (MIS) Fusion of the Sacroiliac Joint: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "J5, J6, J8, J15, JJ, JK, JM, JE and JF (as of 04/17/2025)", "source_date": "2023-06-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/537955379/3a302-minimally-invasive-surgical-mis-fusion-sacroiliac-joint-medical-necessity-and-documentation", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine whether minimally invasive surgical fusion of the sacroiliac joint met Medicare coverage criteria and was reasonable and necessary.", "codes_text": "27279", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators, LLC, Local Coverage Determination (LCD) L36494- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 2/01/2016; Retired 4/16/2025. 9. CGS Administrators, LLC, Local Coverage Article (LCA) A56535- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 2/01/2016; Retired 4/16/2025 10. CGS Administrators, LLC, Local Coverage Determination (LCD) L39802-Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025; Revised 05/15/2025 11. CGS Administrators, LLC, Local Coverage Article (LCA) A59682-Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025 12. CGS Administrators, LLC, Local Coverage Determination (LCD) L39383-Sacroiliac Joint Injections and Procedures; Effective 03/19/2023; Revised 04/02/2026 13. CGS, Administrators, LLC, Local Coverage Article (LCA) A59154-Billing and Coding: Sacroiliac Joint Injections and Procedures; Effective 03/19/2023; Revised 03/26/2026 14. National Government Services, Inc., LCD L36406- Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 4/01/2016; Revised 10/10/2019 15. National Government Services, Inc., LCA A57431- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac (SI) Joint; Effective 10/10/2019; Revised 01/01/2026 16. Noridian Healthcare Solutions. LLC, Local Coverage Determination (LCD) L39810 – Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025; Revised 10/23/2025 17. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39812 – Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective Retired 10/23/2025 18. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A59695 – Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025; Revised 01/01/2026 19. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCAS) A59697 – Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025; Retired 10/23/2025 20. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L39462 – Sacroiliac Joint Injections and Procedure; Effective 03/19/2023; Revised 03/05/2026 21. Palmetto GBA LCD L39025 - Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022; Revised 05/02/2023; Retired 04/16/2025 22. Palmetto GBA LCA A58739- Billing and Coding: Minimally Invasive Surgical (MIS) Fusion of the Sacroiliac Joint (SIJ); Effective 7/17/2022; Revised 01/01/2025; Retired 04/16/2025 23. Palmetto GBA, LCD L39797 – Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025 24. Palmetto GBA, LCA A59672 – Billing and Coding: Minimally Invasive Arthrodesis of the Sacroiliac Joint (SIJ); Effective 04/17/2025; Revised 01/01/2026 25. Palmetto GBA, LCA – LLC, Local Coverage Determination (LCD) L39402 – Sacroiliac Joint Injections and Procedures; Effective 11/28/2024 26. Wisconsin Physicians Service Insurance Corporation LCD L36000- Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 12/17/2015; Revised 6/27/2024 27. Wisconsin Physicians Service Insurance Corporation LCA A57596- Billing and Coding: Percutaneous minimally invasive fusion/stabilization of the sacroiliac joint for the treatment of back pain; Effective 11/01/2019; Revised 01/01/2026 28. AMA CPT Codebook", "codes": [ "27279" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "2702b23e8acdc735b63776462214988eda69fd05573c549e10ac975a769be451", "raw_sha256": "1c347e3e45065cca6938f6bce1bffaabfdf29d44489b58fc1b4accea85580d4d", "texas": "not-listed", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0218", "issue_number": "0218", "title": "0218-Medical Supplies Billed from Consolidated Billing List During a Home Health Episode: Unbundling", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2023-06-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/568075650/5a301-medical-supplies-billed-consolidated-billing-list-during-home-health-episode-unbundling", "source_id": "cms-rac-approved", "description": "All Medical Supplies included in the Consolidated Billing List and billed during admission of a patient to Home Health services are inclusive to Home Health services. Separately billed non-routine supplies from the Consolidated Billing List will be recovered.", "codes_text": "Consolidated Billing Master Supply List, non-routine supply codes found https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/coding_billing.html", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 42 Code of Federal Regulations (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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 13. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, §40- Covered Services Under a Qualifying Home Health Plan of Care; §50- Coverage of Other Home Health Services 14. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2 - Home health Consolidated Billing Edits in Medicare Systems; Section §10.1.17- Payment Adjustments - Low Utilization Payment Adjustments (LUPAs) 15. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies; §212- Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers 16. CMS Consolidated Billing Master Supply List, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-payment/HomeHealthPPS/coding_billing.html 17. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "f76a3bba209bd702d82fa9759d1bbcead0891368191069e35d7a14b5065e428a", "raw_sha256": "c86d0dd9f7344be3d831153737f53682f615e14a21753cff2f81595ec28e4b1e", "texas": "national", "specialties": [ "DME & supplies", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0217", "issue_number": "0217", "title": "0217-Muscle Flap with Breast Reconstruction or Breast Prosthesis Insertion: Unbundling", "review_type": "Complex", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2023-06-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1555941763/1a298-muscle-flap-breast-reconstruction-or-breast-prosthesis-insertion-unbundling", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if CPT code 15734 warranted separate reimbursement given that a flap is considered inclusive to breast reconstruction (19357-19364, 19367-19369) or breast prosthesis (19340, 19342) procedures. Documentation will be reviewed to support that the flap (15734) was performed at a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. Billed services that are not supported by the medical record will be denied as unbundling.", "codes_text": "Target: 15734 Reference: 19340, 19342, 19357, 19361, 19364, 19367, 19368, 19369", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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. 42 CFR §424.5(a)(6)- Basic conditions- Sufficient information 9. NCCI Policy Manual, Chapter 1- General Correct Coding Policies 10. NCCI Policy Manual, Chapter 3- Surgery: Integumentary System; CPT codes 10000-19999; J. Breast (Incision, Excision, Introduction, Repair and Reconstruction), #7 11. CPT Assistant, December 2012, Volume 22, Issue 12, page 6- Island Pedicle Flaps 12. CPT Assistant, April 2014, Volume 24, Issue 4, Page 10- Surgery: Integumentary System, Repair Abdominal Wall After Free Flap for Breast Reconstruction, 15734 13. CPT Assistant, July 2021, Volume 31, Issue 7, Page 8-Surgery-Integumentary System, 15734 14. AMA CPT Codebook", "codes": [ "15734", "19340", "19342", "19357", "19361", "19364", "19367", "19368", "19369" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ba97a5b1a03d9b5b9661f17220ed0ace695f559885ff7d41ae9aff11ad7cc6c2", "raw_sha256": "ff3d043a492fcd3f300fd06dbb7df1e7d26b262d57e6fdb58cae27b57bed9ce6", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0216", "issue_number": "0216", "title": "0216-Wearable Automatic External Defibrillators: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2023-06-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/721360016/5a291-wearable-automatic-external-defibrillators-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if a Wearable Automatic External Defibrillator is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "K0606, K0607, K0608, K0609", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)-Replacement of Items; §1834(m)-Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 42 CFR §410.78- Telehealth Services 10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 11. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 12. 42 CFR §414.65-Payment for Telehealth Services 13. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 14. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 15. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 16. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4-Signature Requirements; §3.3.2.5-Amendments, Corrections and Delayed Entries in Medical Documentation §3.5-Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 17. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 18. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 19. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCD L33690, Automatic External Defibrillators, Effective 10/01/2015; Revised 01/01/2020 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCA A52458, Automatic External Defibrillators – Policy Article, Effective 10/01/2015; Revised 09/04/2025 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 22. AMA CPT Codebook", "codes": [ "K0606", "K0607", "K0608", "K0609" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "58538ecc01ffd93d04ba7d07592c27261a482de32138cff10ad1ef9b63ade200", "raw_sha256": "bd8e8ba2e0e5b9aff0a764b7956fdea4913079bf187db5d91aa9781f4799cb57", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0215", "issue_number": "0215", "title": "0215-Canes, Crutches, and Walkers within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME by Supplier; DME by Physician", "jurisdiction": "All DME MACs", "source_date": "2023-04-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/228771083/0215-canes-crutches-and-walkers-within-reasonable-useful-lifetime-excessive-units", "source_id": "cms-rac-approved", "description": "Claims for canes, crutches, and/or walkers billed within the five-year reasonable useful lifetime of a previously reimbursed item billed with an identical HCPCS for the same beneficiary will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117, E0118, E0130, E0135, E0140, E0141, E0143, E0144, E0147, E0148, E0149", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination LCD L33733- Canes and Crutches; Effective 10/01/2015; Revised 01/01/2020 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article LCA A52459- Canes and Crutches- Policy Article; Effective 10/01/2015; Revised 01/01/2020 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination LCD L33791- Walkers; Effective 10/01/2015, Revised 01/01/2020 17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article LCA A52503- Walkers- Policy Article; Effective 10/01/2015; Revised 10/01/2025 18. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article LCA A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 19. HCPCS Level II Codebook", "codes": [ "E0100", "E0105", "E0110", "E0111", "E0112", "E0113", "E0114", "E0116", "E0117", "E0118", "E0130", "E0135", "E0140", "E0141", "E0143", "E0144", "E0147", "E0148", "E0149" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "e5e4dbce5c6115709b0cec57fe18539c6967b8b34e836318fea4de213f18438d", "raw_sha256": "21699ec0437a1e6ada9c244098c20d8eb7b666b943fa48b0d040127d88d1b25e", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0214", "issue_number": "0214", "title": "0214-Transurethral Waterjet Ablation of the Prostate for Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms (LUTS): Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2023-04-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1382700332/0214-transurethral-waterjet-ablation-prostate-benign-prostatic-hyperplasia-bph-lower-urinary-tract", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine whether transurethral waterjet ablation services met Medicare coverage criteria and were reasonable and necessary.", "codes_text": "Primary Code: 0421T Secondary Code: C2596 (for DOS on or prior to 12/31/2025) and 52597 (for DOS on or after 01/01/2026)", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators, LLC, LCD L38378- Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective 4/01/2020; Revised 04/02/2026 9. CGS Administrators, LLC, LCA A57926- Billing and Coding: Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (BPH); Effective 4/01/2020; Revised 04/02/2026 10. First Coast Service Options, Inc., LCD L38726- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 04/06/2025 11. First Coast Service Options, Inc., LCA A58264- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/01/2026 12. National Government Services, Inc., LCD L38367- Fluid Jet System Treatment for LUTS/BPH; Effective 4/01/2020; Revised 09/07/2025 13. National Government Services, Inc., LCA A56797- Billing and Coding: Fluid Jet System Treatment for LUTs/BPH; Effective 4/01/2020; Revised 01/01/2026 14. Noridian Healthcare Solutions, LLC, LCD L38705- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 03/05/2026 15. Noridian Healthcare Solutions, LLC, LCD L38707- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Retired 03/05/2026 16. Noridian Healthcare Solutions, LLC, LCA A58227- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 03/05/2026 17. Noridian Healthcare Solutions, LLC, LCA A58229- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Retired 03/05/2026 18. Novitas Solutions, Inc., LCD L38712- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 04/06/2025 19. Novitas Solutions, Inc., LCA A58243- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 01/01/2026 20. Palmetto GBA LCD L38549- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 12/14/2025 21. Palmetto GBA LCA A58008- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/27/2026 22. Wisconsin Physicians Service Insurance Corporation LCD L38682- Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 12/14/2025 23. Wisconsin Physicians Service Insurance Corporation LCA A58209- Billing and Coding: Transurethral Waterjet Ablation of the Prostate; Effective 12/27/2020; Revised 01/01/2026 24. AMA CPT Codebook 25. HCPCS Level II Codebook", "codes": [ "0421T", "52597", "C2596" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "bedc242afab5eab867230b3d5815ad4b3050356f0b286e6334f4ca99929a6ac5", "raw_sha256": "a59463f89009a0238287c0e108157b148a564af3c829f546ea1d1a692a8962e4", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0212", "issue_number": "0212", "title": "0212-Hospice General Inpatient Care: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Hospice", "jurisdiction": "J15, J6, JK, JM", "source_date": "2023-04-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/484496563/0212-hospice-general-inpatient-care-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if Hospice General Inpatient Care (GIP) was reasonable and necessary to achieve pain control or acute or chronic symptom management which could not be managed in any other setting. Claims that do not meet the indications of coverage and/or medical necessity will be recoded to Routine Hospice Care 0651 and result in an overpayment.", "codes_text": "REV. Code 0656 – General Inpatient Care Applicable Policy Codes 1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1812(a)(4), (a)(5), and (d)- Scope of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1813(a)(4)(A)- Deductibles and Coinsurance 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(a)(7)- Conditions of and Limitations on Payment for Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1814(i)(1)(A)- Payment for Hospice Care 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1815(a) and (e)(2)(D)- Payment to Providers of Services 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(m)- Payment of Benefits 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §§1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A), (a)(1)(C), (a)(6), and (a)(9)- Exclusions from Coverage and Medicare as Secondary Payer 10. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1879 (g)(2)- Limitation of Liability of Beneficiary Where Medicare Claims are Disallowed 11. 42 CFR §405.929- Post-Payment Review 12. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 13. 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 14. 42 CFR §405.986 - Federal Health Insurance for The Aged and Disabled, Good Cause for Reopening 15. 42 CFR §411.15(k)(2) - Exclusions from Medicare and Limitations On Medicare Payment, Particular Services Excluded from Coverage 16. 42 CFR §418– Hospice Care 17. 42 CFR §424.5(a)(6)- Basic Conditions 18. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 1, §10- General program Benefits, §10.1- Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and Skilled Nursing Facility (SNF) Services - A Brief Description 19. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4, §60- Certification and Recertification by Physicians for Hospice Care 20. Medicare Benefit Policy Manual, Chapter 9, §10- Requirements—General; §20-Certification and Election Requirements; §40-Benefit Coverage 21. Medicare Benefit Policy Manual Chapter 9, §40.1.5- Short-Term Inpatient Care 22. Medicare Claims Processing Manual, Chapter 1, §60.4.1- Outpatient Billing with an ABN (Occurrence Code 32) 23. Medicare Claims Processing Manual, Chapter 11, §30- Billing and Payment for General Hospice Services 24. Medicare Claims Processing Manual Chapter 11, §100- Billing for Hospice Denials 25. Medicare Claims Processing Manual, Chapter 30, §50- Advance Beneficiary Notice of Non-coverage (ABN) 26. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 27. CGS Local Coverage Determination L34538- Hospice Determining Terminal Status; Effective 10/01/2015, Revised 06/27/2024 28. NGS Local Coverage Determination L33393 Hospice- Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019 29. NGS Local Coverage Article A52830 Billing and Coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019 30. HCPCS Level II Codebook", "policy_text": "", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "e3718b1f0e35356f5f5ac8637b875e40ddb1c16e366929e1eecf57cd7f3def61", "raw_sha256": "44794bfca352909fc3c3202acfe3263cae424386f0364c6003ca3966905dc451", "texas": "not-listed", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0210", "issue_number": "0210", "title": "0210 - Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2022-06-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/551206715/0210-hypoglossal-nerve-stimulation-obstructive-sleep-apnea-medical-necessity-and-documentation", "source_id": "cms-rac-approved", "description": "Hypoglossal nerve stimulation (HNS) is reasonable and necessary for the treatment of moderate to severe obstructive sleep apnea (OSA) when coverage criteria are met. Documentation will be reviewed to determine if HNS meets Medicare coverage criteria, applicable coding guidelines, and/or are medically reasonable and necessary.", "codes_text": "CPT 64582", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 2. SSA, Title XVIII- Health Insurance for the Aged and Disabled, §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 National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, Section 240.4.1 -Sleep Testing for Obstructive Sleep Apnea (OSA) 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. Palmetto GBA, LCD L38276- Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, Effective 06/21/2020, Revised 04/13/2023 10. Palmetto GBA, LCA A58075- Billing and Coding: Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea, Effective 06/21/2020; Revised 01/01/2022 11. First Coast Service Options, Inc., LCD L38398- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020 12. First Coast Service Options, Inc., LCA A56953 - Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/16/2020; Revised 01/01/2022 13. Novitas Solutions, Inc., LCD L38385- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020 14. Novitas Solutions, Inc., LCA A56938- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 01/01/2022 15. National Government Services, Inc., LCD L38387-Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 04/01/2020 16. National Government Services, Inc., LCA A57092- Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 01/01/2022 17. Wisconsin Physicians Service Insurance Corporation, LCD L38528- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 06/14/2020, Revised 04/25/2024 18. Wisconsin Physicians Service Insurance Corporation, LCA A57944-Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 06/14/2020; Revised 01/01/2025 19. Noridian Healthcare Solutions, LLC, LCD L38310(JE)- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020 20. Noridian Healthcare Solutions, LLC, LCD L38312(JF)- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020 21. Noridian Healthcare Solutions, LLC, LCA A57948(JE)- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 12/01/2024 22. Noridian Healthcare Solutions, LLC, LCA A57949(JF)- Billing and Coding: Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 03/15/2020; Revised 12/01/2024 23. CGS Administrators, LLC, LCD L38307- Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 03/06/2025 24. CGS Administrators, LLC, LCA A57149- Billing and Coding: Hypoglossal Nerve Stimulation for Treatment of Obstructive Sleep Apnea, Effective 04/01/2020; Revised 03/06/2025 25. American Hospital Association (AHA) Coding Clinic for HCPCS- Volume 22, Number 2, Second Quarter 2022, Page 1-2, New CPT code for drug-induced sleep endoscopy 26. AMA CPT Assistant, March 2022, Volume 32, Issues 3, Page 7, Reporting Hypoglossal Nerve Stimulator Services 27. AMA CPT Codebook", "codes": [ "64582" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "bf9e8f9242aa8cfd9a75cfc13d16cb48948c35ec3cdbdbd7e74aeb33144a2946", "raw_sha256": "9e59f90f3610c25d9a4040e420202fb5f2c4a980d6e4e8527f399c9fa350d656", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0209", "issue_number": "0209", "title": "0209-Parenteral Nutrition Therapy with Dates of Service on/after September 5, 2021: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2021-12-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1179691051/0209-parenteral-nutrition-therapy-dates-service/after-september-5-2021-medical-necessity-and", "source_id": "cms-rac-approved", "description": "This review will determine if Parenteral Nutrition is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Documentation will be reviewed to determine if claims for parenteral nutrition, with dates of service on or after September 5, 2021, meet coverage criteria and/or are medically reasonable and necessary.", "codes_text": "B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery; §120- Prosthetic Devices 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, Prosthetics, Orthotics, and Supplies (DMEPOS);§5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; (*Historical, for claims with Dates of Service prior to 01/01/2020) 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. Medicare National Coverage Determination Manual, NCD Section 180.2- Enteral and Parenteral Nutrition Therapy (*Historical, for claims with Dates of Service Prior to 01/01/2022) 23. Medicare National Coverage Determination Manual, NCD Section 180.2- Enteral and Parenteral Nutrition Therapy; Revised 01/01/2022; Retired 4/10/2023- Effective January 1, 2022, the Centers for Medicare & Medicaid Services determined that no national coverage determination (NCD) is appropriate at this time for Enteral and Parenteral Nutritional Therapy. In the absence of an NCD, coverage determinations will be made by the Medicare Administrative Contractors under 1862(a)(1)(A) of the Social Security Act. 24. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, LCD L38953- Parenteral Nutrition, Effective 9/5/2021; Revised 7/02/2023 25. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A58836- Parenteral Nutrition; Effective 9/5/2021; Revised 7/02/2023 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 27. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023 28. HCPCS Level II Codebook", "codes": [ "B4164", "B4168", "B4172", "B4176", "B4178", "B4180", "B4185", "B4189", "B4193", "B4197", "B4199", "B4216", "B4220", "B4222", "B4224", "B5000", "B5100", "B5200" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "bf451d3deed52db9abea26648c089127389a3c257f781924e49be51853df5203", "raw_sha256": "a7ce8a02fe061dd2e6e5032e91f27c55f372b99538e90be987dad16b9bd2bf02", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0208", "issue_number": "0208", "title": "0208-Enteral Nutrition Therapy with Dates of Service on/after September 5 2021: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2021-12-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/335736235/0208-enteral-nutrition-therapy-dates-service/after-september-5-2021-medical-necessity-and", "source_id": "cms-rac-approved", "description": "Enteral nutrition is considered reasonable and necessary for a patient with a functioning gastrointestinal tract who, due to pathology to, or non-function of, the structures that normally permit food to reach the digestive tract, cannot maintain weight and strength commensurate with his or her general condition. Documentation will be reviewed to determine if claims for enteral nutrition, with dates of service on or after September 5, 2021, meet coverage criteria and/or are medically reasonable and necessary.", "codes_text": "B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Time frames 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery; §120- Prosthetic Devices 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 19. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Documentation Requirements for DMEPOS Supplied as Refills to the Original Order; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 20. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, LCD L38955- Enteral Nutrition, Effective 09/05/2021; Revised 01/01/2024 21. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A58833- Enteral Nutrition- Policy Article, Effective 09/05/2021; Revised 10/01/2023 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 23. HCPCS Level II Codebook", "codes": [ "B4034", "B4035", "B4036", "B4081", "B4082", "B4083", "B4087", "B4088", "B4149", "B4150", "B4152", "B4153", "B4154", "B4155", "B4157", "B4158", "B4159", "B4160", "B4161", "B4162", "B9002" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d1fe1b4466f05c53dcf0e90a22e8bc1d821fb680a201afab9a48614e6b752aae", "raw_sha256": "beabac11549877c81229ffefb43e4293e53de043ef20dcae590d38228b709182", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0206", "issue_number": "0206", "title": "0206-Positron Emission Tomography (PET) for Initial Treatment Strategy in Oncologic Conditions: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Hospital Outpatient; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2021-05-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/894041311/0206-positron-emission-tomography-pet-initial-treatment-strategy-oncologic-conditions-medical", "source_id": "cms-rac-approved", "description": "Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) is covered only in clinical situations in which PET results may assist in avoiding an invasive diagnostic procedure, or in which the PET results may assist in determining the optimal location to perform an invasive procedure. PET would also be considered reasonable and necessary when clinical management of the patient would differ depending on the staging of the cancer identified, and in clinical situations in which the stage of the cancer remains in doubt after completing a standard diagnostic workup or it is expected that conventional imaging study information is insufficient for clinical management of the patient. Medical records will be reviewed to determine if the utilization of FDG PET studies for initial anti-tumor treatment strategy are medically necessary according to Medicare coverage indications.", "codes_text": "78608, 78811, 78812, 78813, 78814, 78815, 78816, A9552", "policy_text": "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 Benefit 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 §411.15 - Particular Services Excluded from Coverage, (k) - Any Services Not Reasonable and Necessary 8. National Coverage Determination Manual, Ch. 1, Part 4, §220.6.17 Positron Emission Tomography (PET) (FDG) for Oncologic Conditions 9. Medicare Claims Processing Manual, Ch. 13 - Radiology Services and Other Diagnostic Procedures, §60 – Positron Emission Tomography (PET) Scans - General Information; §60.1 - Billing Instructions, (D)- Post-Payment Review for PET Scans; §60.3.1 - Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005; §60.3.2 - Tracer Codes Required for Positron Emission Tomography (PET) Scans; §60.7 - Expanded Coverage of PET Scans Effective for Services on or After July 1, 2001 10. Medicare Claims Processing Manual, Ch. 13 – Radiology Services and Other Diagnostic Procedures, §60.16. A-Billing and Coverage Changes for PET Scans Effective for Services on or After April 3, 2009 https://www.cms.gov/medicare/coverage/determinationprocess/downloads/petforsolidtumorsoncologicdxcodesattachment_NCD220_6_17.pdf 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 12. Noridian LCA A54666: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023 13. Noridian LCA A54668: Billing and Coding Positron Emission Tomography Scans Coverage. Effective date 10/01/2015; Revised date 10/01/2023; Retired date 10/01/2023 14. Novitas LCA A53132: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 10/01/2015; Revised date 10/01/2021; Retired date 03/24/2022 15. First Coast Service Options, Inc LCA A58826: Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Oncologic Conditions. Effective date 04/01/2021; Revised date 10/01/2021; Retired date 03/24/2022 16. ICD-10-CM Diagnosis Codebook 17. AMA CPT Codebook 18. HCPCS Level II Codebook", "codes": [ "78608", "78811", "78812", "78813", "78814", "78815", "78816", "A9552" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "58d1d2d3a3f1ea1102717aa7dcbb1df1f4c42e808fb21d6d664f6810a9a1b3d0", "raw_sha256": "0720febdab3144fb5265c72d6e808d540e754e77332b43f132a6caeca401b9ec", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0205", "issue_number": "0205", "title": "0205-Next Generation Sequencing: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Laboratory", "jurisdiction": "All A/B MACs", "source_date": "2021-05-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1339267557/0205-next-generation-sequencing-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Next Generation Sequencing (NGS) as a diagnostic laboratory test is reasonable and necessary and covered nationally, when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all of the National Coverage Determination (NCD) requirements are met. The documentation will be reviewed to determine if NGS as a diagnostic laboratory test was medically necessary according to the indications in the NCD.", "codes_text": "0111U, 0022U, 0037U", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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 §410.32-Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions, (a)-Ordering diagnostic tests 8. Medicare National Coverage Determination (NCD) Manual, Chapter 1, Part 2- Coverage Determinations, §90.2-Next Generation Sequencing for Patients with Somatic (Acquired) and Germline (Inherited) Cancer; Effective: 01/27/2020; Implementation: 11/13/2020 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. U.S Food & Drug Administration- https://www.fda.gov/medical-devices/vitro-diagnostics/list-cleared-or-approved-companion-diagnostic-devices-vitro-and-imaging-tools 11. AMA CPT Codebook 12. Annual ICD-10-CM Manual", "codes": [ "0022U", "0037U", "0111U" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8364deca3d119e393630a7beebc20a7876c64ebc59d5a6d90696e151a7b3b046", "raw_sha256": "c9a784a3220afe8e2ed4aa90124531a184043c3fe32f67f11542aaddc0ccc828", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0204", "issue_number": "0204", "title": "0204-Vagus Nerve Stimulation: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2021-02-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/2000119920/0204-vagus-nerve-stimulation-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Vagus Nerve Stimulation (VNS) is reasonable and necessary for patients with medically refractory partial onset seizures for whom surgery is not recommended or for whom surgery has failed. VNS is not reasonable and necessary for all other types of seizure disorders which are medically refractory and for whom surgery is not recommended or for whom surgery has failed. VNS is reasonable and necessary for treatment-resistant depression through Coverage with Evidence Development (CED). VNS for treatment of resistant depression is non-covered when furnished outside of a CMS-approved CED study. Medical documentation will be reviewed to determine if the vagus nerve stimulator meets Medicare coverage criteria and/or is reasonable and necessary.", "codes_text": "64568, 95976, 95977, C1827", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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 National Coverage Determination (NCD) Manual, Chapter 1-Coverage Determinations, §160.18- Vagus Nerve Stimulation (VNS) 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 32- Billing Requirements for Special Services, §200- Billing Requirements for Vagus Nerve Stimulation (VNS) ); §200.2 – ICD-10 Diagnosis Codes for Vagus Nerve Stimulation 10. Vagus Nerve Stimulation (VNS) for Treatment Resistant Depression (TRD) https://www.cms.gov/Medicare/Coverage/Coverage-with-Evidence-Development/VNS 11. AMA CPT Codebook", "codes": [ "64568", "95976", "95977", "C1827" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "eba773bacc88ce08567847b4a4161eae98e961845085a102503b4ff247ea63d7", "raw_sha256": "324869dc7a7eadd28135ca63136b369f20d1e796625dd7f6d5d4fc4db4d3a561", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0202", "issue_number": "0202", "title": "0202- Skilled Nursing Facility (SNF) Consolidated Billing for Ambulance Transports: Unbundling", "review_type": "Automated", "provider_type": "Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2021-01-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/372806127/0202-skilled-nursing-facility-snf-consolidated-billing-ambulance-transports-unbundling", "source_id": "cms-rac-approved", "description": "Certain ambulance services are included in SNF consolidated billing and may not be billed as Part B services to the A/B MAC, when the beneficiary is in a Part A stay.", "codes_text": "A0426, A0427, A0428, A0429, A0434, A0425", "policy_text": "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. 42 CFR § 409.27(c) – Other services generally provided by (or under arrangements made by) SNFs 8. Medicare Claims Processing Manual, Chapter 6 – SNF Inpatient Part A Billing, §20.3.1 - Ambulance Services 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. General Explanation of the Major Categories I. – V. for Skilled Nursing Facility (SNF) Consolidated Billing – https://www.cms.gov/files/document/09majorcatexplpdf 11. SNF Consolidated Billing - https://www.cms.gov/medicare/coding-billing/skilled-nursing-facility-snf-consolidated-billing 12. HCPCS Level II Codebook", "codes": [ "A0425", "A0426", "A0427", "A0428", "A0429", "A0434" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "e05eda51aaa8a05fc56374349a1aab011b07ee66f0a6261bb649b3951ea7145e", "raw_sha256": "4d9670d24732480b4819b88e423181d82f290a4bf9ef7517646aafb26b1d7cc5", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0201", "issue_number": "0201", "title": "0201-Hospice Continuous Home Care: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Hospice", "jurisdiction": "All HHH MACs", "source_date": "2021-01-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1781035297/0201-hospice-continuous-home-care-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if hospice Continuous Home Care services were reasonable and necessary to achieve palliation and management of the patient’s acute medical symptoms to maintain the terminally ill patient at home, based on the documentation in the medical record.", "codes_text": "REV Codes 0652 HCPCS G0299, G0300, G0156", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1812(a)(4), (a)(5), and (d)- Scope of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1813(a)(4)(A)- Deductibles and Coinsurance 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1814(a)(7)- Conditions of and Limitations on Payment for Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1814(i)(1)(A)- Payment for Hospice Care 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1815(a) and (e)(2)(D)- Payment to Providers of Services 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1833(e)- Payment of Benefits 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1861(u)- Provider of Services and (dd)- Hospice Care; Hospice Program 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1862(a)(1)(A) and (a)(1)(C)- Exclusions from Coverage and Medicare as Secondary Payer 9. 42 CFR §405.929- Post-Payment Review 10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 11. 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 12. 42 CFR §405.986 - Good Cause for Reopening 13. 42 CFR § 411.15(k)(2) - Particular Services Excluded from Coverage 14. 42 CFR § 418.22 - Certification of terminal illness 15. 42 CFR § 418.24 - Election of hospice care 16. 42 CFR § 418.56 Condition of participation: Interdisciplinary group, care planning, and coordination of services 17. 42 CFR, § 418.204(a) Special coverage requirements; Periods of crisis. 18. 42 CFR, § 418.302 - Payment, Procedures for hospice care. 19. 42 CFR, § 424.5(a)(6) – Basic Conditions, Sufficient Information 20. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 - Physician Certification and Recertification of Services, § 60- Certification and Recertification by Physicians for Hospice Care 21. Medicare General Information, Eligibility and Entitlement Manual, Chapter 5 - Definitions, Section 60 - Hospice Defined 22. Medicare Benefit Policy Manual, Chapter 9, §§10- Requirements—General; 20- Certification and Election Requirements; 40- Benefit Coverage; 50- Limitation on Liability for Certain Hospice Coverage Denials; 80- Hospice Pre-election evaluation and counseling services. 23. Medicare Claims Processing Manual, Chapter 11- Processing Hospice Claims 24. Medicare Claims Processing Manual, Chapter 30 - Financial Liability Protections, §Section 50- Advance Beneficiary Notice of Non-coverage (ABN) 25. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1- 3.6.6 26. CGS Administrators, LLC, LCD L34538- Hospice Determining Terminal Status; Effective 10/01/2015; Revised 08/07/2025. 27. National Government Services, Inc., LCD L33393 Hospice Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019. 28. National Government Services, Inc., LCA A52830 Billing and coding: Hospice: Determining Terminal Status; Effective 10/01/2015; Revised 11/14/2019 29. CMS Transmittal 13664, Change Request (CR) 14384 (effective 10/01/2025): Manual Updates Adding language to the Timing and Content of Certification, Revocation and Discharge Guidance, and Hospice Election 30. CMS, Hospice: CMS Flexibilities to Fight Covid-19, Revised 05/10/2023. Hospice: CMS Flexibilities to Fight COVID-19 31. HCPCS Level II Codebook", "codes": [ "G0156", "G0299", "G0300" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "6ce3d035bf8ee44d3ff4535194462ebcf4343cf3813406015552d403453ddb96", "raw_sha256": "c1a860415724b90e318586845651ce2954543869d37ac99d2ffcda1705727a1f", "texas": "unresolved", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0200", "issue_number": "0200", "title": "0200-Air Ambulance: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2021-01-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1180351415/0200-air-ambulance-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This complex review will be examining rotatory wing (helicopter) aircraft claims or fixed wing (airplane) claims to determine if air ambulance transport was reasonable and medically necessary as well as whether documentation requirements have been met.", "codes_text": "A0430, A0431, A0435, A0436", "policy_text": "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)(7)- Medical and Other Health Services 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 (I)(14)- Establishment of Fee Schedule for Ambulance Services 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.40- Coverage of ambulance services, (c) Levels of service; (e) Medical necessity requirements 10. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements. 11. 42 CFR §414.605 Definitions 12. 42 CFR §414.610 Basis of Payment 13. 42 CFR §424.36- Signature Requirements 14. 42 CFR §424.37- Evidence of Authority to Sign on behalf of the Beneficiary 15. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information 16. Medicare Benefit Policy Manual (MBPM), Chapter 10- Ambulance Services, §10.4 Air Ambulance Services, §20.1.2 Beneficiary Signature Requirements, §30.1.2 Air Ambulance Services Medicare Claims Processing Manual 17. Medicare Claims Processing Manual (MCPM), Chapter 15- Ambulance, §20.3 Air Ambulance 18. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 19. HCPCS Level II Codebook", "codes": [ "A0430", "A0431", "A0435", "A0436" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "1310f4dee5a7b8afa92fe4a26f174622a244b59fc27accf87c27963eea37e572", "raw_sha256": "885efc101bb3ffb63bcaf1d0654ece7a6bb21a4a132cd692dc3e89b4456c2f24", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0198", "issue_number": "0198", "title": "0198-Deep Brain Stimulation- Inpatient Procedure: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient", "jurisdiction": "All A/B MACs", "source_date": "2020-11-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/67902966/0198-deep-brain-stimulation-inpatient-procedure-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Deep brain stimulation (DBS) is an established treatment for people with movement disorders, such as essential tremor, Parkinson's disease and dystonia. DBS involves implanting electrodes within certain areas of the brain; these electrodes produce electrical impulses that regulate abnormal impulses within the brain. The amount of stimulation is controlled by a pacemaker-like device placed under the skin in the chest and connects to the electrodes in the brain. Medicare will consider DBS to be reasonable and necessary for the treatment of Parkinson’s disease under certain conditions.", "codes_text": "00H03MZ, 00H04MZ, 00H60MZ, 00H63MZ, 00H64MZ, 0H85XZZ, 0JQ60ZZ, 0JQ63ZZ, 00H00MZ, 0H80XZZ, 0HSSXZZ", "policy_text": "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 National Coverage Determinations Manual, Chapter 1, Part 2, §160.24 - Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease 8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §50 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease; §50.1- Coverage Requirements; §50.2.1- - Part A Intermediary Billing Procedures; §50.4.1- Allowable Covered Diagnosis Codes (effective 01/29/2024); §50.4.2- Allowable Covered Procedure Codes 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AHA ICD-10-PCS Procedure Codebook 11. AHA ICD-10-CM Diagnosis Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "92e2f4eb4da776fbeaba1eac0ffe0d91d4777f4834d43153a38bf4b9a47b8f7d", "raw_sha256": "81e4547698c8faa9ffb818cf92f92ad5d368b0279808c4841aa2b81fc5ecde1a", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0196", "issue_number": "0196", "title": "0196-Deep Brain Stimulation- Outpatient Procedure: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2020-11-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1629765189/0196-deep-brain-stimulation-outpatient-procedure-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Deep brain stimulation (DBS) is an established treatment for people with movement disorders, such as essential tremor, Parkinson's disease and dystonia. DBS involves implanting electrodes within certain areas of the brain; these electrodes produce electrical impulses that regulate abnormal impulses within the brain. The amount of stimulation is controlled by a pacemaker-like device placed under the skin in the chest and connects to the electrodes in the brain. Medicare will consider whether the initial placement of Deep Brain Stimulation is reasonable and necessary for the treatment of Parkinson’s disease and Essential Tremor, under certain conditions.", "codes_text": "61885, 61886, 95970, 95971, 95972, 95973, 95983, 95984", "policy_text": "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 National Coverage Determinations Manual, Chapter 1, Part 2, §160.24 - Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease 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 32- Billing Requirements for Special Services, §50 Deep Brain Stimulation for Essential Tremor and Parkinson’s Disease; §50.1- Coverage Requirements; §50.2- Billing Requirements; §50.4.3- Healthcare Common Procedure Coding System (HCPCS) 10. AMA CPT Codebook", "codes": [ "61885", "61886", "95970", "95971", "95972", "95973", "95983", "95984" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d59ec617e8a9617184f691e152d8a759c0d95f13d72690e335c59ab46296b138", "raw_sha256": "9a868943da8988d5bade22b6358df73c9301725078daf3069d9f5e048473ce47", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0195", "issue_number": "0195", "title": "0195-Implantable Automatic Defibrillators- Inpatient Procedure: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2020-10-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/290097877/0195-implantable-automatic-defibrillators-inpatient-procedure-medical-necessity-and-documentation", "source_id": "cms-rac-approved", "description": "The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications.", "codes_text": "0JH608Z, 0JH609Z, 0JH638Z, 0JH639Z, 0JH808Z, 0JH809Z, 0JH838Z, 0JH839Z", "policy_text": "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 National Coverage Determinations (NCD) Manual: Chapter 1 – Coverage Determinations, Part 1, §20.4- Implantable Cardioverter Defibrillators (ICDs) 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 32- Billing Requirements for Special Services, §270- Claims Processing for Implantable Automatic Defibrillators; §270.1- Coding Requirements for Implantable Automatic Defibrillators; §270.2- Billing Requirements for Patients Enrolled in a Data Collection System 10. CGS Local Coverage Article A57994- Billing and Coding: Implantable Automatic Defibrillators; Effective 01/01/2021; Revised 11/22/2023 11. First Coast Local Coverage Article A56341- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Retired 7/6/2021 12. NGS Local Coverage Article A56326- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 3/03/2023 13. Noridian Local Coverage Article A56340- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 7/31/2023 14. Noridian Local Coverage Article A56342- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 7/31/2023 15. Novitas Local Coverage Article A56355- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Retired 7/6/2021 16. Palmetto Local Coverage Article: A56343- Billing and Coding: Implantable Automatic Defibrillators; Effective 3/26/2019; Revised 10/01/2023 17. WPS Local Coverage Article A56391- Billing and Coding: Implantable Automatic Defibrillators; Effective 5/13/2019; Revised 10/01/2023 18. ICD-10 Clinical Modification (ICD-10-CM) and ICD-10- Procedural Coding System (PCS) (ICD-10-PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "625b51fbb4fe63b9fa522dfb80db01e2ad3faf013507bbc85f0617eff13b8915", "raw_sha256": "0f780a6af7d5d2d30fff63e115f9d8ca1c6f53ee0cf8d069d044cb9e102a46f3", "texas": "national", "specialties": [ "Cardiology", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0192", "issue_number": "0192", "title": "0192-Ventricular Assist Device: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2020-09-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/110509641/0192-ventricular-assist-device-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "A ventricular assist device (VAD) is surgically attached to one or both intact ventricles and is used to assist or augment the ability of a damaged or weakened native heart to pump blood. The documentation will be reviewed to determine if initial insertion of a left ventricular assist device (LVAD) was placed for a Medicare-covered indication.", "codes_text": "02HA0QZ, 02HA0RJ, 02HA0RS, 02HA0RZ, 02HA3QZ, 02HA3RJ, 02HA3RS, 02HA3RZ, 02HA4QZ, 02HA4RJ, 02HA4RS, 02HA4RZ", "policy_text": "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 National Coverage Determinations (NCD) Manual, Chapter 1- Coverage Determinations, §20.9.1 - Ventricular Assist Devices (VADs) 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 32- Billing Requirements for Special Services, §320.3-§320.3.2- Ventricular Assist Devices (VADs) 10. AMA CPT Codebook 11. CMS ICD-10 PCS: https://www.cms.gov/medicare/coding-billing/icd-10-codes", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "255b8e023efc6793d3993288fcab3ef7a821a2896abe3bae3c474e3df5e60e60", "raw_sha256": "501f5553ec87dd545f1072a62985de26f9d60c71b81dafb2bff40194c79bb7d8", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0191", "issue_number": "0191", "title": "0191- Polysomnography: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2020-09-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1892898572/0191-polysomnography-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if polysomnography is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "95808, 95810, 95811", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 3. 42 CFR §405.929- Post-Payment Review 4. 42CFR §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 §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 8. Medicare National Coverage Determination Manual, Chapter 1, Part 4, §240.4.1- Sleep Testing for Obstructive Sleep Apnea (OSA) 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §70.B- Medical Conditions for Which Testing is Covered; §70.C- Polysomnography for Chronic Insomnia Is Not Covered 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6 12. CGS Administrators, LLC, LCD L36902- Polysomnography and Other Sleep Studies; Effective 3/6/2017; Revised 02/27/25 13. CGS Administrators, LLC, LCA A57049- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 9/26/2019; Revised 02/27/25 14. First Coast Service Options, Inc., LCD L33405- Polysomnography and Sleep Testing; Effective 10/01/2015; Revised 7/01/2020 15. First Coast Service Options, Inc., LCA A57496- Billing and Coding: Polysomnography and Sleep Testing; Effective 10/03/2018; Revised 5/16/2024 16. Noridian Healthcare Solutions, LLC, LCD L34040- Polysomnography and Other Sleep Studies; Effective 10/01/2015; Revised 12/01/2019 17. Noridian Healthcare Solutions, LLC, LCD L36861- Polysomnography and Other Sleep Studies; Effective 06/05/2017; Revised 12/01/2019 18. Noridian Healthcare Solutions, LLC, LCA A57697- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019 19. Noridian Healthcare Solutions, LLC, LCA A57698- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 12/01/2019 20. Novitas Solutions, Inc., LCD L35050- Outpatient Sleep Studies; Effective 10/01/2015; Revised 01/01/2021 21. Novitas Solutions, Inc., LCA A56923- Billing and Coding: Outpatient Sleep Studies; Effective 9/12/2019; Revised 01/01/2023 22. Palmetto GBA, LCD L36593- Polysomnography; Effective 6/13/2016; Revised 03/20/25 23. Palmetto GBA, LCA A56995- Billing and Coding: Polysomnography; Effective 9/12/2019; Revised 03/07/2024 24. WPS, LCD L36839- Polysomnography and Other Sleep Studies; Effective 2/16/2017; Revision effective 07/27/2023 25. WPS, LCA A56903- Billing and Coding: Polysomnography and Other Sleep Studies; Effective 8/29/2019; Revised 07/27/2023 26. National Government Services, Inc., LCA A53019- Polysomnography and Sleep Studies- Medical Policy Article; Effective 10/01/2015; Revised 10/31/2019 27. AMA CPT Codebook", "codes": [ "95808", "95810", "95811" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b1e30da2a0b3d914d4e3ebe0f09e5b59d53134b1375c2d3ba266eaa785df9d7a", "raw_sha256": "6eacd561b8c67c4d75f4959a2ffd0859af7289ddd25f848ce48c13dceeb839f3", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0190", "issue_number": "0190", "title": "0190-Skilled Nursing Facility with Patient-Driven Payment Model: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "SNF", "jurisdiction": "All A/B MACs", "source_date": "2020-09-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/753511782/0190-skilled-nursing-facility-patient-driven-payment-model-medical-necessity-and-documentation", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if the Skilled Nursing Facility stay meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.", "codes_text": "TOB 21X", "policy_text": "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 1814(a)(2)- Conditions of and Limitations on Payment for Services 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 CFR §409.30- Basic Requirements 9. 42 CFR §409.31- Level of care requirement 10. 42 CFR §409.32- Criteria for skilled services and the need for skilled services 11. 42 CFR §409.33- Examples of skilled nursing and rehabilitation services 12. 42 CFR §409.34- Criteria for “daily basis” 13. 42 CFR §409.35- Criteria for “practical matter” 14. 42 CFR §409.36- Effect of discharge from posthospital SNF care 15. 42 CFR §411.15(p)- Services furnished to SNF residents 16. 42 CFR §413.337- Methodology for calculating the prospective payment rates 17. 42 CFR §413.343- Resident Assessment data 18. 42 CFR §424.5(a)(6) – Basic conditions 19. 42 CFR §424.11(b)- Obtaining the certification and recertification statements 20. 42 CFR §424.20- Requirements for posthospital SNF care 21. 42 CFR §483.20- Resident assessment 22. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, §40- Certification and Recertification by Physicians for Extended Care Services 23. Medicare Benefit Policy Manual, Chapter 8- Coverage of Extended Care (SNF) Services Under Hospital Insurance, §20- Prior Hospitalization and Transfer Requirements, §30- Skilled Nursing Facility Level of Care- General, §40- Physician Certification and Recertification for Extended Care Services 24. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §220.1.3- Certification and Recertification of Need for Treatment and Therapy Plans of Care 25. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §30- Billing SNF PPS Services; §120- Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) 26. Medicare Claims Processing Manual, Chapter 25- Completing and Processing the Form CMS-1450 Data Set 27. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 28. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.1- Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Claims; §6.1.4- Medical Review Process; §6.3 Medical Review of Certification and Recertification of Residents in SNFs 29. MDS 3.0 RAI Manual, October 2019 (on or before 09/30/2023) 30. MDS 3.0 RAI Manual, version 1.18.11 v5, October 2023 (on or after 10/01/2023) 31. CMS.gov Minimum Data Set (MDS) 3.0 Technical Information: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation 32. ICD-10-CM Official Guidelines for Coding and Reporting", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "81523dd1bc546d2bbddd223e279365c700ed088382e3b0fbcb1195cdfa50b01d", "raw_sha256": "a57362767811bee1d73c4f18564b198db5372b629a4908e08670bcaeb50ff36d", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0189", "issue_number": "0189", "title": "0189-Continuous Glucose Monitor: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2020-09-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/828750808/0189-continuous-glucose-monitor-supplies-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if a therapeutic continuous glucose monitor meets coverage criteria and/or is medically reasonable and necessary.", "codes_text": "K0554, K0553", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 19. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 20. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §40.2 Home Blood Glucose Monitors 21. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §190.20- Blood Glucose Testing 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 10/01/2024 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464- Glucose Monitor- Policy Article; Effective 10/01/2015; Revised 02/18/2025 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 25. HCPCS Level II Codebook", "codes": [ "K0553", "K0554" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "cbd327b2652590b489efdb9b62bbe0734eb802c7f9ecaa2d51fc55ec5e217efb", "raw_sha256": "06146c5ca12d202b1054b26d9eb6454f7799e0756569c7222c85c5a8c0a2acc3", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0187", "issue_number": "0187", "title": "0187-Nerve Conduction Studies: Excessive Units", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2020-09-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1146164386/0187-nerve-conduction-studies-excessive-units", "source_id": "cms-rac-approved", "description": "Medical documentation will be reviewed to determine if the use of nerve conduction studies meets Medicare coverage criteria and is reasonable and necessary.", "codes_text": "95905, 95907, 95908, 95909, 95910, 95911, 95912, 95913", "policy_text": "1. 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. SSA, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 3. 42 Code of Federal Regulations (CFR) §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 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 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening 8. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.23- Sensory Nerve Conduction Threshold Tests (sNCTs) 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80- Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. CGS, Local Coverage Determination L35897- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 05/01/2025 12. First Coast Local Coverage Determination L34859- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 12/10/2023 13. NGS, Local Coverage Determination L35098- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 11/21/2019 14. Noridian Healthcare Solutions, LLC, Local Coverage Determination L36524- Nerve Conduction Studies and Electromyography; Effective: 06/01/16; Revised 12/01/2019 15. Noridian Healthcare Solutions, LLC, Local Coverage Determination L36526- Nerve Conduction Studies and Electromyography; Effective: 06/01/2016; Revised 12/01/2019 16. Novitas Solutions, Inc., Local Coverage Determination L35081- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 12/10/2023 17. Palmetto GBA Local Coverage Determination L35048- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 11/16/2023 18. WPS Local Coverage Determination L34594- Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 05/29/2025 19. CGS, Local Coverage Article A57307- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 9/26/2019; Revised 05/08/2025 20. First Coast Local Coverage Article A57123- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/03/2018; Revised 01/01/2025 21. First Coast Local Coverage Article A56035- Nerve Conduction Studies and Electromyography- Revision to the Part A and Part B LCD; Effective: 5/31/2018, Retired 09/24/2021 22. NGS, Local Coverage Article A57668- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 11/21/2019; Revised 01/01/2025 23. Noridian Healthcare Solutions, LLC, Local Coverage Article A54969- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/01/2016; Revised 01/01/2025 24. Noridian Healthcare Solutions, LLC, Local Coverage Article A54992- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/01/2016; Revised 01/01/2025 25. Novitas Solutions, Inc., Local Coverage Article A54095- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/01/2015; Revised 01/01/2025 26. Palmetto GBA Local Coverage Article A56619- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 6/13/2019; Revised 01/01/2025 27. WPS Local Coverage Article A57478- Billing and Coding: Nerve Conduction Studies and Electromyography; Effective: 10/31/2019; Revised 05/29/2025 28. AMA CPT Codebook", "codes": [ "95905", "95907", "95908", "95909", "95910", "95911", "95912", "95913" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "be8c0c28a47f0059e0738fd0b14f146abed4069877456c9b3aa4017d12b42c4e", "raw_sha256": "34ec61527bd13cf6f4c3bced912285c918df9c897eadd94012aaa1d6b767ade3", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0186", "issue_number": "0186", "title": "0186-Duplex Scans of Extracranial Arteries: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "J5, J6, J8, J15, JH, JK, JL, JN (JE, JF, JJ, JM are excluded)", "source_date": "2020-08-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0a225-duplex-scans-extracranial-arteries-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if a duplex scan of the extracranial arteries reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied.", "codes_text": "93880, 93882", "policy_text": "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. 42 CFR §410.32(a)- Ordering Diagnostic Tests 8. 42 CFR §410.32(b)- Diagnostic x-ray and other diagnostic tests 9. 42 CFR §410.33- Independent Diagnostic Testing Facility 10. National Coverage Determinations Manual, Chapter 1, Part 1, §20.17- Noninvasive Tests of Carotid Function 11. National Coverage Determinations Manual, Chapter 1, Part 4, §220.5- Ultrasound Diagnostic Procedures 12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80- Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests 13. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §10.1 - Billing Part B Radiology Services and Other Diagnostic Procedures 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.1 –3.6 .6 15. CGS LCD L34045: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 11/02/2023 16. First Coast LCD L33695: Non-Invasive Extracranial Arterial Studies; Effective 10/01/2015; Revised 01/08/2019 17. NGS LCD L33627: Non-Invasive Vascular Studies; Effective 10/01/2015; Revised 10/01/2019 18. Novitas LCD L35397: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 10/17/2019 19. WPS LCD L35753: Non-Invasive Cerebrovascular Studies; Effective 10/01/2015; Revised 10/26/2023 20. CGS LCA A56697: Billing and Coding: Non-Invasive Vascular Studies; Effective 07/11/2019; Revision Effective: 01/01/2024 21. First Coast LCA A57670: Billing and Coding: Non-Invasive Extracranial Arterial Studies; Effective 10/03/2018 22. NGS LCA A56758: Billing and Coding: Non-Invasive Vascular Studies; Effective 08/01/2019; Revised: 10/01/2023 23. Novitas LCA A52992: Billing and Coding: Non-invasive Cerebrovascular Arterial Studies; Effective 10/01/2015; Revised 8/02/2019 24. WPS LCA A57592: Billing and Coding: Non-Invasive Cerebrovascular Studies; Effective 11/01/2019; Revised 10/01/2023 25. AMA CPT Codebook", "codes": [ "93880", "93882" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "40fd6edb76b62b2d5df1b4fe68ab2828429f4976904f1553defa161b6221eeb9", "raw_sha256": "e53052b4a04f97330abe8a7d2320545749466fdbad7c682549b836c37a72f768", "texas": "conditional", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0185", "issue_number": "0185", "title": "0185-Total Knee Arthroplasty: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center, Professional Services", "jurisdiction": "J5, J6, J8, JE, JF, JH, JJ, JK, JL, JM, JN, J15", "source_date": "2020-08-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/2a233-total-knee-arthroplasty-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "For purposes of coverage under Medicare, Total Knee Arthroplasty (TKA), also referred to as a joint replacement, has proven to be an important medical advancement. Knee Arthroplasty is most commonly performed for diseases which affect the function of the knee joint (the lower end of the femur, the upper end of the tibia and patella). Occasionally, there may be a need to redo a TKA, often referred to as a revision total knee. In revisional surgery it is important to provide replacement of the components of the previous surgery responsible for the failure. The goal of total knee replacement surgery is to relieve pain and improve or increase functional activity of the beneficiary. This review only focuses on total (involving the entire joint) knee arthroplasties. The documentation will be reviewed to determine if a TKA is medically necessary according to the guidelines outlined in the LCDs and LCAs of FCSO, Novitas, NGS, Palmetto GBA, and Noridian.", "codes_text": "CPT Codes- 27445, 27446 (CGS only), 27447, 27486, 27487 PCS Codes (FCSO ONLY) - 0SPC0JZ, 0SPD0JZ, 0SRC069, 0SRC06A, 0SRC06Z, 0SRC07Z, 0SRC0EZ, 0SRC0J9, 0SRC0JA, 0SRC0JZ, 0SRC0M9, 0SRC0MA, 0SRC0MZ, 0SRC0N9, 0SRC0NA, 0SRC0NZ, 0SRD0EZ, 0SRD0M9, 0SRD0MA, 0SRD0MZ, 0SRD0N9, 0SRD0NA, 0SRD0NZ, 0SRC0KZ, 0SRD069, 0SRD06A, 0SRD06Z, 0SRD07Z, 0SRD0J9, 0SRD0JA, 0SRD0JZ, 0SRD0KZ, 0SRT07Z, 0SRT0J9, 0SRT0JA, 0SRT0JZ, 0SRT0KZ, 0SRU07Z, 0SRU0J9, 0SRU0JA, 0SRU0JZ, 0SRU0KZ, 0SRV07Z, 0SRV0J9, 0SRV0JA, 0SRV0JZ, 0SRV0KZ, 0SRW07Z, 0SRW0J9, 0SRW0JA, 0SRW0JZ, 0SRW0KZ, 0SWC0JZ, 0SWD0JZ", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators LLC, LCD L40232-Total Joint Arthroplasty; Effective 03/15/2026 9. CGS Administrators LLC, LCA A60250-Billing and Coding: Total Joint Arthroplasty; Effective 03/15/2026 10. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019 11. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 01/01/2026 12. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019 13. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 08/08/2019; Revised 01/01/2026 14. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019 15. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 01/01/2026 16. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023 17. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 01/01/2026 18. Noridian Healthcare Solutions, LLC, LCD L36575- Total Knee Arthroplasty; Effective 9/7/2016; Revised 11/06/2025 19. Noridian Healthcare Solutions, LLC, LCA A57685- Billing and Coding: Total Knee Arthroplasty; Effective 01/01/2026 20. Noridian Healthcare Solutions, LLC, LCD L36577- Total Knee Arthroplasty; Effective 9/7/2016; Revised 12/01/2019; Retired 11/06/2025 21. Noridian Healthcare Solutions, LLC, LCA A57686- Billing and Coding: Total Knee Arthroplasty; Effective 12/01/2019 ; Retired 11/06/2025 22. Wisconsin Physicians Service (WPS) Insurance Corporation, LCD L39911: Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025 23. Wisconsin Physicians Service (WPS) Insurance Corporation, LCA A59811: Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024; Revised 01/01/2026 24. AMA CPT Codebook 25. AHA ICD-10-PCS Procedure Codebook", "codes": [ "27445", "27446", "27447", "27486", "27487" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "72a646d740f04072543cd79d54f95e8330dab1263b44df00344b62c320311821", "raw_sha256": "49498d907497cea8f67d05a1c0deb13a0b1079be80f5bf66209e620591e90342", "texas": "texas", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0184", "issue_number": "0184", "title": "0184-Total Hip Arthroplasty: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital; Outpatient Hospital; Professional Services; Ambulatory Surgical Center", "jurisdiction": "J5, J6, J8, JE, JF, JH, JJ, JK, JL, JM, JN, J15", "source_date": "2020-08-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/2a232-total-hip-arthroplasty-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if total hip arthroplasty meets Medicare coverage requirements.", "codes_text": "27130, 27132, 27134, 27137, 27138 (FCSO, NGS, Novitas, Palmetto, Noridian, WPS, and CGS)) PCS Codes (FCSO ONLY) - 0SP90JZ, 0SPB0JZ, 0SR9019, 0SR901A, 0SR901Z, 0SR9029, 0SR902A, 0SR902Z, 0SR9039, 0SR903A, 0SR903Z, 0SR9049, 0SR904A, 0SR904Z, 0SR9069, 0SR906A, 0SR906Z, 0SR907Z, 0SR90EZ, 0SR90J9, 0SR90JA, 0SR90JZ, 0SR90KZ, 0SRB019, 0SRB01A,0SRB01Z, 0SRB029, 0SRB02A, 0SRB02Z, 0SRB039, 0SRB03A, 0SRB03Z, 0SRB049, 0SRB04A, 0SRB04Z, 0SRB069, 0SRB06A, 0SRB06Z, 0SRB07Z, 0SRB0EZ, 0SRB0J9, 0SRB0JA, 0SRB0JZ, 0SRB0KZ, 0SW90JZ, 0SWB0JZ", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators LLC, LCD L40232-Total Joint Arthroplasty; Effective 03/15/2026 9. CGS Administrators LLC, LCA A60250-Billing and Coding: Total Joint Arthroplasty; Effective 03/15/2026 10. First Coast Service Options, Inc., LCD L33618- Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 01/8/2019 11. First Coast Service Options, Inc., LCA A57765- Billing and Coding: Major Joint Replacement (Hip and Knee); Effective 10/03/2018; Revised 01/01/2026 12. Novitas Solutions, Inc., LCD L36007- Lower Extremity Major Joint Replacement (Hip and Knee); Effective 10/01/2015; Revised 11/14/2019 13. Novitas Solutions, Inc., LCA A56796- Billing and Coding: Lower Extremity Major Joint Replacement (Hip and Knee); Effective 8/8/2019; Revised 01/01/2026 14. National Government Services, Inc., LCD L36039-Total Joint Arthroplasty; Effective 12/01/2015; Revised 10/10/2019 15. National Government Services, Inc., LCA A57428- Billing and Coding: Total Joint Arthroplasty; Effective 10/10/2019; Revised 01/01/2026 16. Palmetto GBA, LCD L33456-Total Joint Arthroplasty; Effective 10/01/2015; Revised 6/15/2023 17. Palmetto GBA, LCA A56777- Billing and Coding: Total Joint Arthroplasty; Effective 8/01/2019; Revised 01/01/2026 18. Noridian Healthcare Solutions, LLC, LCD L34163- Total Hip Arthroplasty; Effective 10/01/2015; Revised 11/06/2025 19. Noridian Healthcare Solutions, LLC, LCD L36573- Total Hip Arthroplasty; Effective 9/7/2016; Revised 12/01/2019; Retired 11/06/2025 20. Noridian Healthcare Solutions, LLC, LCA A57683- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019; Revised 11/06/2025 21. Noridian Healthcare Solutions, LLC, LCA A57684- Billing and Coding: Total Hip Arthroplasty; Effective 12/01/2019; Retired 11/06/2025 22. Wisconsin Physicians Service Insurance Corp., LCD L39911 - Total Joint Arthroplasty; Effective 10/13/2024; Revised 02/28/2025 23. Wisconsin Physicians Service Insurance Corp., LCA A59811 - Billing and Coding: Total Joint Arthroplasty; Effective 10/13/2024; Revised 01/01/2026 24. AMA CPT Codebook 25. ICD-10-PCS Procedure Codebook", "codes": [ "27130", "27132", "27134", "27137", "27138" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "7a3dbfbd8d8166195a91006cdf3dfa2a63c53f87da7ab24f99caf086fc642269", "raw_sha256": "3642b08819a73a9073d341734e4ac4230a034c9f350230d296d5df62fe7efe0b", "texas": "texas", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0183", "issue_number": "0183", "title": "0183-Specialty Care Transport: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2020-08-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0a221-specialty-care-transport-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Medical documentation for SCT will be reviewed to determine the Medicare defined conditions have been met for payment.", "codes_text": "A0434, A0425", "policy_text": "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. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions, (c) Levels of service, and (e)(1) and (3) Medical necessity requirements 8. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements. 9. 42 CFR §414.605 Definitions 10. 42 CFR §414.610 Basis of Payment 11. 42 CFR §424.36- Signature Requirements 12. 42 CFR §424.37- Evidence of Authority to Sign In on behalf of the Beneficiary 13. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. Medicare Benefit Policy Manual (MBPM), Chapter 10 Ambulance Services, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services 16. Medicare Claims Processing Manual, Chapter 15 Ambulance, §10.2 Summary of the Benefit; §30 General Billing Guidelines, (A) Modifiers Specific to Ambulance Service Claims and (B) HCPCS Codes 17. HCPCS Level II Codebook", "codes": [ "A0425", "A0434" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "bba417eaec65a84c9e3bc35656c5a5807d528cd50a73abcfc6e52363f508eafd", "raw_sha256": "8415ce1d14767a7a35e3aedba5acdfe729d5845d81033b9e9e59c24497a0f88e", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0182", "issue_number": "0182", "title": "0182-Reduction of Technical Component, Diagnostic Cardiovascular Services", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2020-08-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1055468429/0182-reduction-technical-component-diagnostic-cardiovascular-services", "source_id": "cms-rac-approved", "description": "CPT/HCPCS codes with a Multiple Procedure Indicator of “6” are subject to a 25% reduction of the Technical Component (TC) when multiple procedures are billed on the same date of service, for the same patient, by the same physician, on the same claim. Claims incorrectly processed will be re-priced with the 25% reduction and the overpaid amount will be recovered. If the CPT/HCPCS code has a Multiple Procedure Indicator of ‘6’ then 75% of the TC portion (codes with an Indicator of ‘1’) will be allowed and if the PC/TC Indicator is ‘3’ (TC only codes) 75% of the Full Fee Schedule for that code will be allowed.", "codes_text": "CPT/HCPCS Codes with a multiple procedure indicator of “6” (Diagnostic cardiovascular services subject to the MPPR methodology) per the Medicare Physician Fee Schedule (indicated under the “Multiple Procedure” column)", "policy_text": "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 23- Fee Schedule Administration and Coding Requirements, §30.2 - MPFSDB Record Layout 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. CMS.gov - Multiple Procedure Payment Reduction File (based on the dates of service), Diagnostic Cardiovascular Services Subject to the Multiple Procedure Payment Reduction (MPPR) 10. MPFS (Medicare Physician Fee Schedule) Relative Value Files- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files 11. AMA CPT Codebook 12. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ea3c45229c92a5355691575dcfcf1ffd54b51a9102c75f11100b3085897bd63c", "raw_sha256": "576c94412fc0f7102ef92f05cc1f9dd842072bd1ea3739c6ebc2e615cf1880be", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0178", "issue_number": "0178", "title": "0178-Manual Wheelchairs: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2020-02-04", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0178-manual-wheelchairs-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine whether a Manual Wheelchair is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "K0001, K0002, K0003, K0004, K0005, K0006, K0007", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determination Manual, Chapter 1- Coverage Determinations, Part 4, 280.3- Mobility Assistive Equipment (MAE) 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33788- Manual Wheelchair Bases, Effective 10/01/2015; Revised 01/01/2020 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52497- Manual Wheelchair Bases- Policy Article, Effective 10/01/2015; Revised 07/01/2024 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024", "codes": [ "K0001", "K0002", "K0003", "K0004", "K0005", "K0006", "K0007" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d6c4792ecaacac8a61db3409a7e14bfb2f2375e1423b22f0f5d7527ffa95b011", "raw_sha256": "53e757374215dccb57bb0f7bc7fcf2abaadd20bf2646ee0f4dec6b230ff4e422", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0177", "issue_number": "0177", "title": "0177-Hospital Beds: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2020-02-04", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0177-hospital-beds-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Hospital Beds must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined in Local Coverage Determination for Hospital Beds. Medical documentation will be reviewed to determine that services were reasonable and necessary.", "codes_text": "E0250, E0251, E0260, E0261, E0255, E0256, E0265, E0266, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0301, E0302 E0303, and E0304", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(m) 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 11. 42 CFR §410.78- Telehealth Services 12. 42 CFR §414.210(f)- Payment for Replacement of Equipment 13. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 14. 42 CFR §414.65- Payment for Telehealth Services 15. Medicare National Coverage Determination Manual, Chapter 1- Coverage Determinations, Part 4, 280.7- Hospital Beds 16. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 17. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 18. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 19. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service Prior to 10/12/2021) 21. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 22. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33820- Hospital Beds and Accessories, Effective 10/01/2015; Revised 1/01/2020 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Coverage Article A52508- Hospital Beds and Accessories- Policy Article, Effective 10/01/2015; Revised 1/01/2020 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020 (historical, for claims with Dates of Service prior to 01/01/2023) 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023", "codes": [ "E0250", "E0251", "E0255", "E0256", "E0260", "E0261", "E0265", "E0266", "E0290", "E0291", "E0292", "E0293", "E0294", "E0295", "E0296", "E0297", "E0301", "E0302", "E0303", "E0304" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "065ecc73495b07fb6239df7d6640c1efeeaf9c929405ea59c118c9da9defc53c", "raw_sha256": "7c20c7ef1ec25babeaa2ac3bf2b95de3726d38259ce56c091f1f5565d6f89c10", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0174", "issue_number": "0174", "title": "0174-Cervical Orthoses within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "DME MACs", "source_date": "2019-12-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/1940999997/0174-cervical-orthoses-within-reasonable-useful-lifetime-excessive-units", "source_id": "cms-rac-approved", "description": "Claims for cervical orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously-paid identical cervical orthosis (identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0700, L0710, L0810, L0820, L0830, L1000, L1001, L1005, L1200, L1300, L1310, L1499", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, § §110.2.C- Repairs, Maintenance, Replacement, and Delivery and § 130- Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes. 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. HCPCS Level II Codebook", "codes": [ "L0112", "L0113", "L0120", "L0130", "L0140", "L0150", "L0160", "L0170", "L0172", "L0174", "L0180", "L0190", "L0200", "L0220", "L0700", "L0710", "L0810", "L0820", "L0830", "L1000", "L1001", "L1005", "L1200", "L1300", "L1310", "L1499" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "499a0277e14ac1f6b91a7b8f094d74a491f64bbd0ff2027658d9d31e837229cd", "raw_sha256": "bb8245374ce9385a4cfa39b3886ce1a25ccfa97284fb3577c701b0ca7407fb57", "texas": "unresolved", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0173", "issue_number": "0173", "title": "0173-Surgical Dressings: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-12-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpseditcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0173-surgical-dressings-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if the Surgical Dressing is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied.", "codes_text": "A6010, A6011, A6021, A6022, A6023, A6024, A6196, A6197, A6198, A6199, A6209, A6210, A6211, A6212, A6213, A6214, A6215", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and other Health Services, §100- Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Chapter 7- SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §60- Billing for Durable Medical Equipment (DME), Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings) 18. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 19. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33831- Surgical Dressings; Effective 10/01/2015; Revised 01/01/2024 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A54563- Surgical Dressings- Policy Article; Effective 10/01/2015; Revised 12/05/2024 24. 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 25. 25. HCPCS Level II Codebook", "codes": [ "A6010", "A6011", "A6021", "A6022", "A6023", "A6024", "A6196", "A6197", "A6198", "A6199", "A6209", "A6210", "A6211", "A6212", "A6213", "A6214", "A6215" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "04a987f037010b64b8001a48983c584f37e9fb23c8cc4e20dd23413e87f24067", "raw_sha256": "ed0a0e67757fba0f2542552a947455e8559bebfc0e7763ed204947d1659e6e7a", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0171", "issue_number": "0171", "title": "0171-Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-12-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0171-erythropoiesis-stimulating-agents-cancer-patients-medical-necessity-and-documentation", "source_id": "cms-rac-approved", "description": "Erythropoiesis stimulating agents (ESAs) stimulate the bone marrow to make more red blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need for blood transfusion in patients with specific clinical indications. Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria.", "codes_text": "J0881, J0885, and Q5106 that were billed with modifiers EA and EB", "policy_text": "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 Determinations (NCD) Manual, Chapter 1- Coverage Determinations, Part 2, §110.21 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §50 Drugs and Biologicals 9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals, §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §80.9- Required Modifiers for ESAs Administered to Non-ESRD Patients; and §80.12- Claims Processing Rules for ESAs Administered to Cancer Patients for Anti-Anemia Therapy 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. CGS Administrators, LLC, LCD L34356- Erythropoiesis Stimulating Agents (ESA); Effective 10/01/2015; Revised 03/05/2026 12. First Coast LCD L36276- Erythropoiesis Stimulating Agents; Effective 10/01/2015; Retired 02/09/2023 13. Palmetto GBA LCD L39237- Erythropoiesis Stimulating Agents; Effective 07/24/2022; Revised 03/13/2025 14. WPS LCD L34633- Erythropoiesis Stimulating Agents (ESAs); Effective 10/01/2015; Revised 05/29/2025 15. CGS Administrators, LLC, LCA A56462- Billing and Coding: Erythropoiesis Stimulating Agents (ESA), Effective 10/03/2019; Revised 03/05/2026 16. First Coast LCA A57628- Billing and Coding: Erythropoiesis Stimulating Agents; Effective 10/03/2018; Retired 02/09/2023 17. Palmetto LCA A58982- Billing and Coding: Erythropoiesis Stimulating Agents; Effective 07/24/2022; Revised 04/01/2025 18. WPS LCA A56795- Billing and Coding: Erythropoiesis Stimulating Agents (ESAs); Effective 08/01/2019; Revised 04/01/2025 19. AMA CPT Codebook 20. HCPCS Level II Codebook 21. AHA ICD-10-CM Diagnosis Codebook", "codes": [ "J0881", "J0885", "Q5106" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "e513644310e83417b9af7a7c89c2a74002a484051063a36d63ec34612b5533f3", "raw_sha256": "4a897bd6f4b3967e6c88992391c96d7553b97fc522e9eb44ba254ba36e5ea93a", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0170", "issue_number": "0170", "title": "0170-Renal and Peripheral Angiography: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-12-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0170-renal-and-peripheral-angiography-medical-necessity-and-documentation-requirements-", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if diagnostic (aka stand-alone) renal and peripheral angiography procedures meet Medicare coverage criteria, meet applicable coding guidelines, and/or are medically reasonable and necessary.", "codes_text": "36245, 36246, 36247, 36248, 36251, 36252, 36253, 36254", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. First Coast LCD L36767 - Aortography and Peripheral Angiography; Effective 10/31/2016; Revised 10/01/2019 9. First Coast LCA A55847 – Aortography and Peripheral Angiography Coding Guidelines; Effective 10/31/16; Retired 10/01/2019 10. First Coast LCA A57056 – Billing and Coding: Aortography and Peripheral Angiography; Effective 10/03/18; Revised date 03/01/2024 11. Novitas LCD L35092 - Diagnostic Abdominal Aortography and Renal Angiography Effective 10/01/2015; Revised date 11/7/2019 12. Novitas LCA A56682- Billing and Coding: Diagnostic Abdominal Aortography and Renal Angiography; Effective date 7/11/2019; Revised date 03/01/2024 13. AMA CPT Codebook 14. AMA CPT Codebook, Appendix L", "codes": [ "36245", "36246", "36247", "36248", "36251", "36252", "36253", "36254" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8e57aab2af6be9dfab04d3d485926287465fee7a760daa810a46b63352ce9b31", "raw_sha256": "d46cb43e47454ee3940100eb137885a75973ad2ca0541a7f41e397fc8fba67cd", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0169", "issue_number": "0169", "title": "0169-Outpatient Services within 3 Days Prior to and Including the Date of a Hospital Admission: Unbundling", "review_type": "Automated", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-12-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/816234134/0169-outpatient-services-within-3-days-prior-and-including-date-hospital-admission-unbundling", "source_id": "cms-rac-approved", "description": "All diagnostic (including clinical diagnostic laboratory tests) services and related non-diagnostic services provided to a beneficiary by the admitting hospital within 3 days (for IPPS Hospitals) prior to or 1 day (NON IPPS Hospitals) prior to and including the date of the beneficiary's admission are deemed to be inpatient services and included in the inpatient payment. Unbundled services will be denied and result in an overpayment.", "codes_text": "Diagnostic codes are identified as any CPT/HCPCS code billed with a revenue code: 0254, 0255, 030X, 031X, 032X, 0341, 0343, 035X, 0371, 0372, 040X, 046X, 0471, 0481 or 0489 (billed with HCPCS 93451-93464, 93503, 93505), 93563-93568, 93571-93572, 93593-93598 (effective 01/01/2022), and G0278), 0482, 0483, 053X, 061X, 062X, 073X, 074X, 0918, 092X", "policy_text": "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- Inpatient Hospital Billing, §40.3(B)- Outpatient Services Treated as Inpatient Services - Preadmission Diagnostic Services; §40.3(D) Outpatient Services Treated as Inpatient Services - Other Preadmission Services 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook 10. HCPCS Level II Codebook", "codes": [ "93451", "93464", "93503", "93505", "93563", "93568", "93571", "93572", "93593", "93598", "G0278" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "38634670ac20f68647088b4f5d115c89167c508499798c5693c722547ee0a476", "raw_sha256": "62a5dccbe9c4c43a5cec4ef92f310d13885f60fc493c902b64e4ac0d623d1b0d", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0167", "issue_number": "0167", "title": "0167-Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-09-10", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0167-ankle-foot-orthoses-and-knee-ankle-foot-orthoses-within-the-reasonable-useful-lifetime-excessive-units", "source_id": "cms-rac-approved", "description": "Claims for Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously paid identical Ankle-Foot Orthoses or Knee-Ankle-Foot Orthoses (identical HCPCS code), for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2006, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4631", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 110.2 – Repairs, Maintenance, Replacement, and Delivery (C) – Replacement Medicare Benefit Policy 12. Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6. 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686: Ankle-Foot/Knee-Ankle-Foot Orthosis; Effective 10/01/2015; Revised 01/23/2024 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52457: Ankle-Foot/Knee-Ankle-Foot Orthosis- Policy Article; Effective 10/01/2015; Revised 01/23/2024 17. HCPCS Level II Codebook", "codes": [ "L1900", "L1902", "L1904", "L1906", "L1907", "L1910", "L1920", "L1930", "L1932", "L1940", "L1945", "L1950", "L1951", "L1960", "L1970", "L1971", "L1980", "L1990", "L2000", "L2005", "L2006", "L2010", "L2020", "L2030", "L2034", "L2035", "L2036", "L2037", "L2038", "L2106", "L2108", "L2112", "L2114", "L2116", "L2126", "L2128", "L2132", "L2134", "L2136", "L4350", "L4360", "L4361", "L4370", "L4386", "L4387", "L4396", "L4397", "L4631" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "3293c49509bded69352b07280d35fb7f5d4d3565693ff480809f0cc63e5a21d1", "raw_sha256": "065907d2b14c5aecda4d2875886461a14ea6e3817f19c095c30291f9f0705492", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0165", "issue_number": "0165", "title": "0165-Positron Emission Tomography for Dementia and Neurodegenerative Diseases: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-09-10", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0165-positron-emission-tomography-for-dementia-and-neurodegenerative-diseases-medical", "source_id": "cms-rac-approved", "description": "Under specific requirements, Medicare covers FDG (fluorodeoxyglucose) Positron Emission Tomography (PET) scans for the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer’s disease (AD). Medical records will be reviewed to determine if the utilization of PET scan for the diagnosis or treatment of dementing neurodegenerative diseases is medically necessary according to Medicare coverage indications.", "codes_text": "78608, A9552", "policy_text": "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. 42 CFR §410.32- Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions 8. Medicare National Coverage Determinations Manual, Ch. 1, Part 4-Coverage Determinations, §220.6.13-FDG Positron Emission Tomography (PET) for Dementia and Neurodegenerative Diseases 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.1- Billing Instructions, (D)- Post-Payment Review for PET Scans 11. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.12- Coverage for PET Scans for Dementia and Neurodegenerative Diseases 12. Medicare Claims Processing Manual, Ch. 13- Radiology Services and Other Diagnostic Procedures, §60.3.1- Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005 13. First Coast A59049- Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions; Effective 4/22/2022; Revised 10/13/2023 14. Novitas LCA A53134- Billing and Coding: NCD Coding Article for Positron Emission Tomography (PET) Scans Used for Non-Oncologic Conditions; Effective 10/01/2015; Revised 10/13/2023 15. Noridian LCA A54666- Billing and Coding: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Retired 10/01/2023 16. Noridian LCA A54668- Billing and Coding: Positron Emission Tomography Scans Coverage; Effective 10/1/2015; Retired 10/01/2023 17. AMA CPT Codebook 18. HCPCS Level II Codebook", "codes": [ "78608", "A9552" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "1ae3e2e8fec3a42d00a39a0eb3bc52a76c693687f02f8a163e6b87670908e3b2", "raw_sha256": "1acbfee9c63bb666f72a9f6913d45b8c5132861db2a6b7c93bbec963b6f693af", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0164", "issue_number": "0164", "title": "0164-Bilateral Indicator '3': Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-09-10", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0164-bilateral-indicator-3-incorrect-coding", "source_id": "cms-rac-approved", "description": "A Bilateral Indicator of \"3\" indicates the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with either a modifier 50 or modifiers RT and LT, and a ‘2’ in the units field, reimbursement is based on 100% of the Medicare allowed amount for each side less any applicable multiple procedure pricing rules. This query identifies claims with underpayments due to code being submitted with a quantity of \"1” when performed bilaterally.", "codes_text": "Bilateral Indicator ‘3’ codes Applicable References 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 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, §40.7- Claims for Bilateral Surgeries C.3 9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §50.6 Physician Fee Schedule Payment Policy Indicator File Record Layout 10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements – Addendum – Medicare Physician Fee Schedule Database (PFSDB) Record Layouts and Field Descriptions 11. Physician Fee Schedule | CMS 12. Physician Fee Schedule Relative Value Files- PFS Relative Value Files | CMS 13. AMA CPT Codebook", "policy_text": "", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8a118639941d4b65f01e774d97608ba8a618bcc04590cf9bc99ec3507fef3773", "raw_sha256": "5402f0555f42e7ebea57a6cc8c4310044bb3845c32687d1996e5254c6b576c35", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0160", "issue_number": "0160", "title": "0160-Intravenous Immune Globulin for the Treatment of Autoimmune Blistering Diseases: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-09-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0160-intravenous-immune-globulin-for-the-treatment-of-autoimmune-blistering-diseasesmedical", "source_id": "cms-rac-approved", "description": "Medical documentation will be reviewed to determine if the use of intravenous immune globulin for the treatment of Autoimmune Blistering Diseases (AMBDs) meets Medicare coverage criteria and is reasonable and necessary.", "codes_text": "J1459, J1552 (Novitas Only), J1553, J1556, J1557, J1561, J1566, J1568, J1569, J1572, J1554, J1576, J1599", "policy_text": "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 National Coverage Determinations (NCD) Manual, Part 4- Coverage Determinations, §250.3- Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases 8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §80.6- Intravenous Immune Globulin 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4 Reasonable and Necessary Provisions in LCDs 11. CGS Administrators LCD L35891- Intravenous Immune Globulin; Effective 10/01/2015; Revised 03/27/2025 12. First Coast Service Options (FCSO) LCD L34007- Immune Globulin; Effective 10/01/2015; Revised 02/05/2023 13. Palmetto GBA LCD L34580- Intravenous Immunoglobulin (IVIG); Effective 10/01/2015; Revised 04/04/2024 14. NGS LCA A52446- Intravenous Immune Globulin IVIG; Effective 10/01/2015; Revised 10/01/2022, Retired 10/31/2022 15. CGS LCA A56779- Billing and Coding: Intravenous Immune Globulin; Effective 08/01/2019; Revised 03/27/2025 16. First Coast Service Options (FCSO) LCA A57778- Billing and Coding: Immune Globulin; Effective 10/03/2018: Revised 01/01/2025 17. Noridian LCA A57187- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 07/01/2023 18. Noridian LCA A54641- Intravenous Immune Globulin: (IVIg) – NCD – 250.3; Effective 11/07/2015 19. Noridian LCA A54643- Intravenous Immune Globulin: (IVIg) – NCD – 250.3; Effective 11/07/2015; Revised 11/07/2015 20. Noridian LCA A57194- Billing and Coding: Immune Globulin Intravenous (IVIg); Effective 10/01/2019; Revised 07/01/2023 21. Novitas LCA A56786- Billing and Coding: Immune Globulin; Effective 08/08/2019; Revised 01/01/2025 22. Palmetto LCA A56718- Billing and Coding: Intravenous Immune Globulin (IVIG); Effective 07/25/2019; 10/01/2024 23. WPS LCA A57554- Billing and Coding: Immune Globulins; Effective 11/01/2019: Revised 10/01/2024 24. HCPCS Level II Codebook 25. AHA ICD-10-CM Diagnosis Codebook", "codes": [ "J1459", "J1552", "J1553", "J1554", "J1556", "J1557", "J1561", "J1566", "J1568", "J1569", "J1572", "J1576", "J1599" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "16cc6f61d3ece95004daa943aa06747ec06eae9747697640502b9fb15dd76bce", "raw_sha256": "a38875287a3d4318101f8ee031b4b270b7fbe2c71934ca5fe4c8642b69471dc6", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0161", "issue_number": "0161", "title": "0161-Therapeutic, Prophylactic, and Diagnostic Infusions: Incorrect Coding and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-07-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0161-therapeutic-prophylactic-and-diagnostic-injections-and-infusions-medical-necessity", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if correct billing, coding, and medical necessity guidelines for Therapeutic, Prophylactic, and Diagnostic Injections and Infusions were met.", "codes_text": "96365, 96366", "policy_text": "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 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §230- Billing and Payment for Drugs and Drug Administration 8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals 9. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §90.2- Drugs, Biologicals, and Radiopharmaceuticals 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. AMA CPT Codebook", "codes": [ "96365", "96366" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0cb5c26a0a0f6721eb94099b8cfd0c64cb84124fd1c80a87db1d41cb0b184f07", "raw_sha256": "a5eb0fb399a049d7778774a4916db3e45b84ff6a545e38ee196cffa638c3e4b4", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0157", "issue_number": "0157", "title": "0157-Discontinued Procedure Prior to the Administration of Anesthesia: Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-07-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0157-discontinued-procedure-prior-to-the-administration-of-anesthesia-coding-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Modifiers provide a way for hospitals to report and be paid for expenses incurred in preparing a patient for surgery and scheduling a room for performing the procedure where the service is subsequently discontinued. This instruction is applicable both to outpatient hospital departments and to ambulatory surgical centers. Documentation will be reviewed to determine if the billed procedures meets Medicare coverage criteria and applicable coding guidelines for the use of modifiers 73 and 74.", "codes_text": "Paid HCPCS with one of the following ICD-10-CM diagnosis codes- Z53, Z53.0, Z53.01, Z53.09, Z53.1, Z53.2, Z53.20, Z53.21, Z53.29, Z53.8, Z53.9", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. 42 CFR §419.44 Payment Reductions for Procedures 9. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §10.5- Discounting; §20.6- Use of Modifiers, §20.6.1- Where to Report Modifiers on the Hospital Part B Claim, and §20.6.4- Modifiers 73 and 74 10. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40.4- Payment for Terminated Procedures 11. AMA CPT Codebook 12. AMA CPT Codebook, Appendix A Modifiers 13. ICD-10-CM Diagnosis Codebook 14. AHA Coding Clinic for HCPCS, 2007, Volume 7, Number 1, Page 1- Use of Modifiers 52, 73, and 74 and Anesthesia Reporting under OPPS 15. AHA Coding Clinic for HCPCS, 2008, Volume 8, Number 2, Pages 1-4- Special Issue: Modifiers 52, 73, and 74 16. AHA Coding Clinic for HCPCS, 2016, Volume 16, Number 1, Page 12- Appropriate Use of Modifiers for Discontinued Services under the OPPS 17. AMA CPT Assistant, September 2003, Page 3- Hospital Outpatient Reporting Part IV: Use of the CPT Modifiers ’52,’ ’58,’ ’59,’ ’73,’ ’74,’ ’76,’ ’77,’ ’78,’ and ‘91’", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "e3de40053b7ea3e07c5cb0de6aa412a8e49bce886d69d7394570b7f94f5f355c", "raw_sha256": "50c9f0b8333bb662f9b91fa5880d8caf2c42bdb839e201485d52abf2f9689daa", "texas": "national", "specialties": [ "Anesthesia & pain" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Review the anesthesia and underlying procedure codes together, including same-date billing and the applicable coverage and documentation requirements.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0158", "issue_number": "0158", "title": "0158-Outpatient Therapy Services During Home Health: Unbundling", "review_type": "Automated", "provider_type": "Outpatient Hospital; Outpatient Rehabilitation Facility (ORF); Skilled Nursing Facility (SNF)- Outpatient", "jurisdiction": "All A/B MACs", "source_date": "2019-06-04", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0158-outpatient-therapy-services-during-home-health-unbundling", "source_id": "cms-rac-approved", "description": "On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x. Therapy services should not be billed separately during a home health episode of care as the services are bundled into the Home Health Consolidated Billing payment.", "codes_text": "CPT/HCPCS codes billed with Revenue codes 042x, 043x or 044x", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20- Home Health Prospective Payment System (HH PPS) Consolidated Billing 9. Medicare Claims Processing Manual, Chapter 10- Home Health Agency Billing, §20.2.2 - Therapy Editing 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "adf53cd90741acb6558f272d78dde8866ec175f5b4da1d30b3a99e527f639026", "raw_sha256": "26ef811a52edab4f3025d2d04b61567dfeaa51a3c1dd8d14a29b1df4c70ea212", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0153", "issue_number": "0153", "title": "0153-Ambulatory Surgical Center Coding Validation", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC)", "jurisdiction": "All A/B MACs", "source_date": "2019-06-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0153-ambulatory-surgical-center-coding-validation", "source_id": "cms-rac-approved", "description": "Ambulatory Surgical Center (ASC) coding requires that procedural information, as coded and reported by the ASC on its claim, match both the physician description and the information contained in the beneficiary's medical record. Reviewers will validate the targeted CPT/HCPCS code and associated modifiers by reviewing the procedures affecting or potentially affecting payment.", "codes_text": "Claims with payment indicator A2; G2; J8; P2; P3; R2", "policy_text": "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. 42 CFR §424.5(a)(6)- Sufficient information 8. Medicare Claims Processing Manual, Chapter 12- Physician/ Non-physician Practitioners § 40.1- Definition of a Global Surgical Package 9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §20.3- Rebundling of CPT Codes; §40.1- Payment to Ambulatory Surgical Centers for non-ASC Services; §40.5- Payment for Multiple Procedures 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. Ambulatory Surgical Center Payment System; Addendum AA; Payment indicators A2 (Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight), G2 (Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight); J8 (Device-intensive procedure; paid at adjusted rate. ASC Payment rates, P2 (Office-based surgical procedure on ASC list in CY 2008 or later with MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight), P3 (Office-based surgical procedure added to ASC list in CY 2008 or later with MPFS non-facility PE RVUs; payment based on MPFS non-facility PE RVUs), and R2 (Office-based surgical procedure on ASC list in CY 2008 or later without MPFS nonfacility PE RVUs; payment based on OPPS relative payment weight) available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates.html 12. National Correct Coding Initiative (NCCI) Policy Manual 13. AMA CPT Codebook 14. HCPCS Level II Codebook 15. AMA CPT Assistant 16. AHA Coding Clinic for HCPCS 17. Review Choice Demonstration (RCD) for Certain Ambulatory Surgical Center ASC Services | CMS", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a2aecb95d51e27ff08c527093ba5deeb1c59f5f8f637ffc2980306894858b881", "raw_sha256": "9ad883f7d6a663f3ead46b59e69a9fdc107f69a9567420abbf4498bb9106a41a", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0155", "issue_number": "0155", "title": "0155-Upper Limb Orthotics within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-05-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0155-upper-limb-orthoses-within-the-reasonable-useful-lifetime", "source_id": "cms-rac-approved", "description": "Claims for upper limb orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously-paid identical upper limb orthosis (identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "L3650, L3660, L3670, L3671, L3674, L3675, L3677, L3678, L3702, L3710, L3720, L3730, L3740, L3760, L3761, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3809, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3916, L3917, L3918, L3919, L3921, L3923, L3924, L3929, L3930, L3931, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3981, L3982, L3984, L3995", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110.2.C- Repairs, Maintenance, Replacement, and Delivery and §130- Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. HCPCS Level II Codebook", "codes": [ "L3650", "L3660", "L3670", "L3671", "L3674", "L3675", "L3677", "L3678", "L3702", "L3710", "L3720", "L3730", "L3740", "L3760", "L3761", "L3762", "L3763", "L3764", "L3765", "L3766", "L3806", "L3807", "L3808", "L3809", "L3900", "L3901", "L3904", "L3905", "L3906", "L3908", "L3912", "L3913", "L3915", "L3916", "L3917", "L3918", "L3919", "L3921", "L3923", "L3924", "L3929", "L3930", "L3931", "L3956", "L3960", "L3961", "L3962", "L3967", "L3971", "L3973", "L3975", "L3976", "L3977", "L3978", "L3980", "L3981", "L3982", "L3984", "L3995" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8e64e85520861af06702bbce63d9735a6528b5814c254be5f5c0dd068073bd45", "raw_sha256": "6aee0832aaa7e826936411e541b93313b8c79e6985f9e59c58d16ef386e6d6a1", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0154", "issue_number": "0154", "title": "0154-Non-Emergency Ambulance Services- Advanced Life Support and Basic Life Support: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2019-05-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0154-non-emergency-ambulance-services-als-and-bls-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment.", "codes_text": "A0426, A0428, A0425", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(7)- Medical and Other Health Services 9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)- (16)- Establishment of Fee Schedule for Ambulance Services 10. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions; (b) Basic rules; (c) Levels of service; (e) Medical necessity requirements 11. 42 CFR 410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements 12. 42 CFR 414.605 Definitions 13. 42 CFR 414.610 Basis of Payment 14. 42 CFR 424.36- Signature Requirements 15. 42 CFR 424.37 Evidence of Authority to Sign on behalf of the Beneficiary. 16. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information 17. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services 18. Medicare Claims Processing Manual, Chapter 15- Ambulance, §10.2 – Summary of the Benefit 19. HCPCS Level II Codebook", "codes": [ "A0425", "A0426", "A0428" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "c76ddc48d837f150c01f60be6ba72ff0754ac43e73dc783f30c03aec6d8526b3", "raw_sha256": "442397567455cd267883f9ffece5e0b5e06e6ba1c39ec1f3e3be28956a8c3925", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0152", "issue_number": "0152", "title": "0152-Blood Glucose Test or Reagent Strips: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-04-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0152-hcpcs-a4253-blood-glucose-test-or-reagent-strips", "source_id": "cms-rac-approved", "description": "The quantity of glucose test strips that are covered depends upon the usual medical needs of the diabetic patient. Documentation will be reviewed to determine if the utilization guidelines for blood glucose test strips were met.", "codes_text": "A4253", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §40.2 Home Blood Glucose Monitors 15. Medicare National Coverage Determinations Manual, Chapter 1- Coverage Determinations, §190.20- Blood Glucose Testing 16. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 17. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 18. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 19. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 21. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 22. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective Date: 10/01/2015; Revised 01/01/2024 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464- Glucose Monitor- Policy Article; Effective Date: 10/01/2015; Revised 01/01/2024 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023 (*Historical, for claims with Dates of Service prior to 01/01/2023) 26. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 27. HCPCS Level II Codebook", "codes": [ "A4253" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "6ee7462d361fbdab05eb7ba777ca68f1de9aa93f2e3c49af6db2e24cd5e48a4f", "raw_sha256": "631dfe7e92d80cba7e2f93e2f00e43cb6f7c941d9ea77079c353ebef71abb582", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0151", "issue_number": "0151", "title": "0151-Physician/Non-physician Practitioner Coding Validation", "review_type": "Complex", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-04-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0151-physician-non-physician-practitioner-coding-validation", "source_id": "cms-rac-approved", "description": "The Medicare Physician Fee Schedule (MPFS) is the primary method of payment for enrolled health care professionals. Documentation will be reviewed to determine if professional services that affecting MPFS payment meet Medicare coverage criteria and applicable coding guidelines.", "codes_text": "CMS Medicare Physician Fee Schedule status code “A”", "policy_text": "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- – Establishing Good Cause for Reopening 7. 42 CFR §414- Payment for Part B Medical and other Health Services, Subpart A – General Provisions, Subpart B – Physicians and other Practitioners, Subpart E – Determination of Reasonable Charges under ESRD Program 8. 42 CFR §414.40- Coding and Ancillary Policies 9. 42 CFR §415- Services Furnished by Physicians in Providers, Supervising Physicians in Teaching Settings, and Residents in Certain Settings 10. 42 CFR §419.44- Payment Reductions for Procedures 11. Medicare Claims Processing Manual, Chapter 12- Physicians/Non-physician Practitioners 12. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. AMA CPT Codebook 15. HCPCS Level II Codebook 16. AMA CPT Assistant 17. National Correct Coding Initiatives (NCCI) Policy Manual 18. CMS Medicare Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html 19. American Hospital Association (AHA) Coding Clinic", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "160810a391dc9da9e2f6ea01c26bf7212e4931a95e07bc1715ed103f48a8db92", "raw_sha256": "ec98c54268b5a5657dbf28e500df719458e8b92d3d1ae5938499ae04c22dd567", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0149", "issue_number": "0149", "title": "0149-Subsequent Hospital Visit and Discharge Day Management on the Same Day: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-04-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0149-subsequent-hospital-visit-and-discharge-day-management-billed-on-same-day", "source_id": "cms-rac-approved", "description": "CMS does not reimburse a subsequent hospital visit in addition to hospital discharge day management service on the same day by the same provider. CPT codes 99231 – 99233 will be considered overpayments and will be recovered.", "codes_text": "99231, 99232, 99233, 99238, 99239", "policy_text": "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 12- Physicians/ Nonphysician Practitioners, §30.6.5- Physicians in Group Practice 8. Medicare Claims Processing Manual, Chapter 12-Physicians/ Nonphysician Practitioners, §30.6.9.2- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231-99239); §30.6.9.2(C)- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook", "codes": [ "99231", "99232", "99233", "99238", "99239" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "11e3483a6ebc3a707198a15529cd016392a425d6840ea7535553b3e246aac7b8", "raw_sha256": "8061db68d571c85fcc599c103a019ef38419de2b70dfe1df577932a3bfe77c9e", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0148", "issue_number": "0148", "title": "0148-Same Knee Orthosis within Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-04-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0148-knee-orthosis-within-the-rul", "source_id": "cms-rac-approved", "description": "Claims for knee orthoses with dates of service within the reasonable useful lifetime from the date of service of a previously-paid identical knee orthosis (identical HCPCS code) for the same beneficiary, for the same anatomical site, will be denied as the reasonable useful lifetime requirement has not been met.", "codes_text": "L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860, L2275, L2320, L2330, L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2780, L2785, L2795, L2800, L2810, L2820, L2830, K0672", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- LCD L33318- Knee Orthoses; Effective 10/01/2015; Revised 01/01/2025 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- Local Coverage Article A52465- Knee Orthoses- Policy Article; Effective 10/01/2015; Revised 01/01/2025 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426-Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024", "codes": [ "K0672", "L1810", "L1812", "L1820", "L1830", "L1831", "L1832", "L1833", "L1834", "L1836", "L1840", "L1843", "L1844", "L1845", "L1846", "L1850", "L1851", "L1852", "L1860", "L2275", "L2320", "L2330", "L2385", "L2390", "L2395", "L2397", "L2405", "L2415", "L2425", "L2430", "L2492", "L2750", "L2755", "L2780", "L2785", "L2795", "L2800", "L2810", "L2820", "L2830" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "72da9c7f7b305b79789f5551fc324c199dc916e55fedc8470c022306aa6601ef", "raw_sha256": "6800c48396ec07151bf9fb85d3ded3500021e4bd259837d8bd4c2b9d0d2617c3", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0141", "issue_number": "0141", "title": "0141-Therapeutic Shoes and Inserts for Persons with Diabetes: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-04-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0141-therapeutic-shoes-and-inserts-for-persons-with-diabetes", "source_id": "cms-rac-approved", "description": "This review will determine if the documentation submitted for review meets Medicare’s coverage requirements for Diabetic Shoes and Inserts. Claims where the documentation submitted does not support the coverage requirements will be denied.", "codes_text": "A5500, A5501, A5512, A5513, A5514", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, § 1834 (a)(2), §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA) 1861(s)(12)- Definitions of Services, Institutions, Etc.; Medical and Other Health Services 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS): Scope and conditions 11. 42 CFR §410.78 – Telehealth services 12. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 13. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 14. 42 CFR §414.65- Payment for Telehealth Services 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §140, Therapeutic Shoes for Individuals with Diabetes 17. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under 18. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 19. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 20. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service Prior to 10/12/2021; 21. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 22. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Determination L33369: Therapeutic Shoes for Persons with Diabetes; Effective 10/01/2015; Revised 01/01/2020 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC Local Coverage Article A52501: Therapeutic Shoes for Persons with Diabetes- Policy Article; Effective 10/01/2015, Revised 11/05/2020 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 26. CMS.gov Primary Care First Model Options: https://innovation.cms.gov/innovation-models/primary-care-first-model-options 27. HCPCS Level II Codebook", "codes": [ "A5500", "A5501", "A5512", "A5513", "A5514" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "cebdc38983d7d5f48cf66e7e910b1661c03dae012104dd7270e22bf8ae576274", "raw_sha256": "7e581f3f460c1b5166a8db991cb5d6270c7be88c8561c5c44ddf27b2f55ca491", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0144", "issue_number": "0144", "title": "0144-Prefabricated Knee Orthoses: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-04-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0144-off-the-shelf-knee-orthosis", "source_id": "cms-rac-approved", "description": "The medical record will be reviewed to determine if the prefabricated knee orthoses meet the indications of coverage and/or medical necessity requirements.", "codes_text": "L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1836, L1843, L1845, L1850, L1851, L1852, L2397, L2395, L2810, L2385, L2395", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(h)(1)-Payment for Prosthetic Devices and Orthotics and Prosthetics 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 11. 42 CFR §410.78- Telehealth Services 12. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 13. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 14. 42 CFR §414.65- Payment for Telehealth Services 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L33318- Knee Orthoses; Effective 10/01/2015; Revised 01/25/2026 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52465- Knee Orthoses- Policy Article; Effective 10/01/2015; Revised 01/2501/2026 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 24. HCPCS Level II Codebook 25. AHA ICD-10-CM Codebook", "codes": [ "L1810", "L1812", "L1820", "L1830", "L1831", "L1832", "L1833", "L1836", "L1843", "L1845", "L1850", "L1851", "L1852", "L2385", "L2395", "L2397", "L2810" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ebfa6f2cb0adb9df79f797007f1a71314c354ec1db9f4ab403a0a9167b331851", "raw_sha256": "bb8849f9bc0631efb48427d765bdadc19dc1f0e807e4edc72d929d17603e80f8", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0150", "issue_number": "0150", "title": "0150-Mohs Micrographic Surgery: Incorrect Coding and Incorrect Units Billed", "review_type": "Complex", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-03-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0150-mohs-micrographic-surgery-mms-incorrect-units-billed", "source_id": "cms-rac-approved", "description": "Mohs Micrographic Surgery is a two-step process in which: 1) The tumor is removed in stages, followed by immediate histologic evaluation of the margins of the specimen(s); and 2) Additional excision and evaluation is performed until all margins are clear. This review will verify that the physician who performs the Mohs surgery is acting as both surgeon and pathologist. Reviewers will determine if the correct number of units have been billed for additional Mohs micrographic technique staging unit(s) for HCPCS 17312 and 17314. Billing of excessive or insufficient units or a change in coding will be adjusted accordingly.", "codes_text": "17312,17314", "policy_text": "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 Program Integrity Manual, Chapter 3 Verifying Potential Errors and Taking Corrective Actions; §§3.1-3.6.6 8. AHA Coding Clinic for HCPCS, Third Quarter 2013, Volume 13, Number 3, Page 1-3 Reporting MOHS micrographic surgery (MMS) 9. CPT Assistant, October 2014, Volume 24, Issue 10, Page 14-Frequently Asked Questions, Surgery-Integumentary System, Mohs Surgery, Tissue Block 10. CPT Assistant, November 2006, Volume 16, Issue 11, Pages 1-7 Mohs Micrographic Surgery 11. CPT Assistant, February 2014, Volume 24, Issue 2, Page 10-Coding Clarification: Mohs Surgery (17311-17315) 12. AMA CPT Codebook", "codes": [ "17312", "17314" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "1c49b0de7fc8fc701858fad93add0bd6abcf912f2c3bcb59b56f30c7d4c27079", "raw_sha256": "a8795e3dec6e94dc37dd690147e1b87adee8185348c6aa5d35e233eaf6945832", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0147", "issue_number": "0147", "title": "0147-Magnetic Resonance Imaging Procedures: Excessive Units", "review_type": "Automated", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-03-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0147-unbundling-of-mri-procedures", "source_id": "cms-rac-approved", "description": "When a more extensive Magnetic Resonance Imaging (MRI) Procedure is performed on the same site as a less extensive MRI procedure, the less extensive MRI procedure is bundled into the more extensive MRI procedure.", "codes_text": "70540, 70542, 70543, 70544, 70545, 70546, 70547. 70548, 70549, 70551, 70552, 70553, 70557, 70558, 70559, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 75557, 75559, 75561", "policy_text": "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 12 -Physicians/Non-physician Practitioners, Sections 30 – Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures 8. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, § 40 – Magnetic Resonance Imaging (MRI) Procedures 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook", "codes": [ "70540", "70542", "70543", "70544", "70545", "70546", "70547", "70548", "70549", "70551", "70552", "70553", "70557", "70558", "70559", "71550", "71551", "71552", "72141", "72142", "72146", "72147", "72148", "72149", "72156", "72157", "72158", "72195", "72196", "72197", "73218", "73219", "73220", "73221", "73222", "73223", "73718", "73719", "73720", "73721", "73722", "73723", "74181", "74182", "74183", "75557", "75559", "75561" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "89ccc363b29c21092a5d0f6d67322e44d091d9e1bec22d126b707c26223e1f36", "raw_sha256": "3bdb67e5378c9f27987d960cd2c2a9d8685b4a872bb411da4d82c4a71a353199", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0146", "issue_number": "0146", "title": "0146-Computed Tomography Scans: Excessive Units", "review_type": "Automated", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-03-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0146-unbundling-of-ct-scans", "source_id": "cms-rac-approved", "description": "When a more extensive CT Scan is performed on the same site as a less extensive CT Scan, the less extensive CT Scan is bundled into the more extensive CT Scan.", "codes_text": "70450, 070460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72121, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 74176, 74177, 74178, 74261, 74262", "policy_text": "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 12 -Physicians/Non-physician Practitioners, Section 30- Correct Coding Policy, (H)- Most Extensive Procedures and (J)- With/Without Procedures 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook", "codes": [ "70450", "70470", "70480", "70481", "70482", "70486", "70487", "70488", "70490", "70491", "70492", "71250", "71260", "71270", "72121", "72125", "72126", "72127", "72128", "72129", "72130", "72132", "72133", "72192", "72193", "72194", "73200", "73201", "73202", "73700", "73701", "73702", "74150", "74160", "74170", "74176", "74177", "74178", "74261", "74262" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a407cae5d095e8ace85ff2f250bfb967df08fd55e808107f9fd958334f03f8d0", "raw_sha256": "f11a8da3b2b4e588308311770922373e0bb14f8d808aae7c07e697aba7b9de80", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0142", "issue_number": "0142", "title": "0142-Ambulatory Surgical Center Services Billed During a Covered Part A Skilled Nursing Facility Stay: Unbundling", "review_type": "Automated", "provider_type": "Ambulatory Surgical Center (ASC); Skilled Nursing Facility (SNF)", "jurisdiction": "All A/B MACs", "source_date": "2019-03-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0142-asc-services-during-a-covered-part-a-snf-stay", "source_id": "cms-rac-approved", "description": "Services provided by a freestanding non-hospital ASC (Ambulatory Surgery Center) are included under the SNF Consolidated Billing Provisions. Certain services are not payable because they are included in SNF Consolidated Billing. Codes found in the SNF Consolidated Billing – Part A MAC Updates are overpayments and will be recovered", "codes_text": "Annual SNF Consolidated Billing Part A MAC Codes", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 3. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, §1815(a)- Payment to Providers of Services 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 CFR §424.5(a)(6)- Sufficient Information 9. 42 CFR § 424.32(a)(1) - Basic requirements for all claims 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.1.2- Other Excluded Services Beyond the Scope of a SNF Part A Benefit 12. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §110.2.7- Edit to Prevent Payment of Facility Fees for Services Billed by an Ambulatory Surgical Center (ASC) when Rendered to a Beneficiary in a Part A Stay 13. SNF Consolidated Billing – Annual Updates for Part A MAC https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling 14. General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing- General Explanation of the Major Categories for Skilled Nursing Facility (SNF) Consolidated Billing (cms.gov) 15. HCPCS Level II Codebook 16. AMA CPT Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "93a83350813375892f699fa477301de329dd37e078739c0a0f9f2ebc18090eec", "raw_sha256": "75549750333abe490ba2e958b3f947f922787d81d2c61e075bac8fa19b9b9ae1", "texas": "national", "specialties": [ "Orthopedics & surgery", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0140", "issue_number": "0140", "title": "0140-Pulmonary Rehabilitation: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-03-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0140-pulmonary-rehabilitation", "source_id": "cms-rac-approved", "description": "Pulmonary rehabilitation is a physician or nonphysician practitioner-supervised program for COPD and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Medical Documentation will be reviewed to determine if pulmonary rehabilitation is medically reasonable and necessary as well as meeting Federal guidelines and Medicare coverage criteria.", "codes_text": "94625, 94626", "policy_text": "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) §§1861 (s)(2)(CC) - Medical and Other Health Services- (fff) Pulmonary Rehabilitation 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 CFR § 410.47- Pulmonary Rehabilitation Program: Conditions for Coverage 9. 42 CFR §411.15(k)(1)- Particular services excluded from coverage 10. 42 CFR §424.5(a)(6)- Basic Conditions, Sufficient Information 11. Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 240.8 - Pulmonary Rehabilitation Services 12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2024 13. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §231- Pulmonary Rehabilitation (PR) Program Services Furnished on or After January 1, 2010 14. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4- PR Services Effective for Dates of Service On or After January 1, 2024 15. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §140.4.1- PR Services Furnished on or After January 1, 2010 16. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 17. Noridian LCA A52770 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/01/2015; Revised 10/01/2023 18. Noridian LCA A56152 Billing and Coding: Pulmonary Rehabilitation Services; Effective 10/08/2018; Revised 10/01/2023 19. AMA CPT Code Book 20. HCPCS Level II Codebook", "codes": [ "94625", "94626" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "814ec55902cd79914da66f0319190e469a3ff5835a0a08366e9a81dd198738dc", "raw_sha256": "89a3d861144a3a702eb35fca11f827b04a3d1f5406e089eee09ae65c8eebae87", "texas": "national", "specialties": [ "Therapy & rehabilitation", "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0129", "issue_number": "0129", "title": "0129-Hyperbaric Oxygen Therapy for Diabetic Wounds: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-02-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0129-hyperbaric-oxygen-therapy-hbot-for-diabetic-wounds", "source_id": "cms-rac-approved", "description": "For purposes of coverage under Medicare, Hyperbaric Oxygen Therapy (HBOT) is a modality in which the entire body is exposed to oxygen under increased atmospheric pressure. The patient is entirely enclosed in a pressure chamber breathing 100% oxygen (O2) at greater than one atmosphere pressure. The use of HBO therapy is covered as adjunctive therapy only after there are no measurable signs of healing for at least 30 days of treatment with standard wound therapy and must be used in addition to standard wound care. Medical records will be reviewed to determine if Hyperbaric Oxygen Therapy (HBOT) is medically necessary according to Medicare coverage indications.", "codes_text": "G0277", "policy_text": "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. 42 Code of Federal Regulations §424.5- Basic Conditions, (a)(6)- Sufficient Information 8. 42 Code of Federal Regulations §411.15- Particular Services Excluded from Coverage, (k)- Any Services not Reasonable and Necessary, (1) 9. CMS National Coverage Determination Manual, Chapter 1- Coverage determinations, §20.29- Hyperbaric Oxygen Therapy 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. HCPCS Level II Codebook 12. AHA ICD-10-CM Diagnosis Codebook", "codes": [ "G0277" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "940a2564e8989962a79074edb7d99e4d863c501848c120a6ebccf1d9055c4a9f", "raw_sha256": "fb4bdf8977e612af7b3cdd5bc5a4d82e6433c59bc6c8952d30aa5630262db11a", "texas": "national", "specialties": [ "Pulmonary & sleep", "Dermatology & wound" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0139", "issue_number": "0139", "title": "0139-Vertebroplasty or Kyphoplasty: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-02-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0139-complex-medical-necessity-vertebroplasty-and-kyphoplasty-vertebral-augmentation", "source_id": "cms-rac-approved", "description": "Vertebroplasty and kyphoplasty will be reviewed for medical necessity whether billed as an initial procedure, a repeat procedure or if performed at more than one vertebral level. Services that were not medically reasonable and necessary will be denied and will result in an overpayment.", "codes_text": "22510, 22511, 22512, 22513, 22514, 22515, 20225, 22310, 22315, 22325, 22327", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators, LLC, LCD L38201- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 11/20/2025 9. CGS Administrators, LLC, LCA A57282- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/18/2019; Revised 10/08/2025 10. First Coast Service Options, Inc., LCD L34976- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 07/11/2021 11. First Coast Service Options, Inc., LCA A57872- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 07/12/2020 12. National Government Services, Inc., LCD L33569- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 04/01/2026 13. National Government Services, Inc., LCA A56178- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 04/01/2026 14. Noridian Healthcare Solutions, LLC, LCD L34106- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 01/10/2021; Retired 11/06/2025 15. Noridian Healthcare Solutions, LLC, LCD L34228- Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 11/20/2025 16. Noridian Healthcare Solutions, LLC, LCA A56572- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 11/06/2025 17. Noridian Healthcare Solutions, LLC, LCA A56573- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Osteoporotic Vertebral Compression Fracture (VCF); Effective 12/01/2019; Revised 01/10/2021; Retired 11/06/2025 18. Novitas Solutions, Inc., LCD L35130- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 10/01/2015; Revised 07/11/2021 19. Novitas Solutions, Inc., LCA A57752- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/21/2019; Revised 07/12/2020 20. Palmetto GBA LCD L38737- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 11/20/2025 21. Palmetto GBA LCA A58275- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 11/28/2021; Revised 08/21/2022 22. Wisconsin Physicians Service Insurance Corp., LCD L38213- Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 07/30/2026 23. Wisconsin Physicians Service Insurance Corp., LCA A57630- Billing and Coding: Percutaneous Vertebral Augmentation (PVA) for Vertebral Compression Fracture (VCF); Effective 12/16/2019; Revised 08/01/2024 24. AMA CPT Codebook", "codes": [ "20225", "22310", "22315", "22325", "22327", "22510", "22511", "22512", "22513", "22514", "22515" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d981708a3126341fb1c4edabc971f9aeed49d55cb2792d2c2e38cd94e0836b82", "raw_sha256": "76711a168b5ca85ad1c80ce743084645db10923a7aefb1f7d25d6139f8a6c9be", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0138", "issue_number": "0138", "title": "0138-Skilled Nursing Facility Consolidated Billing for Therapies: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-02-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0138-snf-consolidated-billing-for-therapies", "source_id": "cms-rac-approved", "description": "Physical therapy, Occupational therapy, and/or Speech-Language pathology services, regardless of whether they are furnished by (or under the supervision of) a physician or other health care professional, are bundled into the SNF’s global per diem payment for a resident’s covered Part A stay. They are also subject to the SNF “Part B” consolidated billing requirement (for services furnished to SNF residents during noncovered stays) and must be billed by the SNF alone for its Part B residents on a 22x type of bill.", "codes_text": "Therapy CPT/HCPCS codes Included in File 4. SNF Part B Consolidated Billing files", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 3. Social Security Act (SSA) 1888(e)(2)(A)(ii)- Services excluded 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 Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing, §10.3- Types of Services Subject to the Consolidated Billing Requirement for SNFs, §20.5- Therapy Services 9. Medicare Claims Processing Manual, Chapter 6-SNF Inpatient Part A Billing, §20.1.1-Physician’s Services and Other Professional Services Excluded From Part A PPS Payment and the Consolidated Billing Requirement 10. Medicare Claims Processing Manual, Chapter 7- SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §110- Carrier Claims Processing for Consolidated Billing for Physician and Non-Physician Practitioner Services Rendered to Beneficiaries in a Non-Covered SNF Stay 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 12. Medicare SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling 13. AMA CPT Codebook 14. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8c5094e039e2432e8a472456eb20ac01b6b82002e02fb7cb1e3ffbd897d11fc4", "raw_sha256": "d625b6d68a753e822582446555b2e6b273918ab464dc5bf43ae84c6bbc4c43b4", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0136", "issue_number": "0136", "title": "0136-Radiologic Examination of the Chest: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-01-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0136-medical-necessity-and-coding-of-chest-x-rays", "source_id": "cms-rac-approved", "description": "Radiographs of the chest are common tests performed in many outpatient offices (radiology and many others), clinics, outpatient hospital departments, inpatient hospital episodes, skilled nursing facilities, homes, and other settings. They can be used for many pulmonary diseases, cardiac diseases, infections and inflammatory diseases, chest and upper abdominal trauma situations, malignant and metastatic diseases, allergic and drug related diseases. This review will ensure chest x-rays are paid when billed appropriately and only when medically necessary. Claims that are billed inappropriately or that do not meet medical necessity requirements will result in an overpayment.", "codes_text": "71045, 71046, 71047, 71048", "policy_text": "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 6. 42 CFR §405.986- Good Cause for Reopening 7. 42 CFR, §410.32, Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions. 8. 42 CFR §411.15(a)(1) – Particular services excluded from coverage, (a) Routine physical checkups (1) Examinations performed for a purpose other than treatment or diagnosis of a specific illness, symptoms, complaint, or injury, except for screening 9. 42 CFR 486.100 - Condition for coverage: Compliance with Federal, State, and local laws and regulations 10. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §§80.4-80.4.4- Coverage of Portable X-Ray Services Not Under the Direct Supervision of a Physician 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6.1- Definitions 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 13. Noridian Local Coverage Determination: L37547- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019 14. Noridian Local Coverage Article (LCA): A57497- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021 15. Noridian Local Coverage Determination: L37549- Chest X-Ray Policy; Effective 6/22/2018; Revised 11/01/2019 16. Noridian Local Coverage Article (LCA): A57498- Billing and Coding: Chest X-Ray Policy, Effective 11/01/2019, Revised 10/01/2021 17. AMA CPT Codebook", "codes": [ "71045", "71046", "71047", "71048" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8aa1ba4ad7ebec707e646266184e2aafe308acfbf694b93dbc2104a15bcfd368", "raw_sha256": "9087fae2f4d81a42b36e2638b2ed0dbc0b69f69125c9edd20fea622af9179ccc", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0135", "issue_number": "0135", "title": "0135-Cardiac Rehabilitation: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2019-01-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0135-cardiac-rehabilitation", "source_id": "cms-rac-approved", "description": "Cardiac rehabilitation (CR) is a physician or nonphysician practitioner-supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment. Medical Documentation will be reviewed to determine if cardiac rehabilitation is medically reasonable and necessary as well as meets Federal guidelines and Medicare coverage criteria.", "codes_text": "93797, 93798, G0422, G0423", "policy_text": "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 1848(b)(5)- Treatment of Intensive Cardiac Rehabilitation Program 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(2)(CC), (DD)- Medical and Other Services- Cardiac Rehabilitation Program, Intensive Cardiac Rehabilitation Program 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(eee)(1), (4)(A)- Cardiac Rehabilitation Program; Intensive Cardiac Rehabilitation Program 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR §410.49 – Cardiac rehabilitation program and intensive cardiac rehabilitation program: Conditions of coverage 11. Medicare National Coverage Determinations (NCD), Part 1 - Coverage Determinations, § 20.10.1 - Cardiac Rehabilitation Programs for Chronic Heart Failure; §20.31 - Intensive Cardiac Rehabilitation (ICR) Programs; §20.31.1 – The Pritikin Program; §20.31.2 - Ornish Program for Reversing Heart Disease; §20.31.3 – Benson-Henry Institute Cardiac Wellness Program 12. Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, §232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished on or After January 1, 2010 13. Medicare Claims Processing Manual, Chapter 32 – Billing Requirements for Special Services, §140- Cardiac Rehabilitation Programs, Intensive Cardiac Rehabilitation Programs, and Pulmonary Rehabilitation Programs; §140.2- Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010; §140.3- Intensive Cardiac Rehabilitation Program Services Furnished on or after January 1, 2010 14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. AMA CPT Codebook 16. HCPCS Level II Codebook", "codes": [ "93797", "93798", "G0422", "G0423" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "cf31d4a523afeb27926a94a4bb6884c678dc8f8b8a13dc595782109719762b61", "raw_sha256": "445296729a7b79d7e047b961bddf2ceb6f6daeafae94166d3f1f50066c86cf09", "texas": "national", "specialties": [ "Therapy & rehabilitation", "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0134", "issue_number": "0134", "title": "0134-Cryosurgery of the Prostate: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2019-01-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0134-cryosurgery-of-the-prostate", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine whether Cryosurgery of the Prostate Gland services met Medicare coverage criteria and were reasonable and necessary", "codes_text": "55873", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare National Coverage Determinations Manual (NCD), Chapter 1 Coverage Determinations, Part 4 (Sections 200-310.1), §230.9 Cryosurgery of Prostate 9. Medicare Claims Processing Manual, Chapter 32 Billing Requirements for Special Services, §180 Cryosurgery of the Prostate Gland 10. AMA CPT Codebook", "codes": [ "55873" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d0fe6d47d3274aaf5f2a3ceecb4322d3f85bac6dd26c17e7c601de2d3cfe9ea3", "raw_sha256": "89283f3d3ffb733b02d85c56dab805b82e63b5ff6823b0c2d922ac766199bb98", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0131", "issue_number": "0131", "title": "0131-Pneumatic Compression Device: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-01-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0131-pneumatic-compression-device", "source_id": "cms-rac-approved", "description": "A physician or other qualified health care professional who reports Transitional Care Management CPT codes 99495 or 99496 may not report telephone service CPT codes 99441–99443 for the same beneficiary during the timeframe covered by the Transitional Care Management codes. Reporting both constitutes unbundling of services, and any payments will be recouped.", "codes_text": "99441, 99442, 99443", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. Medicare National Coverage Determination Manual, Chapter 1, Part 4 (Sections 200-310.1) Coverage Determinations, §280.6- Pneumatic Compression Devices 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, LCD L33829: Pneumatic Compression Devices; Effective 10/01/2015; Revised 10/22/2023 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52488: Pneumatic Compression Devices- Policy Article; Effective 10/01/2015; Revised 01/01/2020; Revised 10/22/2023 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 26. HCPCS Level II Codebook", "codes": [ "99441", "99442", "99443" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a9c6c2280b42e2efb7ffe0a8a8602abd46763504eec13b548573d9bde769ca1c", "raw_sha256": "a03de89cd41e679b3ececd609dfa7a6daa3938ae217b7e1397d0836217e3ecad", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0128", "issue_number": "0128", "title": "0128-Spinal Orthoses within the Reasonable Useful Lifetime: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2019-01-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0128-spinal-orthoses-within-the-reasonable-useful-lifetime-rul", "source_id": "cms-rac-approved", "description": "Claims for more than one spinal orthosis (identical HCPCS code) for the same beneficiary within the reasonable useful lifetime will be denied.", "codes_text": "L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 42 Code of Federal Regulations (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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 11. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 12. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L33790- Spinal Orthoses: TLSO and LSO; Effective 10/01/2015, Revised 01/01/2020 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52500- Spinal Orthoses: TLSO and LSO-Policy Article; Effective 10/01/2015, Revised 01/23/2024 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 17. HCPCS Level II Codebook", "codes": [ "L0470", "L0472", "L0480", "L0482", "L0484", "L0486", "L0488", "L0490", "L0491", "L0492", "L0621", "L0622", "L0623", "L0624", "L0625", "L0626", "L0627", "L0628", "L0629", "L0630", "L0631", "L0632", "L0633", "L0634", "L0635", "L0636", "L0637", "L0638", "L0639", "L0640", "L0641", "L0642", "L0643", "L0648", "L0649", "L0650", "L0651" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "73cdf7dc1e4b3772769aee0918eb43dd85ee976a5c7a1093c84f115272833b7a", "raw_sha256": "30649331b8ecdade5b82ad21ad3ee868e6c0bc14ecdfb00048a18d9b34dac0ef", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0133", "issue_number": "0133", "title": "0133-Positron Emission Tomography Scans Paid without Tracer Codes- Independent Diagnostic Testing Facility: Non-Allowable Service", "review_type": "Automated", "provider_type": "IDTF (Independent Diagnostic Testing Facility)", "jurisdiction": "All A/B MACs", "source_date": "2018-12-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0133-positron-emission-tomography-scans-paid-without-tracer-codes-independent-diagnostic-testing", "source_id": "cms-rac-approved", "description": "All PET Scans require the use of radiopharmaceutical diagnostic imaging agent (tracer). Claims billed without the required Tracer HCPCS codes will be recovered as overpayments.", "codes_text": "PET SCAN CPT Codes - 78429, 78430, 78431, 78432, 78433, 78434, 78491, 78492, 78459, 78608, 78811, 78812, 78813, 78814, 78815, 78816 Tracer Codes – A9515, A9526, A9552, A9555, A9586, A9587, A9588, A9595, A9597, A9598, Q9982, Q9983", "policy_text": "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 13- Radiology Services and Other Diagnostic Procedures, §60.3.1- Appropriate CPT Codes Effective for PET Scans for Services Performed on or After January 28, 2005; effective 09/07/2021 8. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.3.2- Tracer Codes Required for Positron Emission Tomography (PET Scans); Effective 09/07/2021 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [ "78429", "78430", "78431", "78432", "78433", "78434", "78459", "78491", "78492", "78608", "78811", "78812", "78813", "78814", "78815", "78816", "A9515", "A9526", "A9552", "A9555", "A9586", "A9587", "A9588", "A9595", "A9597", "A9598", "Q9982", "Q9983" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "3ae2389822b6443da0b4a4c42a0e17d865e2a213867bed89554c92c6265c65ba", "raw_sha256": "6c810c3119711fbdbe1f1759f929d3bb11b72d16ebc023da5918f07f736d145a", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0126", "issue_number": "0126", "title": "0126-Endoscopy Procedures: Diagnostic and Surgical Billed Same Day", "review_type": "Automated", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-12-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0126-endoscopy-procedures-diagnostic-and-surgical-same-day-", "source_id": "cms-rac-approved", "description": "Surgical endoscopy includes diagnostic endoscopy. A diagnostic endoscopy HCPCS/CPT code shall not be reported with a surgical endoscopy code. If multiple endoscopic services are performed, the most comprehensive code describing the service(s) rendered shall be reported.", "codes_text": "45378, 45330", "policy_text": "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 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- Correct Coding Policy, (E)- Separate Procedures, (G)- Family of Codes, and (H)- Most Extensive Procedures 9. National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services, Chapter VI – Digestive System CPT Codes 40000 - 49999, §C – Endoscopic Services 10. AMA CPT codebook", "codes": [ "45330", "45378" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "dd6f14a7d0fc3ccdaa0efa243e8271094672e10673a59d81cf0c335eb74f1c5e", "raw_sha256": "4f5436e8542259aaf2a664257603b03c520ab9c73bc485218bc1757f3fa64063", "texas": "national", "specialties": [ "Gastroenterology", "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0124", "issue_number": "0124", "title": "0124-Part B Therapies During Inpatient: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-12-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0124-part-b-therapies-in-a-hospital-setting", "source_id": "cms-rac-approved", "description": "For HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base, payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist, or speech language therapist in private practice.", "codes_text": "HCPCS/CPT Codes with a PC/TC Indicator of \"7\" in the MPFSDB", "policy_text": "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: CMS Publication 100-04; Chapter 23, - Fee Schedule Administration and Coding Requirements; Addendum- MPFSDB File Record Layout and Field Descriptions (For Historical Medicare Physician Fee Schedule Database (MPFSDB) Layouts 2001 – 2018, refer to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Historical-MPFSDB-Layouts.pdf located on the CMS Physician Fee Schedule web page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched) 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook 10. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0364c70a4901a4244d47f3e62245c71c5703d97a69bbce3b147ff929736e4da3", "raw_sha256": "d4ca4453f7fe73609d8e0d3f7b4215eabcd746573aa3cd14c5062f204457ad7b", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0115", "issue_number": "0115", "title": "0115-Professional Claims with Place of Service Home Overlapping Inpatient Hospital Stay: Services Billed Not Rendered", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-11-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0115-home-visits-physician-services-overlapping-inpatient-stay", "source_id": "cms-rac-approved", "description": "Home Visits for professional services should not overlap an active Inpatient Stay. Professional claims billed with a home-related place of service that overlaps an inpatient hospital stay will be denied.", "codes_text": "90901, 90912, 90913, 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92601, 92602, 92603, 92604, 92605, 92606, 92607, 92608, 92609, 92610, 92611, 92612, 92614, 92616, 95851, 95852, 96000, 96001, 96002, 96003, 96105, 96125, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97537, 97542, 97545, 97546, 97597, 97598, 97602, 97605, 97606, 97750, 97755, 97760, 97761, 97763, 97799, 20999, G0279, G0281, G0283, G0329", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2(B)- Exact Duplicate Claims, Claims Submitted by Physicians, Practitioners, and other Suppliers (except DMEPOS Suppliers) 9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Record Layout and Field Descriptions 10. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30- Services Paid Under the Medicare Physician’s Fee Schedule 11. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, §10.5- Place of Service Codes and Definitions 12. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30- Physician Services 13. AMA CPT Codebook 14. HCPCS Level II Codebook 15. CMS Medicare Physician Fee Schedule, Relative Value Files, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files.html", "codes": [ "20999", "90901", "90912", "90913", "92507", "92508", "92521", "92522", "92523", "92524", "92526", "92601", "92602", "92603", "92604", "92605", "92606", "92607", "92608", "92609", "92610", "92611", "92612", "92614", "92616", "95851", "95852", "96000", "96001", "96002", "96003", "96105", "96125", "97012", "97016", "97018", "97022", "97024", "97026", "97028", "97032", "97033", "97034", "97035", "97036", "97039", "97110", "97112", "97113", "97116", "97124", "97129", "97139", "97140", "97150", "97161", "97162", "97163", "97164", "97165", "97166", "97167", "97168", "97530", "97533", "97537", "97542", "97545", "97546", "97597", "97598", "97602", "97605", "97606", "97750", "97755", "97760", "97761", "97763", "97799", "G0279", "G0281", "G0283", "G0329" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "acea34321e2e6b77b174ef15112978caa3538d6904bc4eadf608834a6dc1ee8c", "raw_sha256": "ada707758b047ab7c35da3efa84db01b545e439d668c34cdf9e894bbe673d5c0", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0123", "issue_number": "0123", "title": "0123-Technical Component of Diagnostic Procedures during Inpatient: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-11-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0123-technical-component-tc-of-diagnostic-procedures-during-an-inpatient-stay", "source_id": "cms-rac-approved", "description": "When billed on the same date of service as an inpatient hospital claim, the Technical Component (TC) of diagnostics is not payable to the Part B provider. The technical component is performed by the facility while a patient is in a covered Part A Inpatient Stay.", "codes_text": "CPT Code Range 10000-99999 (Excluding CPT Codes 70000-89999) with PC/TC Indicators of 1 and 3", "policy_text": "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 Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §30.1-Provider-Based Physician Services 8. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, Addendum-MPFSDB File Record Layout and Field Descriptions 9. Medicare Claims Processing Manual, Chapter 23- Fee Schedule Administration and Coding Requirements, §30- Services Paid Under the Medicare Physician’s Fee Schedule 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. Physician Fee Schedule, https://www.cms.gov/medicare/physician-fee-schedule/search 12. AMA CPT Codebook", "codes": [ "10000", "70000", "89999", "99999" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "25fe66a770fa0e432d79a90fbd2ca7ff745bff8efaecac1934c89741d7078094", "raw_sha256": "043994d8fedb9b1d6e0cd0c15cf5d575505c0d6c0b57765e62adcea9703f9582", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0073", "issue_number": "0073", "title": "0073 - Inpatient Rehabilitation Facility: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Rehabilitation Facility (IRF)", "jurisdiction": "All A/B MACs", "source_date": "2018-11-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0073-inpatient-rehabilitation-facility-irf-stays-meeting-requirements-to-be-considered-reasonable-and-necessary-", "source_id": "cms-rac-approved", "description": "Medicare only pays for services that are reasonable and necessary for the setting billed. The inpatient rehabilitation facility (IRF) benefit is designed to provide intensive rehabilitation therapy in a resource intensive inpatient hospital environment for beneficiaries who, due to the complexity of their nursing, medical management, and rehabilitation needs, require and can reasonably be expected to benefit from an inpatient stay and an interdisciplinary team approach to the delivery of rehabilitation care. In order for IRF care to be considered reasonable and necessary, the documentation in the beneficiary’s IRF medical record must demonstrate a reasonable expectation that CMS criteria, as defined in 42 C.F.R. §§412.600-622 and CMS Pub. 100-02, Ch. 1 section 110, was met at the time of admission to the IRF. Claims that do not meet the indications of coverage and/or medical necessity will be denied and result in an overpayment.", "codes_text": "Inpatient Rehabilitation Facility, 11X", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1815(a)- Payment to Providers of Services 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e)- Payment of Benefits 4. Social Security Act (SSA), Title XVII- Health Insurance for the Aged and Disabled, §1834(m)(4)(F)- Telehealth Service 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1886(j)- Prospective Payment for Inpatient Rehabilitation Services 6. 42 CFR §400.200- Subchapter A, General Provisions, Definitions for Public Health Emergency 7. 42 CFR §405.929- Post-Payment Review 8. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 9. 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 10. 42 CFR 405.986- Good Cause for Reopening 11. 42 CFR §411.15(k)(1)- Any Services that are not Reasonable and Necessary 12. 42 CFR 412.29- Classification criteria for payment under the inpatient rehabilitation facility prospective payment system 13. 42 CFR 412.604(c)- Completion of patient assessment instrument 14. 42 CFR 412.606(b)- Comprehensive Assessments 15. 42 CFR 412.612(a) - Responsibilities of the clinician 16. 42 CFR §412.620- Patient classification system 17. 42 CFR 412.622- Basis of Payment, (a)- Method of Payment, (3)- IRF Coverage Criteria, (4)- Documentation, (5)- Interdisciplinary Team Approach to Care, and (c) Definitions- Week 18. 42 CFR 414.65- Payment for Telehealth Services 19. 42 CFR §424.32- Basic requirements for all claims 20. 45 CFR §162.1002(c)- Medical data code sets, for the period on or after October 1, 2015 21. Medicare Benefit Policy Manual, Chapter 1- Inpatient Hospital Services Covered Under Part A, §110 – Inpatient Rehabilitation Facility (IRF) Services 22. Medicare Claims Processing Manual, Ch. 1- General Billing Requirements, §80.3.2.2- Consistency Edits for Institutional Claims 23. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §140.3- Billing Requirements Under IRF PPS 24. Medicare Program Integrity Manual MPIM, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "353ae00063009389b6214ffa91952d5318ed9d14417c3e179b6a449c102e9c3d", "raw_sha256": "b93c705497fd5c6c9ff5216f497f321ccde6e257545cbb58ce906bb2fb56ee57", "texas": "national", "specialties": [ "Therapy & rehabilitation", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0114", "issue_number": "0114", "title": "0114-Durable Medical Equipment Billed during Hospice Period: Unbundling", "review_type": "Automated", "provider_type": "DME Physician, DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-10-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0114-dme-while-in-hospice", "source_id": "cms-rac-approved", "description": "All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services or any claims billed after the admit date of a patient to Hospice services and null discharge date (when patient status code is 30), will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier.", "codes_text": "CMS DMEPOS Fee Schedule: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII, §1861(dd)(1) of the Social Security Act- Hospice Care; Hospice Program 5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 42 CFR §405.929- Post-Payment Review 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS): Scope and conditions 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR, Section 418.202 (f), Hospice Care, Covered Services, Medical Appliances and Supplies, Including Drugs and Biologicals 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)) §10.2- Coverage Table for DME Claims; §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and required as a Result of Services Which Are Not Covered Under Medicare 15. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 16. CMS DMEPOS Fee Schedule, https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule. 17. AMA CPT Codebook 18. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "266308fb1d3f08a6f25441936d9732a8d02f3435d2cb63eedbe23d9ff6e22436", "raw_sha256": "1a1b307e107c2bd23b6cfc8626a44d06243de3ccd1ae8da56fb07596c3a29286", "texas": "national", "specialties": [ "DME & supplies", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0119", "issue_number": "0119", "title": "0119-Epidural Steroid Injection: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-10-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0119-transforaminal-epidural-steroid-injection-to-the-lumbar-or-sacral-level", "source_id": "cms-rac-approved", "description": "Epidural injections are generally performed to treat pain arising from spinal nerve roots. These procedures may be performed via three distinct techniques, each of which involves introducing a needle into the epidural space by a different route of entry. These are termed the interlaminar, caudal, and transforaminal approaches. The procedures involve the injection of a solution containing local anesthetic with or without corticosteroids. In order to be considered medically necessary, they must meet certain indications and procedural requirements.", "codes_text": "64483, 64484", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators, LLC, Local Coverage Determination L39015- Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/9/2023 9. CGS Administrators, LLC, Local Coverage Article A58731- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 03/13/2025 10. First Coast Service Options, Inc., Local Coverage Determination L33906- Epidural Steroid Injections for Pain Management; Effective 10/01/2015; Revised 12/12/2021 11. First Coast Service Options, Inc., Local Coverage Article A56651- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 10/03/2018; Revised 11/16/2023 12. National Government Services, Inc., Local Coverage Determination L39036- Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/23/2023 13. National Government Services, Inc., Local Coverage Article A58745- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/05/2021; Revised 11/23/2023 14. Noridian Healthcare Solutions, LLC (JE), Local Coverage Determination; L39240 Epidural Steroid Injections for Pain Management; Effective: 6/19/2022 15. Noridian Healthcare Solutions, LLC, Local Coverage Determination L39242- Epidural Steroid Injections for Pain Management; Effective: 6/19/2022 16. Noridian Healthcare Solutions, LLC, Local Coverage Article A58993- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 6/19/2022; Revised 11/15/2023 17. Noridian Healthcare Solutions, LLC, Local Coverage Article A58995- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 6/19/2022; Revised 11/15/2023 18. Novitas Solutions, Inc., Local Coverage Determination L36920- Epidural Injections for Pain Management; Effective: 5/4/2017; Revised 12/12/2021 19. Novitas Solutions, Inc., Local Coverage Article A56681- Billing and Coding: Epidural Injections for Pain Management; Effective: 7/11/2019; Revised 11/16/2023 20. Palmetto GBA, Local Coverage Determination L38994- Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/16/2023 21. Palmetto GBA, Local Coverage Article A58695- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/16/2023 22. Wisconsin Physicians Service, Local Coverage Determination L39054- Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 02/01/2024 23. Wisconsin Physicians Service, Local Coverage Article A58777- Billing and Coding: Epidural Steroid Injections for Pain Management; Effective 12/5/2021; Revised 11/30/2023 24. AMA CPT Codebook", "codes": [ "64483", "64484" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d2bfa307e325e836088ae292a7da1cfaefb35c2e4aa33412e1cf7dec76047f67", "raw_sha256": "d62fc0e162b1c3f15e81f4160687b140dabe1cb6d2430f6ac0aa498a85efe84d", "texas": "national", "specialties": [ "Anesthesia & pain" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0108", "issue_number": "0108", "title": "0108-Facility versus Non-Facility Reimbursement: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-10-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0108-facility-vs-non-facility-reimbursement", "source_id": "cms-rac-approved", "description": "Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and non-facility settings. The rate, facility or non-facility, which a physician service is paid under the MPFS is determined by the Place of service (POS) code that is used to identify the setting where the beneficiary received the face-to-face encounter with the physician, nonphysician practitioner (NPP) or other supplier. In general, the POS code reflects the actual place where the beneficiary receives the face-to-face service and determines whether the facility or non-facility payment rate is paid. However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS codes 19 or 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.", "codes_text": "All CPT/HCPCS codes with site-of-service differentials", "policy_text": "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 Claims Processing Manual Chapter 12- Physician/Non-Physician Practitioners, §20.4.2- - Site of Service Payment Differential", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "f27029fe493960c9e3d2d6494922ef80218438f1aab4e4500fa5ecc69e9b8845", "raw_sha256": "6d10d183a9859a3a6d8ee134c8bc51ef1b3269f2f71b9e6f9c7a560e49a4fadf", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0107", "issue_number": "0107", "title": "0107-Custom Fabricated Knee Orthoses: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-10-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0107-custom-fabricated-knee-orthosesmedical-necessity", "source_id": "cms-rac-approved", "description": "Claims for Custom-Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied.", "codes_text": "L1834, L1840, L1844, L1846, L1860", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 19. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 20. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME, §5.17- Definition of Customized DMEPOS 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33318: Knee Orthoses; Effective 10/01/2015; Revised 01/25/2026 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52465: Knee Orthoses - Policy Article; Effective 10/1/2015, Revised 01/25/2026 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 24. HCPCS Level II Codebook", "codes": [ "L1834", "L1840", "L1844", "L1846", "L1860" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0617535a3256342b6c7d27be4f0febe1ec9d6c19dd80c8a2ac78156ee5d0a202", "raw_sha256": "b866e32d90b5fd2b95044af2efb7c315319a2501ca95e52c1be87bb5d63c4487", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0110", "issue_number": "0110", "title": "0110-Skilled Nursing Facility Consolidated Billing: Part B – Use of Modifier 26, Professional Component", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-09-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0110-skilled-nursing-facility-snf-consolidated-billing-part-b-partial-", "source_id": "cms-rac-approved", "description": "When a Part B CPT/HCPCS code listed on File 2 (Professional Components of Services to be Submitted with a 26 Modifier) is billed during a paid inpatient Part A SNF stay, without modifier 26, the Part B claim will be repriced with modifier 26 to reflect the professional component reduction. The overpayment is identified by the difference between the original paid Part B amount and the re-calculated paid amount based on modifier 26 pricing.", "codes_text": "CPT/HCPCS codes listed on the CMS File 2 - Part A Stay - Professional Components of Services to be Submitted with a 26 Modifier. https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling/FileExplanation.html", "policy_text": "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 Claims Processing Manual, Chapter 6 (SNF Inpatient Part A Billing and SNF Consolidated Billing), §20.1.1- Physician’s Services and Other Professional Services Excluded from Part A PPS Payment and the Consolidated Billing Requirement 9. Medicare Claims Processing Manual, Chapter 25, §75.3 - - Form Locators 31-41, Guidelines for Occurrence and Occurrence Span Utilization 10. SNF Consolidated Billing - Part B Medicare Administrative Contractor (MAC) File Explanation - https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "5ef0ab745512eca40e16e4a2b76595499d8ff2322fc25d9260430b0db39e67d8", "raw_sha256": "1508153b4e142df6c8fc39c58440ae864633ae5c760098cb8b8f86e8a23957d3", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0111", "issue_number": "0111", "title": "0111-Transthoracic Echocardiography: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital; Outpatient Hospital; Skilled Nursing Facility (SNF)", "jurisdiction": "All A/B MACs", "source_date": "2018-09-04", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0111-transthoracic-echocardiography", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if transthoracic echocardiography meets Medicare coverage criteria, meets applicable coding guidelines, and/or is reasonable and necessary.", "codes_text": "93303, 93306, 93307, C8921, C8923", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. 42 Code of Federal Regulations §410.32(a) - Diagnostic X-Ray Tests, Diagnostic Laboratory Tests, and Other Diagnostic Tests: Conditions 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §80.6- Requirements for Ordering and Following Orders for Diagnostic Tests through §80.6.4- Rules for Testing Facility Interpreting Physician to Furnish Different or Additional Tests 10. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.4- Cardiovascular System (Codes 92950- 93799) 11. CGS Administrators, LLC, LCD L34338- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/5/2023 12. First Coast LCD L33768- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Retired 3/01/2023 13. NGS LCD L33577- Transthoracic Echocardiography (TTE); Effective 10/01/2015; Revised 10/01/2019 14. Palmetto GBA LCD L37379- Echocardiography; Effective 9/18/2017; Revised 6/10/2021 15. CGS Administrators, LLC, LCA A57306- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 9/26/2019; Revised 11/16/2023 16. First Coast LCA A57182- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 10/03/2018; Retired 3/01/2023 17. NGS LCA A56781- Billing and Coding: Transthoracic Echocardiography (TTE); Effective 8/01/2019; Revised 10/01/2023 18. Palmetto GBA LCA A56625- Billing and Coding: Echocardiography; Effective 6/20/2019; Revised 10/01/2023 19. AMA CPT Codebook", "codes": [ "93303", "93306", "93307", "C8921", "C8923" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0a8971a8a4105aa59d14f32088bc7db191f6aa67fdebf2fd37d7e2abdd00b1c6", "raw_sha256": "ae1eb98d0c389028fd847641bbe93a87b68ffc24e7dc0e210faf131234665a60", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0067", "issue_number": "0067", "title": "0067-Inpatient Psychiatric Facility Services: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital; Inpatient Psychiatric Facility (IPF)", "jurisdiction": "All A/B MACs", "source_date": "2018-09-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0067-inpatient-psychiatric-facility-services-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Inpatient hospital services furnished to a patient of an inpatient psychiatric facility will be reviewed to determine that services were medically reasonable and necessary.", "codes_text": "11X Hospital Inpatient (Part A) and Inpatient Psychiatric Facility excluding type of bills 118, 11P and 110, 117, 11G, 11H, 11I, 11Q", "policy_text": "1. Title XVIII of the Social Security Act (SSA), Section 1814(a)(2)(A) and (4)- Conditions of and Limitations on Payment for Services 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1815(a)- Payment to Providers of Services 3. Title XVIII of the Social Security Act (SSA), Section 1833(e)- Payment of Benefits 4. Title XVIII of the Social Security Act (SSA), Section 1835(a)- Procedure for Payment of Claims of Providers of Services 5. Title XVIII of the Social Security Act (SSA), Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as Secondary Payer 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986 - Good Cause for Reopening 10. 42 CFR 409.62- Lifetime Maximum on Inpatient Psychiatric Care 11. 42 CFR 412.27(c)- Excluded Psychiatric Units: Additional Requirements 12. 42 CFR 412.404- Conditions for Payment under the Prospective Payment System for Inpatient Hospital Services of Psychiatric Facilities 13. 42 CFR 424.14- Requirements for Inpatient Services of Inpatient Psychiatric Facilities 14. 42 CFR §424.5(a)(6)- Sufficient Information 15. 42 CFR 482.61- Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals 16. Medicare General Information, Eligibility, and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10.9- Inpatient Psychiatric Facility Services Certification and Recertification 17. Medicare Benefit Policy Manual, Chapter 2- Inpatient Psychiatric Hospital Services, section 20- Admission Requirements; section 30- Medical Records Requirements; section 30.1- Development of Assessment/Diagnostic Data; section 30.2- Psychiatric Evaluation; section 30.2.1- Certification and Recertification Requirements; section 30.2.1.1- Certification; section 30.2.1.2- Recertification; section 30.2.1.3- Delayed/Lapsed Certification and Recertification; section 30.3- Treatment Plan; section 30.3.1- Individualized Treatment or Diagnostic Plan; section 30.3.2- Services Expected to Improve the Condition or for Purpose of Diagnosis; section 30.4 - Recording Progress; section 30.5- Discharge Planning and Discharge Summary 18. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, section 190- Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) 19. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 20. American Psychiatric Association Diagnostic and Statistical Manual, Text Revision, Fifth Edition 21. ICD-10-CM codebook, Chapter 5- Mental, Behavioral and Neurodevelopmental disorders (F01-F99) 22. Inpatient Psychiatric Facility PPS FY Addendum A Final PPS Payment Updates https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/InpatientPsychFacilPPS/tools 23. MS-DRG Payment Book current year", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "532bb28b4b6b16644bc1446bb980cfd1b0255ad011af5795a54c3b3b60cafefd", "raw_sha256": "aec2a7c1fbb7fd47ae8c45c77f1feb4e64ecb13a3031a448410013aa91110c55", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0104", "issue_number": "0104", "title": "0104-Add-on Code Paid without Primary Code and/or Denied Primary Code- Ambulatory Surgical Center", "review_type": "Automated", "provider_type": "Ambulatory Surgical Center (ASC)", "jurisdiction": "All A/B MACs", "source_date": "2018-08-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0104-add-ons-paid-without-a-primary-and-or-denied-code-by-asc", "source_id": "cms-rac-approved", "description": "CMS 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 paid. ASC providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied.", "codes_text": "Add on Codes https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims 9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30- Correct Coding Policy 10. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 11. Medicare Claims Processing Manual, Chapter 29- Appeals of Claim Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals 12. Add-on Code Edits, as updated by CMS- https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits 13. AMA CPT Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0027d60c222edc24ea7935ccbe8042371cbabf4f9a5e50bcbc5f98463616d16b", "raw_sha256": "6b7bc424b9f8d9e4e0cd68eb4f7b0e3f95ae0ba11c54f100e7a3221dc897e42e", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0101", "issue_number": "0101", "title": "0101- Ambulatory Payment Classification Coding Validation", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2018-08-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0101-outpatient-hospital-comprehensive-apc-coding-validation-electrodes", "source_id": "cms-rac-approved", "description": "APC coding requires that procedural information, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate the APC by reviewing the billed services affecting or potentially affecting APC reimbursement.", "codes_text": "Claims with status indicators (SI) = J1, T, S, and K", "policy_text": "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. 42 CFR §419- Prospective Payment System for Hospital Outpatient Department Services 8. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS) §§10.1-10.5, 20, 40-50 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook 11. American Medical Association (AMA), Current Procedure Terminology (CPT), Coding and Payment, APC Payment Book, APC Grouping Logic: Comprehensive APCs (SI=J1), APCs for Hospital Part B services paid through a comprehensive APC (SI = J1), Procedure or Service, Not Discounted When Multiple (SI=S), Procedure or Service, Multiple Reduction Applies (SI = T) 12. AMA CPT Assistant 13. Medicare National Correct Coding Initiative (NCCI) Policy Manual 14. CMS Hospital Outpatient PPS, Addendum B Updates, available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html 15. American Hospital Association (AHA) Coding Clinic for Healthcare Common Procedure Coding System (HCPCS)", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "1118ddc59e222fa9e13389adcc8c584e4b611d332be38dd6a18f3422cfe5a8bb", "raw_sha256": "6ccec70b16b6a96adc09e0ef3a05da7ea707ad3053ce18f8c95bf835f5bb6855", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0103", "issue_number": "0103", "title": "0103-Urological Supplies: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-08-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0103-complex-urological-supplies", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Urological Supplies meet coverage criteria and/or are medically reasonable and necessary.", "codes_text": "Primary codes- A4311, A4312, A4314, A4315, A4338, A4341, A4342, A4344, A4351, A4352, A4353, A4354, A4357, A4358, A5102, A5112 Secondary codes- A4217, A4310, A4331, A4332, A4333, A4334, A4356", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33803: Urological Supplies; Effective 10/01/2015; Revised 01/01/2024 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52521: Urological Supplies- Policy Article; Effective 10/01/2015; Revised 4/01/2023 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 25. HCPCS Level II Codebook", "codes": [ "A4217", "A4310", "A4311", "A4312", "A4314", "A4315", "A4331", "A4332", "A4333", "A4334", "A4338", "A4341", "A4342", "A4344", "A4351", "A4352", "A4353", "A4354", "A4356", "A4357", "A4358", "A5102", "A5112" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "29d232af5319b1b1f3c44d6a036554fb315c6ddf7e773216590485452e081605", "raw_sha256": "289ddfbb18ec9abf9f748e9590513e7333cf05b3a2f5972d2bed28c238de74b8", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0100", "issue_number": "0100", "title": "0100-Add-on Code Paid without Primary Code and/or Denied Primary Code- Clinical Laboratory", "review_type": "Automated", "provider_type": "Laboratory/Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2018-07-15", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0100-add-code-paid-without-primary-code-andor-denied-primary-code-clinical-laboratory", "source_id": "cms-rac-approved", "description": "CMS 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. Clinical Laboratory providers paid for Add-On HCPCS/CPT codes without the required Primary code/or Denied Primary code will be denied.", "codes_text": "81266, 81265, 81416, 81415, 81426, 81425, 81536, 81535, 82952, 82951, 86826, 86825, 87187, 87186, 87188, 87503, 87502, 87904, 87903, 88155, 88142-88154, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88164-88167, 88174, 88175, 88177, 88172, 88185, 88184, 88314, 17311-17315, 88302-88309, 88329-88334, 88341, 88342, 88350, 88346, 88364, 88365, 88369, 88368, 88373, 88367, 88388", "policy_text": "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 01- General Billing Requirements, §70- Time Limitations for Filing Part A and Part B Claims 8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.D- Coding Services Supplemental to Principal Procedure (Add-On Codes) Code 9. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 10. Medicare Claims Processing Manual, Chapter 29- Appeals of Claim Decisions, §240- Time Limits for Filing Appeals & Good Cause for Extension of the Time Limit for Filing Appeals 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6 12. National Correct Coding Initiative, Add-on Code Edits https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits 13. AMA CPT Codebook", "codes": [ "17311", "17315", "81265", "81266", "81415", "81416", "81425", "81426", "81535", "81536", "82951", "82952", "86825", "86826", "87186", "87187", "87188", "87502", "87503", "87903", "87904", "88142", "88143", "88147", "88148", "88150", "88152", "88153", "88154", "88155", "88164", "88167", "88172", "88174", "88175", "88177", "88184", "88185", "88302", "88309", "88314", "88329", "88334", "88341", "88342", "88346", "88350", "88364", "88365", "88367", "88368", "88369", "88373", "88388" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0103d0f8ead7a5058d9c8b44ae5bb62abcaee8d72e3807ce318964e41fc647f2", "raw_sha256": "2dfc35ea6054d5ec5d9dcd50978105b2a772d7f039da037b0d5e8667ab2ed2da", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0098", "issue_number": "0098", "title": "0098-Critical Care Professional Services: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-07-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0098-unbundling-of-critical-care", "source_id": "cms-rac-approved", "description": "Certain CPT codes for Part B Professional services for the same Beneficiary, same Date of Service, and Same Provider will be recovered as overpayments as they are not payable when performed on the same day a physician bills for critical care. These services are included in the critical care service and should not be reported separately.", "codes_text": "36000, 36410, 36415, 36591, 36600, 43752, 43753, 71045, 71046, 92953, 93561, 93562, 93598, 94002, 94003, 94004, 94660, 94662, 94760, 94761, 94762", "policy_text": "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 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, § 30.6.12– Critical Care Visits and Neonatal Intensive Care (CPT Codes 99291-99292) 9. AMA CPT Codebook", "codes": [ "36000", "36410", "36415", "36591", "36600", "43752", "43753", "71045", "71046", "92953", "93561", "93562", "93598", "94002", "94003", "94004", "94660", "94662", "94760", "94761", "94762" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "66aa5380574ddeef8aecd84c745d8bf641e691d652752ca2b6a4e5c324cabc61", "raw_sha256": "395cfd1f62911057c48ff755cdc8ce33953b52f51d3f405295294ec5daf82c34", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0099", "issue_number": "0099", "title": "0099-Skilled Nursing Facility Consolidated Billing: Unbundling", "review_type": "Automated", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2018-06-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0099-skilled-nursing-facility-snf-consolidated-billing", "source_id": "cms-rac-approved", "description": "Payment for the Skilled Nursing Facility (SNF) services, listed in the SNF Consolidated Billing Table, Major Category I.F and V.A., provided to beneficiaries by the outpatient facility, in a Medicare covered Part A SNF stay, are included in a bundled prospective payment and are not separately payable. Payment for those services will be recouped as identified overpayments.", "codes_text": "CPT/HCPCS codes listed in the SNF Consolidated Billing Table, Major Category I.F and V.A.", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Biling, §§10-10.4- Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview; §§20- 20.6- Services Included in Part A PPS Payment Not Billable Separately by the SNF 9. CMS SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b6439b75683820200a9929523c6dd659ddeb11e236d9b8dd9ffb53e8c646832d", "raw_sha256": "5dea746998b3b5aecdef102c08d8648839a3723b9d362c20e55c7291eacbc16e", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0095", "issue_number": "0095", "title": "0095-Facet Joint Interventions: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2018-06-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0095-facet-injections", "source_id": "cms-rac-approved", "description": "Facet joint are joints in the spine that aid stability and allow the spine to bend and twist. Facet joint injections are a type of interventional pain management technique used to diagnose or treat back pain. Intraarticular blocks may provide temporary or long-lasting or permanent relief of facet-mediated pain. The review will identify whether the treatment meets indications for coverage and whether it exceeds the limitations of coverage.", "codes_text": "64490, 64491, 64492, 64493, 64494, 64495", "policy_text": "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 4 – Part B Hospital, §20.4 – Reporting of Service Units 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38801: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 02/03/2022 10. Noridian Healthcare Solutions, LLC, Local Coverage Determination (LCD) L38803: Facet Joint Interventions for Pain Management; Effective 4/25/2021; Revised 02/03/2022 11. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58403 - Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 11/06/2022 12. Noridian Healthcare Solutions, LLC, Local Coverage Article (LCA) A58405 - Billing and Coding: Facet Joint Injections for Pain Management; Effective 4/25/2021; Revised 11/06/2022 13. CGS Administrators, LLC, Local Coverage Determination (LCD) L38773 – Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 03/17/22 14. CGS Administrators, LLC, Local Coverage Article (LCA) A58364 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 05/02/21; Revised 11/16/2023 15. First Coast Service Options (FCSO), Inc. Local Coverage Determination (LCD) L33930 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 04/25/21 16. First Coast Service Options (FCSO), Inc. Local Coverage Article (LCA) A57787 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 10/03/18, Revised 11/30/2023 17. National Government Services (NGS), Inc. Local Coverage Determination (LCD) L35936 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 02/10/22 18. National Government Services (NGS), Inc. Local Coverage Article (LCS) A57826 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 12/05/19; Revised 11/06/2022 19. Novitas Solutions, Inc. Local Coverage Determination (LCD) L34892 – Facet Joint Interventions for Pain Management; Effective 10/01/15; Revised 04/25/21 20. Novitas Solutions, Inc. Local Coverage Article (LCA) A56670 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 07/11/19; Revised 11/30/2023 21. Palmetto GBA Local Coverage Determination (LCD) L38765 – Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 05/18/2023 22. Palmetto GBA Local Coverage Article (LCA) A58350 – Billing and Coding: Facet Joint Interventions for Pain Management; Effective 04/25/21; Revised 04/13/2023 23. WPS Insurance Corporation Local Coverage Determination (LCD) L38841 - Facet Joint Interventions for Pain Management; Effective 04/25/21, Revised 03/30/2023 24. WPS Insurance Corporation Local Coverage Article (LCA) A58477–– Billing and Coding: Facet Joint Injections for Pain Management; Effective 04/25/21; Revised 03/30/2023 25. AMA CPT Codebook, 50 - Bilateral Procedures, 59 - Distinct Procedural Service, Appendix D Summary of CPT Add-on Code", "codes": [ "64490", "64491", "64492", "64493", "64494", "64495" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "301bcc3f32fadbcae6f9476ea449154a7aa063086b9a38e3fd02bf313409d411", "raw_sha256": "234921194a4f125afa3689c5fcf9e17f75395765ff68314c87f3c40e1fa813d2", "texas": "national", "specialties": [ "Anesthesia & pain", "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0093", "issue_number": "0093", "title": "0093 - Implantable Automatic Defibrillators- Outpatient Procedure: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2018-05-14", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0093-automatic-defibrillators", "source_id": "cms-rac-approved", "description": "The implantable automatic defibrillator is an electronic device designed to detect and treat life-threatening tachyarrhythmias. The device consists of a pulse generator and electrodes for sensing and defibrillating. Medical documentation will be reviewed for medical necessity to validate that implantable automatic cardiac defibrillators are used only for covered indications.", "codes_text": "33216, 33217, 33224, 33225, 33230, 33231, 33240, 33249, 0571T, 0572T", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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 National Coverage Determinations (NCD) Manual: Chapter 1 – Coverage Determinations, Part 1, Section 20.4- Implantable Cardioverter Defibrillators (ICDs) 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 32- Billing Requirements for Special Services, §270- Claims Processing for Implantable Automatic Defibrillators (ICDs); §270.1- Coding Requirements for Implantable Cardiac Defibrillators (ICDs); §270.2- Billing Requirements for Patients Enrolled in a Data Collection System 10. CGS Local Coverage Article A57994- Billing and Coding: Implantable Automatic Defibrillators; Effective 01/01/2021; Retired 04/06/2026 11. NGS Local Coverage Article A56326- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 04/06/2026 12. Noridian Local Coverage Article A56340- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 04/06/2026 13. Noridian Local Coverage Article A56342- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 09/25/2025 14. Palmetto Local Coverage Article: A56343- Billing and Coding: Implantable Automatic Defibrillators; Effective 03/26/2019; Retired 04/06/2026 15. WPS Local Coverage Article A56391- Billing and Coding: Implantable Automatic Defibrillators; Effective 05/13/2019; Revised 01/01/2026 16. AMA CPT Codebook", "codes": [ "0571T", "0572T", "33216", "33217", "33224", "33225", "33230", "33231", "33240", "33249" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "f0a5fdd1e233186472dfde4ba8b96c79ded5e8011d2e3b682bec9fb0b7f67994", "raw_sha256": "1266771595b9c43f4195a460c33e9af02f2d93a37690cbfe5b9d83497bd58c54", "texas": "national", "specialties": [ "Cardiology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0094", "issue_number": "0094", "title": "0094 - Group 3 Pressure-Reducing Support Surfaces: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-05-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0094-group-3-support-surfaces", "source_id": "cms-rac-approved", "description": "Group 3 Pressure-Reducing Support Surfaces, HCPCS Code E0194, Air-Fluidized Bed is covered for the treatment of Stage III and Stage IV ulcers when the patient meets certain coverage criteria. This review will determine if the item provided was reasonable and necessary for the patient’s condition based on the documentation in the medical record. The reviewer will determine if the use of the Air-Fluidized Bed meets Medicare Coverage criteria.", "codes_text": "E0194", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4, Section 280.8- Air-Fluidized Beds 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, LCD L33692- Pressure Reducing Support Surfaces - Group 3; Effective 10/1/2015; Revised 05/01/2021 22. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A52468- Pressure Reducing Support Surfaces - Group 3- Policy Article; Effective 10/01/2015; Revised 01/01/2020 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 24. CGS Administrators, LLC and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426- Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 25. HCPCS Level II Codebook", "codes": [ "E0194" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "01569435a6493960ac4d983f118c47a9b43e0fb281be7418a4e83fa06c2c3d97", "raw_sha256": "ac58b5faf209a97dec4641c1476f3fcbb5f73d570ada3baa1c6fc37a666101a9", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0092", "issue_number": "0092", "title": "0092 - Percutaneous Implantation of Neurostimulator Electrode Array: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-05-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0092-percutaneous-implantation-of-neurostimulator-electrode-array", "source_id": "cms-rac-approved", "description": "The review shall identify claims billed incorrectly as percutaneous implantation of neurostimulator electrode arrays when the medical record demonstrates the transcutaneous placement of a device.", "codes_text": "64553, 64555, 95971, 95972", "policy_text": "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 National Coverage Determination Manual, Chapter 1, Part 1, §30.3- Acupuncture 8. Medicare National Coverage Determination Manual, Chapter 1, Part 2, §160.7.1(B)- Assessing Patients Suitability for Electrical Nerve Stimulation Therapy 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Noridian Healthcare Solutions, LLC Local Coverage Determination (LCD) L34328 Peripheral Nerve Stimulation Original Effective Date: 10/01/2015, Revised 12/01/2019 11. Noridian Healthcare Solutions, LLC LCD L37360 Peripheral Nerve Stimulation Original Effective Date: 08/27/2018; Revised 12/01/19 12. Noridian Healthcare Solutions, LLC LCA A55530 Billing and Coding Peripheral Nerve Stimulation (JE) Original Effective Date: 8/27/2018, Revised 01/01/2023 13. Noridian Healthcare Solutions, LLC LCA A55531 Billing and Coding: Peripheral Nerve Stimulation (JF) Original Effective Date: 8/27/2018, Revised 01/01/2023 14. Wisconsin Physicians Service Insurance Corporation Local Coverage Article (LCA) A56062 Billing and Coding: Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT), Original Effective Date: 8/01/2018, Revised 05/26/2022, Retired 01/26/2023 15. First Coast Service Options, Inc LCA A54794 Percutaneous electrical nerve stimulation (PENS) and percutaneous neuromodulation therapy (PNT) Original Effective Date: 12/24/2015, retired 01/01/22 16. AMA CPT Codebook", "codes": [ "64553", "64555", "95971", "95972" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "2a6a53ff0756b1a998f1a62597294df8496f76c6f531045a2634ef1f14575bf5", "raw_sha256": "1c157b99b747b627935337fbe0f810f99c574c66bb747db477ef168467c1b9b5", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0091", "issue_number": "0091", "title": "0091 - Duplicate Claims- Professional Services", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-05-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0091-exact-duplicate-claims", "source_id": "cms-rac-approved", "description": "Duplicate payments are any payments paid across more than one claim number for the same Beneficiary, CPT/HCPCS code, and service date by the same provider, in excess of a code’s Medically Unlikely Edit (MUE).", "codes_text": "All CPT, HCPCS codes", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, 10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient” 9. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1.A- Commonly Furnished in Physicians’ Offices 10. Medicare Alpha-Numeric HCPCS File 11. Annual American Medical Association: CPT Manual 12. Annual HCPCS Level II Manual 13. Medicare Part B Drug Average Sales Price; ASP Pricing File https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice 14. U.S. National Library of Medicine DailyMed", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "43d340b528e2134660770025e371f1e16c225b02cd7bb37a8e87c7009d7ab71a", "raw_sha256": "7a189ce524121bbfe911ad7db2f93626c6c44d4db2eae398bae8d586cfa4377c", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0088", "issue_number": "0088", "title": "0088 - Ancillary Services Billed Without an Approved Surgical Procedure", "review_type": "Automated", "provider_type": "Ambulatory Surgery Center (ASC)", "jurisdiction": "All A/B MACs", "source_date": "2018-04-14", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0088-ancillary-services-billed-without-an-approved-surgical-procedure", "source_id": "cms-rac-approved", "description": "Covered ancillary items and services identified in Appendix D are not payable if there is no approved ASC surgical procedure on the same claim or in history for the same date of service and same provider.", "codes_text": "All ancillary services", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §260- Ambulatory Surgical Center Services 9. Medicare Claims Processing Manual, Chapter 14- Ambulatory Surgical Centers, §40- Payment for Ambulatory Surgery 10. CMS Ambulatory Surgery Center Approved HCPCS Code and Payment Rates available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ASCPayment/11_Addenda_Updates 11. AMA CPT Codebook 12. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a1b467f5d106ee9e180a0cc1a8a002d74f5207fe8634d5b5363757b5bf26deb4", "raw_sha256": "50ddc79cf61095688716aa56527d8bcdf465662c05a984ddb9632db125dd70b1", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0090", "issue_number": "0090", "title": "0090 - Laboratory/Pathology Technical Component for Inpatient or Outpatient Hospitals: Unbundling", "review_type": "Automated", "provider_type": "IDTF (Independent Diagnostic Testing Facility); Laboratory; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-04-03", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0090-tc-of-lab-pathology-for-outpatient-hospitals", "source_id": "cms-rac-approved", "description": "The technical component (TC) of lab/pathology services furnished to patients in an inpatient or outpatient hospital setting are not separately payable.", "codes_text": "All Lab/Pathology CPT/HCPCS codes with TC/PC Indicator 1 or 3", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6. 8. Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12 Physician/Non-Physician Practitioners, § 60 (B) Payment for Technical Component (TC) Services 9. Medicare Claims Processing Manual; Chapter 23 – Fee Schedule Administration and Coding Requirements; Addendum – MPFSDB File Record Layout and Field Descriptions", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "5e4febbd542b69c627ccbb1a40f9e02c48ae7a9a5f328e4e35d15ee37b9ab77f", "raw_sha256": "1ac2d3be48326fc6a59d8c6b5a0fad3c4f83569c1f0667c7f5e2746a4ac341c6", "texas": "national", "specialties": [ "Hospital & post-acute", "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0089", "issue_number": "0089", "title": "0089 - Clinical Social Worker during Inpatient: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-03-14", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0089-clinical-social-worker-during-inpatient", "source_id": "cms-rac-approved", "description": "Services of Clinical Social Workers (CSW) rendered during Inpatient Hospital stays are included in the facility’s PPS payment and are not separately payable under Part B. CSW providers are expected to seek reimbursement from the facility.", "codes_text": "90785 - 90899", "policy_text": "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 §1861(hh)- Clinical Social Worker, (hh)(2)- Clinical Social Worker Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 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 CFR §409.10(a)(4)- Included Services- Medical Social Services 9. 42 CFR §410.73- Clinical Social Worker Services 10. 42 CFR §412.509(b)- Furnishing of Inpatient Hospital Services Directly or Under Arrangements 11. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §170- Clinical Social Worker (CSW) Services 12. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. AMA CPT Codebook", "codes": [ "90785", "90899" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a699e4917969ca355fc3e781ab565b64000c8031240f73dece2cf120cec99ca8", "raw_sha256": "8b07b446e5ad24a21c042b2409b176d390c324dff4afc9c2e53cfebc66b03711", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0087", "issue_number": "0087", "title": "0087 - Laboratory Services for End-Stage Renal Disease Subject to Part B Consolidated Billing : Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-03-14", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0087-labs-subject-to-part-b-consolidated-billing-esrd", "source_id": "cms-rac-approved", "description": "The ESRD PPS includes consolidated billing for limited Part B services included in the ESRD facility bundled payment. Certain laboratory services and limited drugs and supplies will be subject to Part B consolidated billing and are not separately payable when provided for ESRD beneficiaries by providers other than the renal dialysis facility.", "codes_text": "Labs subject to ESRD Consolidated Billing found on www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html", "policy_text": "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 Benefit Policy Manual, Chapter 11- End Stage Renal Disease, §20.2- Laboratory Services 8. Medicare Claims Processing Manual, Chapter 8- Outpatient ESRD Hospital, Independent Facility, and Physician/Supplier Claims, §60.1- Lab Services 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. ESRD PPS Consolidated Billing- www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/Consolidated_Billing.html 11. AMA CPT Codebook 12. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b89fc83185834f8c63291ba9362031d4da8dbac450d713bd8f7aeff9149a2319", "raw_sha256": "e4771a6ffc6a1d4e66263bf4094fdb1427d01ee3b956a9b6666fb54e61b8136e", "texas": "national", "specialties": [ "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0085", "issue_number": "0085", "title": "0085 - Laboratory Services Rendered During an Inpatient Stay: Unbundling", "review_type": "Automated", "provider_type": "Laboratory/Ambulance; Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2018-03-13", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0085-lab-services-rendered-during-an-inpatient-stay", "source_id": "cms-rac-approved", "description": "Laboratory services are covered under Part A, excluding anatomic pathology services and certain clinical pathology services. If billed separately, these are considered unbundled services.", "codes_text": "Applicable CPT codes 80047-87912", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.4- Payment of Nonphysician Services for Inpatients 9. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, Section 30.3- Method of Payment for Clinical Laboratory Tests- Place of Service Variation 10. AMA CPT Codebook", "codes": [ "80047", "87912" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a6a6eb328c52f26e0a0c55b9b9fd8e3166c122cb31bd0d0aa2de63d7f1b019f3", "raw_sha256": "39425bb1ff607a4df5f134796faac2dd84d09ef357c29308ed7161757e0ee979", "texas": "national", "specialties": [ "Hospital & post-acute", "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0081", "issue_number": "0081", "title": "0081 - Negative Pressure Wound Therapy: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-02-26", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0081-complex-medical-necessity-negative-pressure-wound-therapy-npwt-with-dwo", "source_id": "cms-rac-approved", "description": "This review will determine if Negative Pressure Wound Therapy is reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied", "codes_text": "E2402, A6550, A7000", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 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 §410.38- Durable Medical Equipment: Scope and Conditions42 C 8. FR, §414.210(f)- Payment for Replacement of Equipment 9. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 10. 42 CFR §405.929 Post-payment review 11. 42 CFR §405.930 Failure to respond to additional documentation request 12. 42 CFR §414.65- Payment for Telehealth Services 13. 42 CFR §410.78 Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.7.3.1 - Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33821: Negative Pressure Wound Therapy Pumps; Effective 10/01/2015; Revised 01/01/2024 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52511: Negative Pressure Wound Therapy Pumps- Policy Article; Effective 10/01/2015; Revised 08/15/2021 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 04/06/2020 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023", "codes": [ "A6550", "A7000", "E2402" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b77250ebb3645b634c9ac9eb40911addb38877340e8ec8b445291cb0afe54fe1", "raw_sha256": "0f26db2ddb53df72c3ca71ec9fbaad13a6360332d99bf4bf57fb6fb1cdc82395", "texas": "national", "specialties": [ "Dermatology & wound" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0080", "issue_number": "0080", "title": "0080 - Group 2 Support Surfaces: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2018-02-13", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0080-group-2-support-surfaces-dwo", "source_id": "cms-rac-approved", "description": "This review will determine if a Group II Pressure Reducing Support Surface is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "E0277, E0371, E0372, E0373", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33642: Pressure Reducing Support Surfaces- Group 2; Effective 10/01/2015; Revised 5/01/2021 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52490: Pressure Reducing Support Surfaces- Group 2- Policy Article; Effective 10/01/2015; Revised 01/01/2020 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 25. HCPCS Level II Codebook", "codes": [ "E0277", "E0371", "E0372", "E0373" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a6c92972a54d0565f596f2f267f0480ccef804bc2132c4dd7360123a03f2572d", "raw_sha256": "8162ed648bf8066c8efb59e99601722c995fb4886d14b939bb5267763b60861a", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0077", "issue_number": "0077", "title": "0077 - Annual Wellness Visit Billed Sooner than Eleven Whole Months Following the Initial Preventative Physical Examination", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2018-01-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0077-annual-wellness-visit", "source_id": "cms-rac-approved", "description": "The Annual Wellness Visit (AWV) is not payable if an Initial Preventive Physical Examination (IPPE) has been paid within the previous eleven (11) whole months.", "codes_text": "G0439, G0402", "policy_text": "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. 42 CFR §411.15- Particular Services Excluded from Coverage, (a)(1)- Routine Checkups 8. 42 CFR §411.15- Particular Services Excluded from Coverage, (k)(15), (16)- Any Services that are not Reasonable and Necessary, (15)-additional preventive services; (16) Annual Wellness Visit with PPE 9. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §140- Annual Wellness Visit (AWV) 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. HCPCS Level II Codebook", "codes": [ "G0402", "G0439" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "60a6dc44fc9b057032d0a086844a756a5670bd63857ac58fbe8e2c4558af11d3", "raw_sha256": "d535a93879752b55670257f8260a58707917a5fec9a703ed4a5b1f45b0b7e339", "texas": "national", "specialties": [ "Primary care" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Check beneficiary eligibility, prior IPPE/AWV history, and the earliest eligible date. Do not substitute a blanket 365-day scheduling rule for Medicare eligibility verification.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0074", "issue_number": "0074", "title": "0074 - Drugs and Biologicals in Single-Dose Vials: Incorrect Units Billed", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-12-21", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0074-excessive-or-insufficient-drugs-and-biologicals", "source_id": "cms-rac-approved", "description": "Claims billed with excessive or insufficient units will be reviewed to determine the actual amount administered and the correct number of billable/payable units.", "codes_text": "C9132, J0178, J0180, J0202, J0221, J0256, J0475, J0485, J0490, J0583, J0585, J0588, J0775, J0881, J0894, J0897, J1299, J1300, J1439, J1459, J1557, J1561, J1566, J1568, J1569, J1572, J1602, J1745, J1786, J1930, J2182, J2323, J2326, J2350, J2353, J2357, J2505, J2507, J2562, J2778, J3101, J3262, J3357, J3380, J3385, J3489, J7312, J7325, J7326, J7327, J9022, J9023, J9033, J9035, J9041, J9042, J9043, J9047, J9055, J9145, J9173, J9176, J9179, J9205, J9228, J9263, J9264, J9271, J9280, J9285, J9299, J9301, J9303, J9305, J9306, J9307, J9308, , J9311, J9312, J9315, J9354, J9395, Q2043, Q2050, J0220, J0480, J0584, J0586, J0587, J0598, J1442, J1610, J1640, J2278, J3111, J3370, J7170, J7179, J7198, J7201, J7205, J7207, J9025, J9032, J9153, P9045, P9047 Added 2/15/2021: J1750, Q0138 Added 10/15/2021: J0179, J0207, J0222, J0223, J0257, J0291, J0401, J0517, J0565, J0596, J0597, J0598, J0638, J0791, J0795, J0840, J0841, J0850, J0875, J0896, J1162, J1190, J1290, J1303, J1322, J1458, J1571, J1575, J1743, J1746, J1931, J1943, J1944, J2350, J2407, J2425, J2426, J2724, J2783, J2786, J2794, J2860, J3032, J3060, J3095, J3241, J3245, J3304, J3358, J3396, J9039, J9044, J9050, J9119, J9120, J9144, J9155, J9203, J9204, J9207, J9210, J9227, J9229, J9309, J9317, J9325, J9330, J9352, J9357, J9358, J9400 Added 7/01/2022: C9074, J0224, J1305, J1823, J2506, J7168, J7311, J7313, J7314, J9047, J9061, J9177, J9223, J9247, J9261, J9266, J9272, J9281, J9308, J9316, J9318, J9319, J9353, Q5103, Q5104, Q5107, Q5108, Q5111, Q5115, Q5118, Q5119, Q5120, Q5121, Q5122 Added 11/15/2023: J0129, J0219, J0491, J0717, J0741, J1302, J1306, J1437, J1448, J1449, J1556, J1559, J1628, J1826, J1952, J2356, J2406, J2777, J3145, J3240, J3315, J7169, J7318, J7322, J7351, J7511, J9037, J9198, J9202, J9245, J9268, J9269, J9274, J9298, J9302, J9332, J9349, J9355, J9356, J9359, J9600, Q3027, Q5123, Q5124, Q5126, Q5128, Q5130", "policy_text": "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. 42 CFR §414.904(a)(3)- Average sales price as the basis for payment; Method of payment 8. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services; §50.3- Incident to Requirements; §60.1- Incident to Physician’s Professional Services 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Medicare Claims Processing Manual, Chapter 17- Drugs and Biologicals, §10- Payment Rules for Drugs and Biologicals; §40- Discarded Drugs and Biologicals; §70- Claims Processing Requirements- General; §90.2- Drugs, Biologicals, and Radiopharmaceuticals; §100.2.9- Submission of Claims with the Modifier JW, “Drug Amount Discarded/Not Administered to Any Patient” 11. Medicare Alpha-Numeric HCPCS File- Alpha-Numeric HCPCS | CMS 12. AMA CPT Codebook 13. HCPCS Level II Codebook 14. Medicare Part B Drug Average Sales Price; ASP Pricing File- https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B-Drugs/McrPartBDrugAvgSalesPrice 15. U.S. National Library of Medicine DailyMed", "codes": [ "C9074", "C9132", "J0129", "J0178", "J0179", "J0180", "J0202", "J0207", "J0219", "J0220", "J0221", "J0222", "J0223", "J0224", "J0256", "J0257", "J0291", "J0401", "J0475", "J0480", "J0485", "J0490", "J0491", "J0517", "J0565", "J0583", "J0584", "J0585", "J0586", "J0587", "J0588", "J0596", "J0597", "J0598", "J0638", "J0717", "J0741", "J0775", "J0791", "J0795", "J0840", "J0841", "J0850", "J0875", "J0881", "J0894", "J0896", "J0897", "J1162", "J1190", "J1290", "J1299", "J1300", "J1302", "J1303", "J1305", "J1306", "J1322", "J1437", "J1439", "J1442", "J1448", "J1449", "J1458", "J1459", "J1556", "J1557", "J1559", "J1561", "J1566", "J1568", "J1569", "J1571", "J1572", "J1575", "J1602", "J1610", "J1628", "J1640", "J1743", "J1745", "J1746", "J1750", "J1786", "J1823", "J1826", "J1930", "J1931", "J1943", "J1944", "J1952", "J2182", "J2278", "J2323", "J2326", "J2350", "J2353", "J2356", "J2357", "J2406", "J2407", "J2425", "J2426", "J2505", "J2506", "J2507", "J2562", "J2724", "J2777", "J2778", "J2783", "J2786", "J2794", "J2860", "J3032", "J3060", "J3095", "J3101", "J3111", "J3145", "J3240", "J3241", "J3245", "J3262", "J3304", "J3315", "J3357", "J3358", "J3370", "J3380", "J3385", "J3396", "J3489", "J7168", "J7169", "J7170", "J7179", "J7198", "J7201", "J7205", "J7207", "J7311", "J7312", "J7313", "J7314", "J7318", "J7322", "J7325", "J7326", "J7327", "J7351", "J7511", "J9022", "J9023", "J9025", "J9032", "J9033", "J9035", "J9037", "J9039", "J9041", "J9042", "J9043", "J9044", "J9047", "J9050", "J9055", "J9061", "J9119", "J9120", "J9144", "J9145", "J9153", "J9155", "J9173", "J9176", "J9177", "J9179", "J9198", "J9202", "J9203", "J9204", "J9205", "J9207", "J9210", "J9223", "J9227", "J9228", "J9229", "J9245", "J9247", "J9261", "J9263", "J9264", "J9266", "J9268", "J9269", "J9271", "J9272", "J9274", "J9280", "J9281", "J9285", "J9298", "J9299", "J9301", "J9302", "J9303", "J9305", "J9306", "J9307", "J9308", "J9309", "J9311", "J9312", "J9315", "J9316", "J9317", "J9318", "J9319", "J9325", "J9330", "J9332", "J9349", "J9352", "J9353", "J9354", "J9355", "J9356", "J9357", "J9358", "J9359", "J9395", "J9400", "J9600", "P9045", "P9047", "Q0138", "Q2043", "Q2050", "Q3027", "Q5103", "Q5104", "Q5107", "Q5108", "Q5111", "Q5115", "Q5118", "Q5119", "Q5120", "Q5121", "Q5122", "Q5123", "Q5124", "Q5126", "Q5128", "Q5130" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "da517fc6158195bdfe8f91a538303e84a1fc19849e4beb684b4f56662c65d8b2", "raw_sha256": "8dd0bea88f5d09a81f9b17e71063ab22f56070478557ab6751718f14210ffb42", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0075", "issue_number": "0075", "title": "0075 - Home Health: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Home Health Agency (HHA)", "jurisdiction": "All HHH MACs", "source_date": "2017-12-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0075-complex-home-health-review-documentation-and-medical-necessity", "source_id": "cms-rac-approved", "description": "This review will determine whether the Home Health care is reasonable and necessary, based on documentation in the medical record.", "codes_text": "Revenue Codes: 042X, 043X, 044X, 023X, 055X, 056X, 057X", "policy_text": "1. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Sections 1814(a)(2)(C) - Conditions of and Limitations on payment for services 2. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1815 – Payment to providers of services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 4. Social Security Act (SSA), Title XVIII-Health Insurance for the Aged and Disabled, Section 1834(m)- Payment for Telehealth Services 5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1835(a)(2)(A) – Procedure for payment of claims of providers of services 6. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(m) – Home Health Services; (o) Home Health Agency; (r) Physician. 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Sections 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer; 1862(a)(1)(A) (I), and 1862(B)(7)(f)- Exclusions from Coverage and Medicare as a Secondary Payer 8. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1891 – Conditions of Participation for Home Health Agencies; Home Health Quality 9. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, § 1895(b)(3)(B)(v)(IV)- Prospective Payment for Home Health Services 10. Coronavirus Aid, Relief, and Economic Security (CARES) Act, Pub. L. No. 116-136, § 3708- Improving Care Planning for Medicare Home Health Services, Effective Date: 03/01/2020 11. 42 CFR §405.929- Post-Payment Review 12. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 13. 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 14. 42 CFR § 405.986- Good Cause for Reopening 15. 42 CFR § 409.41 – Requirement for Payment 16. 42 CFR § 409.42 – Beneficiary qualifications for coverage of services 17. 42 CFR § 409.43 – Plan of care requirements 18. 42 CFR § 409.44 – Skilled services requirements 19. 42 CFR § 409.45 – Dependent services requirements 20. 42 CFR § 409.46 – Allowable administrative costs 21. 42 CFR § 409.47 – Place of service requirements 22. 42 CFR § 409.48- Visits 23. 42 CFR § 409.49- Excluded Services 24. 42 CFR § 414.65- Payment for Telehealth Services 25. 42 CFR § 424.22– Requirement for home health services 26. 42 CFR § 484.2 - Definitions 27. 42 CFR § 484.45- Condition of participation: Reporting OASIS information 28. Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 3 (Sections 170 – 190.34) Coverage Determinations, Section 170.1- Institutional and Home Care Patient Education Programs 29. Medicare General Information, Eligibility and Entitlement Manual, Chapter 4- Physician Certification and Recertification of Services, Section 10- Certification and Recertification by Physicians for Hospital Services – General, Subsection 10.2- Who May Sign Certification or Recertification; Section 30- Certification and Recertification by Physicians and Allowed Practitioners for Home Health Services, Subsection 30.1- Content of Physician or Allowed Practitioner’s Certification 30. Medicare Benefit Policy Manual Chapter 7 - Home Health Services, Section 10.6 - Low Utilization Payment Adjustment (LUPA) 31. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 20- Conditions to be Met for Coverage of Home Health Services 32. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 30- Conditions Patient Must Meet to Qualify for Coverage of Home Health-Effective 01/01/2022; Implementation 05/26/2022 33. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 40- Covered Services Under a Qualifying Home Health Plan of Care 34. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 50- Coverage of Other Home Health Services 35. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 70- Duration of Home Health Services 36. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 80, Specific Exclusions from Coverage as Home Health Services, Subsection 80.10- Telecommunications Technology 37. Medicare Benefit Policy Manual, Chapter 7 - Home Health Services, Section 110- Use of telehealth in Delivery of Home Health Services 38. Medicare Benefit Policy Manual, Chapter 15 – Covered Medical and Other Health Services, Section 60 – Services and Supplies - Subsection- 60.4.1 - Definition of Homebound Patient Under the Medicare Home Health (HH) Benefit (Rev. 11355; Issued: 04/14/22; Effective: 05/16/22; Implementation: 05/16/22) 39. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, Section 180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 40. Medicare Claims Processing Manual, Chapter 10 – Home Health Agency Billing, Section 10 – General Guidelines for Processing Home Health Agency (HHA) Claims 41. Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, §§ 3.2.3.1(A)- Outcome Assessment Information Set (OASIS) and (B)- Plan of Care, and 3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests; 3.3.1.1(B)- Medical Record Review; 3.3.2.1- Documents on Which to Base a Determination; 3.3.2.1.1- Progress Notes and Templates; 3.3.2.2-Absolute Words and Prerequisite Therapies; 3.3.2.4- Signature Requirements; 3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation; 3.5- Postpayment Medical Record Review of Claims; 3.6.2.1- Coverage Determinations; 3.6.2.2- Reasonable and Necessary Criteria; 3.6.2.4- Coding Determination 42. Medicare Program Integrity Manual, Chapter 6, Medicare Contractor Medical Review Guidelines for Specific Services, §6.2.3 The Use of the Patient’s Medical Record Documentation to Support the Home Health Certification, §6.2.1.1 Certification Requirements, §6.2.4 Coding, §6.2.5 Medical Necessity of Services Provided 43. Centers for Medicare and Medicaid Services, Outcome and Assessment Information Set OASIS-E Manual, Updated January 1, 2024 OASIS User Manuals | CMS 44. Palmetto Low Utilization Payment Adjustment (LUPA) Threshold Lookup: https://www.palmettogba.com/palmetto/jmhhh.nsf/DID/1TKOUO16TG#:~:text=The%20LUPA%20threshold%20ranges%20between,threshold%20of%205%20in%202021. 45. CGS Home Health Low Utilization Payment Adjustment (LUPA) Threshold Calculator: https://www.cgsmedicare.com/medicare_dynamic/j15/lupa/lupa_threshold.aspx", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "c89799422812e0d96ca5d054afbb0cd018e946734f100df37f46201cc542f306", "raw_sha256": "44175001e7ef43ce749fc6709d1596cfae74be9104870e46f423c0dd34148975", "texas": "unresolved", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0069", "issue_number": "0069", "title": "0069 - Respiratory Assist Devices: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-12-12", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0069-respiratory-assist-device", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Respiratory Assist Devices meet coverage criteria and /or are medically reasonable and necessary.", "codes_text": "E0470; E0471; E0561; E0562; A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034; A4604, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determination Manual, Ch. 1, Part 4 - Coverage Determinations, §240.9, Noninvasive Positive Pressure Ventilation (NIPPV) in the Home for the Treatment of Chronic Respiratory Failure (CRF) Consequent to Chronic Obstructive Pulmonary Disease (COPD), (I) Respiratory Assist Devices (RADs) 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Post payment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination (LCD) L33800: Respiratory Assist Devices; Effective 10/1/2015; Revised 06/09/2025 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52517: Respiratory Assist Devices- Policy Article; Effective 10/1/2015; Revised 06/09/2025 24. HCPCS Level II Codebook", "codes": [ "A4604", "A7027", "A7028", "A7029", "A7030", "A7031", "A7032", "A7033", "A7034", "A7035", "A7036", "A7037", "A7038", "A7039", "A7044", "A7045", "A7046", "E0470", "E0471", "E0561", "E0562" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "d8fd8987f90e477a93975c4fc105eeec78723f4658990a3790f6dc9707efa923", "raw_sha256": "cb330553aa22145d622a244a86e08c51b609b7711b8839d1de67df60373df9fe", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0072", "issue_number": "0072", "title": "0072 - Outpatient Service Overlapping or During an Inpatient Stay: Duplicate Payments", "review_type": "Automated", "provider_type": "Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2017-10-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0072-outpatient-service-overlapping-or-during-an-inpatient-stay", "source_id": "cms-rac-approved", "description": "Outpatient service dates that fall totally within inpatient admission and discharge dates at the same or another provider or outpatient bill that overlaps an inpatient admission are considered exact duplicates and should be rejected.", "codes_text": "Eligible codes with TOB 11x, 12x and 13x", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. 42 CFR §412.50- Furnishing of inpatient hospital services directly or under arrangements 9. Medical Benefit Policy Manual, Chapter 6- Hospital Services Covered under Part B, §10.2- Other Circumstances in Which Payment Cannot Be Made Under Part A 10. Medical Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims 11. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §120.2 (A)- Exact Duplicates- Submission of Institutional Claims 12. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §40.3 (B)- Outpatient Services Treated as Inpatient Services- Preadmission Diagnostic Services 13. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling 14. Medicare Claims Processing Manual, Chapter 4- Part B Hospital (Including Inpatient Hospital Part B and OPPS), §200.2- Hospital Dialysis Services for Patients With and Without End Stage Renal Disease (ESRD) 15. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4- CWF Editing of Ambulance Claims for Inpatients 16. Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services, §10.2- Billing Requirements 17. Medicare Financial Management Manual, Chapter 3- Overpayments, §10.2- Individual Overpayments 18. AMA CPT Codebook 19. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "10ed362f4b515bec7cad835ba2fc0d88db5e7e04e1e756389098939a636ba19c", "raw_sha256": "860ae3a4074aa72fb96690e6696c8e248f4a8db05b71c0b7d1c21836d940a265", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0070", "issue_number": "0070", "title": "0070-Critical Care Billed on the Same Day as Emergency Room Services: Unbundling", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-10-04", "rac_status": "Approved", "source_url": "https://www.cms.gov/data-research/monitoring-programs/medicare-fee-service-compliance-programs/medicare-fee-service-recovery-audit-program/approved-rac-topics/0070-critical-care-billed-same-day-emergency-room-services-unbundling", "source_id": "cms-rac-approved", "description": "Hospital emergency department services are not payable for the same calendar date as critical care services when billed for the same beneficiary, on the same date of service and by the same service provider (based on Tax ID and Provider Specialty Code).", "codes_text": "99281, 99282, 99283, 99284, 99285", "policy_text": "1. 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. 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 12- Physicians/Nonphysician Practitioners, §30.6.9 - Payment for Inpatient Hospital Visits – General 8. Medicare Claims Processing Manual: Chapter 12- 30.6.9.1 - Payment for Initial Hospital Care Services and Observation or Inpatient Care Services (Including Admission and Discharge Service) 9. Medicare Claims Processing Manual: Chapter 12- §30.6.12 (for dates prior to 5/9/2021) – Critical Care Visits and Neonatal Intensive Care (Codes 99291-99292), Section (H)- Critical Care Services and Other Evaluation and Management Services Provided on Same Day and Section (I) – Critical Care Services Provided by Physicians in Group Practice(s) 10. Medicare Claims Processing Manual: Chapter 12 – 30.6.12 (for dates after 05/09/21) – Critical Care and Neonatal Intensive Care (Codes 99291- 99292) (Effective 01/01/22; Implementation 02/15/22) 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 12. CPT Manual", "codes": [ "99281", "99282", "99283", "99284", "99285" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ad4f48e9f8d452aa44b38de6de2962793d9cd04c657897fec4c034fd20d8e0a1", "raw_sha256": "41b902b68adcbab53e8c394e4fd9c91f7b2efb9bf6b4dd2fdd40742decb7dfe5", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0065", "issue_number": "0065", "title": "0065 - Continuous Positive Airway Pressure Machine without an Obstructive Sleep Apnea Diagnosis", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-09-07", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0065-dme-cpap-without-obstructive-sleep-apnea-diagnosis", "source_id": "cms-rac-approved", "description": "Continuous positive airway pressure machines (CPAPs) billed without the diagnosis of obstructive sleep apnea (OSA) will be denied.", "codes_text": "E0601", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 14. Medicare National Coverage Determinations Manual: Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations; Section 240.4 - Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA); Effective March 13, 2008 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, Effective 10/01/2015; Revised 09/27/2021 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52467: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea- Policy Article; Effective 10/01/2015; Revised 8/8/2021 17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 01/01/2023 18. HCPCS Level II Codebook", "codes": [ "E0601" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "036372e0579f3e98ab5dfcce89a671cf6c764a29e84f04b29846efd9b21e50d5", "raw_sha256": "7fc63040838e1701017bd0c0fce40dc90091c6f0003f9ba4ed24ccc1feafa980", "texas": "national", "specialties": [ "Pulmonary & sleep" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0064", "issue_number": "0064", "title": "0064 - Facility Duplicate Claims", "review_type": "Automated", "provider_type": "Inpatient Hospital; Outpatient Hospital; Skilled Nursing Facility (SNF)", "jurisdiction": "All A/B MACs", "source_date": "2017-09-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0064-facility-duplicate-claims", "source_id": "cms-rac-approved", "description": "Duplicate claims or line date of service items will be denied.", "codes_text": "All CPT and All HCPCS", "policy_text": "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 1 – General Billing Requirements, §120.2- Exact Duplicates 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook 10. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "c8a3cd3509e742daeaf4e6f3f02469fa6c02af178a464e600f0465c4b1be6bc9", "raw_sha256": "989d94ac58a9a56074ce2ca88f3f9389bc1fe939ed2be84c0f259afd18c3214f", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0062", "issue_number": "0062", "title": "0062 - Radiology: Technical Component during Inpatient Stay", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-09-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0062-tc-of-radiology-inpatient-full", "source_id": "cms-rac-approved", "description": "Carriers may not pay for the technical component (TC) of radiology services furnished to patients during inpatient stay. Query identifies TC portion of radiology paid to entities other than the inpatient facility. Findings are limited to claim lines billed with modifier TC and claim lines for service codes with TC/PC Indicator \"1\" and/or “3” for TC component only.", "codes_text": "All CPT/HCPCS codes with TC/PC Indicator 1 and/or 3; Type of Service Indicator code 4 and/or 6; CPT/HCPCS modifier TC (technical component) CPT/HCPCS modifier 26 (professional component). Overpaid claims are limited to CPT Codes in the 70000-79999 range", "policy_text": "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 13 Radiology Services and Other Diagnostic Procedures, § 20.2.1 Hospital and Skilled Nursing Facility (SNF) Patients 8. Medicare Claims Processing Manual, Chapter 23, - Fee Schedule Administration and Coding Requirements; Addendum- MPFSDB File Record Layout and Field Descriptions 9. Medicare Claims Processing Manual, Chapter 26- Completing and Processing Form CMS-1500 Data Set, § 10.7 – Type of Service (TOS) 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. AMA CPT Codebook", "codes": [ "70000", "79999" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b957bc6683698e3e0b9fb6d3f0d1ad228962f288939a2ed3a568c056bab3c5cc", "raw_sha256": "9325ce21e4eec12548cdae77b8c62cc0dfd92184bd15ccfd9fdd5117a21b5ba2", "texas": "national", "specialties": [ "Hospital & post-acute", "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0061", "issue_number": "0061", "title": "0061 - Nursing Facility Services: Excessive Units", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-09-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0061-excessive-units-of-nursing-facility-services", "source_id": "cms-rac-approved", "description": "The Nursing Facility Services codes represent a “per day” service. As such, these codes may only be reported once per day, per Beneficiary, Provider, and date of service. Relevant CPT codes billed more than once per day will result in an overpayment.", "codes_text": "99304, 99305, 99306, 99307, 99308, 99309, 99310", "policy_text": "1. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 3. 42 Code of Federal Regulations §405.929- Post-Payment Review 4. 42 Code of Federal Regulations §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 Code of Federal Regulations §405.986- Good Cause for Reopening 7. Medicare Claims Processing Manual, Chapter 12 Physicians/Nonphysician Practitioners, § 30.6.13 Nursing Facility Services, (B) Visits to Comply with Federal Regulations (42 CFR 483.40 (c) (1)) in the SNF and NF). 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook", "codes": [ "99304", "99305", "99306", "99307", "99308", "99309", "99310" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "2bb727592efa3d401face5640bf7d584d6c6087d7c39dd354efa662975afeeaa", "raw_sha256": "d980cf1612d7d444ec5608e892fd009a9c8dc592bb8bd0a6fe08597f4771b086", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0060", "issue_number": "0060", "title": "0060 - Untimed Therapy: Excessive Units", "review_type": "Automated", "provider_type": "Comprehensive Outpatient Rehabilitation Facility (CORF); Outpatient Hospital; Outpatient Rehabilitation Facility (ORF); Professional Services; Skilled Nursing Facility", "jurisdiction": "All A/B MACs", "source_date": "2017-09-06", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0060-excessive-units-untimed-therapy", "source_id": "cms-rac-approved", "description": "When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider may not exceed (1) in the units billed column per date of service.", "codes_text": "92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609,92611, 92612, 92614, 92616, 97012, 97016, 97018, 97022, 97024, 97028, 97150 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, G0281, G0283, G0329", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. Medicare Benefit Policy Manual: Chapter 15- Covered Medical and Other Health Services, §220- Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance; §230- Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology 9. Medicare Claims Processing Manual, Chapter 5- Part B Outpatient Rehabilitation and CORF Services, §10.3.2- Exceptions Process; §10.6- Functional Reporting; §20.2- Reporting of Service Units with HCPCS 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [ "92507", "92508", "92521", "92522", "92523", "92524", "92526", "92597", "92609", "92611", "92612", "92614", "92616", "97012", "97016", "97018", "97022", "97024", "97028", "97150", "97161", "97162", "97163", "97164", "97165", "97166", "97167", "97168", "G0281", "G0283", "G0329" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "8a7d2b329c84977cbe61c5d6fb537b73eebbea10369d41836d9bf798b40e1f38", "raw_sha256": "390db3210150408553ddc0e289cc103b1f9f1479a77760bc53a70eeac8458bb0", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0049", "issue_number": "0049", "title": "0049 - Ambulance Transfer between Skilled Nursing Facilities: Unbundling", "review_type": "Automated", "provider_type": "Laboratory/Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2017-08-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0049-ambulance-snf-to-snf-transfer", "source_id": "cms-rac-approved", "description": "Under the prospective payment system, some ambulance transportation provided by outside suppliers to SNF residents is included in the SNFs’ Medicare Part A payments and is subject to consolidated billing. Therefore, Medicare Part B payments that suppliers receive for the ambulance transportation are overpayments.", "codes_text": "A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434, A0998", "policy_text": "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. 42 CFR §411.15(p)(3)(iv)- Services furnished to SNF residents 8. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10.3.3- Separately Payable Ambulance Transport Under Part B Versus Patient Transportation That is Covered Under a Packaged Institutional Service 9. Medicare Claims Processing Manual; Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.3.1- Ambulance Services 10. Medicare Claims Processing Manual, Chapter 15- Ambulance, § 30.2.2- SNF Billing 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 12. HCPCS Level II Codebook", "codes": [ "A0021", "A0080", "A0090", "A0100", "A0110", "A0120", "A0130", "A0160", "A0170", "A0180", "A0190", "A0200", "A0210", "A0225", "A0380", "A0382", "A0384", "A0390", "A0392", "A0394", "A0396", "A0398", "A0420", "A0422", "A0425", "A0426", "A0427", "A0428", "A0429", "A0432", "A0433", "A0434", "A0998" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "10e0a877a213443291e199dc6766c618ff02f7225e61b5a0ca34a2b2571cf992", "raw_sha256": "98a6b820963c2b7416fa39fe2f7d5d09dbf8d521e2e4a4b6724a518583347658", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0024", "issue_number": "0024", "title": "0024 - Spinal Orthoses: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-08-02", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0024-complex-comprehensive-spinal-orthosis-delivery", "source_id": "cms-rac-approved", "description": "This review will determine if a Spinal Orthoses is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "L0452, L0480, L0482, L0484, L0486, L0629, L0632, L0634, L0636, L0638, L0640, A9270, L0456, L0457, L0625, L0627, L0637, L0642, L0648, L0650, L0631, L0635, L0639, L0651", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 19. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33790- Spinal Orthoses: TLSO and LSO; Effective 10/01/2015; Revised 01/01/2020 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52500- Spinal Orthoses: TLSO and LSO- Policy Article; Effective 10/01/2015; Revised 01/23/2024 23. HCPCS Level II Codebook", "codes": [ "A9270", "L0452", "L0456", "L0457", "L0480", "L0482", "L0484", "L0486", "L0625", "L0627", "L0629", "L0631", "L0632", "L0634", "L0635", "L0636", "L0637", "L0638", "L0639", "L0640", "L0642", "L0648", "L0650", "L0651" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "91e8dc125c3313bdee5d41e4038908da1106143198a66f865c44a16c24ad01f2", "raw_sha256": "ae1800b702c467876af8a0e15e0bfc1086ef201551f39b445d71d8f2929f79b9", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0056", "issue_number": "0056", "title": "0056 - Evaluation and Management Services in Skilled Nursing Facilities: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-08-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0056-evaluation-and-management-e-m-coding-in-skilled-nursing-facilities", "source_id": "cms-rac-approved", "description": "Claims with CPT inpatient hospital care evaluation and management (E/M) codes billed for services rendered to a patient residing in a skilled nursing facility (SNF), with no inpatient hospital facility claim for the same date of service, will be adjusted to equivalent CPT SNF E/M codes.", "codes_text": "99223, 99232, 99233", "policy_text": "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 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/ Non Physician Practitioners, §30.6.13- Nursing Facility services 9. American Medical Association (AMA) Current Terminology Manual (CPT), Evaluation and Management section, Nursing Facility Services GuidelinesRe", "codes": [ "99223", "99232", "99233" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "90f222e6e4ad1562447fb6064094f98e165da27a99c0940e7fe74d4296a57cd6", "raw_sha256": "b2696ac0057dd35bd9e3024bf2baaa82c7240ae4cb3cd5f95d9b6dd36638f822", "texas": "national", "specialties": [ "Primary care", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0013", "issue_number": "0013", "title": "0013 - Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-07-05", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0013-ankle-foot-orthoses-and-knee-ankle-foot-orthoses-medical-necessity-and-documentation-requirements-", "source_id": "cms-rac-approved", "description": "This review will determine if the Ankle-Foot or Knee-Ankle-Foot Orthosis is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1933, L1940, L1945, L1950, L1951, L1952, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136, L4370, L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33686- Ankle-Foot/ Knee-Ankle-Foot Orthosis, Effective 10/01/2015; Revised 01/01/2025 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52457- Ankle-Foot/ Knee-Ankle-Foot Orthoses- Policy Article, Effective 10/01/2015; Revised 01/01/2025 25. HCPCS Level II Codebook", "codes": [ "L1900", "L1902", "L1904", "L1906", "L1907", "L1910", "L1920", "L1930", "L1932", "L1933", "L1940", "L1945", "L1950", "L1951", "L1952", "L1960", "L1970", "L1971", "L1980", "L1990", "L2000", "L2005", "L2010", "L2020", "L2030", "L2034", "L2035", "L2036", "L2037", "L2038", "L2106", "L2108", "L2112", "L2114", "L2116", "L2126", "L2128", "L2132", "L2134", "L2136", "L2180", "L2182", "L2184", "L2186", "L2188", "L2190", "L2192", "L2200", "L2210", "L2220", "L2230", "L2232", "L2240", "L2250", "L2260", "L2265", "L2270", "L2275", "L2280", "L2300", "L2310", "L2320", "L2330", "L2335", "L2340", "L2350", "L2360", "L2370", "L2375", "L2380", "L2385", "L2387", "L2390", "L2395", "L2397", "L2405", "L2415", "L2425", "L2430", "L2492", "L2500", "L2510", "L2520", "L2525", "L2526", "L2530", "L2540", "L2550", "L2750", "L2755", "L2760", "L2768", "L2780", "L2785", "L2795", "L2800", "L2810", "L2820", "L2830", "L4350", "L4360", "L4361", "L4370", "L4386", "L4387", "L4631" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "0e14e46509bccb66ba2837ffce3023dbca430f11447db87893146f773450559f", "raw_sha256": "7e55d91685699f2937bce7b772277cdf8e75df25fd760a05fb80378f6d6c148d", "texas": "national", "specialties": [ "Orthopedics & surgery", "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0054", "issue_number": "0054", "title": "0054 - Ambulance Billed during Inpatient: Unbundling", "review_type": "Automated", "provider_type": "Laboratory/Ambulance", "jurisdiction": "All A/B MACs", "source_date": "2017-05-19", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0054-ambulance-billed-during-inpatient-stay", "source_id": "cms-rac-approved", "description": "Ambulance services during an Inpatient stay are included in the facility’s PPS payment and are not separately payable under Part B, excluding the date of admission, date of discharge and any leave of absence days. Ambulance providers are expected to seek reimbursement from the inpatient facility. The edits will capture improper payment of ambulance services during an inpatient hospital stay.", "codes_text": "A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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 Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §10.5- Hospital Inpatient Bundling 8. Medicare Claims Processing Manual, Chapter 15- Ambulance, §30.1.4 CWF Editing of Ambulance Claims for Inpatients 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [ "A0425", "A0426", "A0427", "A0428", "A0429", "A0432", "A0433", "A0434" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "6ec0556c1cf5b76124b63623fecc2f6b520c4ee0885fd6579648326e74ef48e5", "raw_sha256": "ffbc58a2ff8549c5d88919e44a5b7b65a59b40991b966fa72ec38827b49c835f", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0020", "issue_number": "0020", "title": "0020 - Patient Lifts: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-05-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0020-complex-medical-necessity-patient-lifts-", "source_id": "cms-rac-approved", "description": "Patient lifts must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined in Local Coverage Determination for Patient Lifts. Medical documentation will be reviewed to determine that services were reasonable and necessary.", "codes_text": "E0630, E0635, E0636, E0639, E0640, E1035, E1036", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service Prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, Prosthetics, Orthotics, and Supplies (DMEPOS);§5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.3- Detailed Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; (*Historical, for claims with Dates of Service Prior to 01/01/2020) 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33799- Patient Lifts; Effective 10/01/2015; Revised 01/01/2020 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52516- Patient Lifts- Policy Article; Effective 10/01/2015; Revised 01/01/2020 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service Prior to 01/01/2023) 25. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024.", "codes": [ "E0630", "E0635", "E0636", "E0639", "E0640", "E1035", "E1036" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "b406a95302b086d2ca28d8589b1f8b8b99281104351448ecffa233496bca8080", "raw_sha256": "5e5cb97edfd9c47b57c17330271c5ce497b8f61a7c93520244b30b28bf34e74e", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0012", "issue_number": "0012", "title": "0012 - Blood Glucose Monitors with Integrated Voice Synthesizer: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-05-08", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0012-blood-glucose-monitors-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if a blood glucose monitor with integrated voice synthesizer meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.", "codes_text": "E2100", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determinations Manual, Chapter 1, §40.2, Home Blood Glucose Monitors 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Items and Services Having Special DME Review Considerations, §5.1- Home Use of DME, Prosthetics, Orthotics, and Supplies (DMEPOS);§5.2- Rules Concerning Orders; §5.2.1- Physician Orders; §5.2.2- Verbal and Preliminary Written Orders; §5.2.4- Written Orders Prior to Delivery; §5.2.5- Face-to-Face Encounter Requirements; §5.2.5.1- Face-to-Face Encounter Conducted by the Physician; §5.2.5.2- Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist; §5.2.6- Date and Timing Requirements; §5.2.7- Requirement of New Orders; §5.2.8- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.5- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.6- Physician Assistant Rules Concerning Orders and CMNs; §5.7- Documentation in the Patient's Medical Record; §5.8- Supplier Documentation; §5.9 Evidence of Medical Necessity; (*Historical, for claims with Dates of Service prior to 01/01/2020) 21. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCD L33822- Glucose Monitors; Effective 10/01/2015; Revised 04/01/2024 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCA A52464- Glucose Monitor- Policy Article; Effective 10/01/2015; Revised 04/01/2024 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024", "codes": [ "E2100" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "34f3e204939b10b14dfb88412d99b0211bef6fdae707d85e0509210207e9f42b", "raw_sha256": "19df31558cc82be26a234aeab4538ee5338a618e078c89007fe4add3238937a6", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0050", "issue_number": "0050", "title": "0050-Add-on Codes Paid without Primary Code and/or Denied Primary Code", "review_type": "Automated", "provider_type": "Outpatient/Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-04-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/250800190/0050-add-codes-paid-without-primary-code-and/or-denied-primary-code", "source_id": "cms-rac-approved", "description": "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.", "codes_text": "Add-on Codes: https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits", "policy_text": "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 Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.D- Coding Services Supplemental to Principal Procedure (Add-On Codes) Code 8. Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, §70 Time Limitations for Filing Part A and Part B Claims 9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.7. F. Add-On Code for Office/Outpatient E/M Visit Complexity ; §40.1 Definition of a Global Surgical Package; §40.8- Claims for Co-Surgeons and Team Surgeons; §40.9- Procedures Billed With Two or More Surgical Modifiers 10. Medicare Claims Processing Manual, Chapter 16- Laboratory Services, §40.8- Date of Service (DOS) for Clinical Laboratory and Pathology Specimens 11. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6. 12. Add-on Code Edits, as updated by CMS- https://www.cms.gov/ncci-medicare/medicare-ncci-add-code-edits 13. AMA CPT Codebook 14. HCPCS Level II Codebook", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ea4762403122794b22c46c0917e34b01dcf393c2b75d54ea06779469fb94613d", "raw_sha256": "144f7e72466c173124854c4eda98c9883b12c7d0fd7ef91db3549bd9aa3f55cf", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0026", "issue_number": "0026", "title": "0026 - Nebulized Drugs: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-04-11", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0026-nebulizers-medical-necessity", "source_id": "cms-rac-approved", "description": "This review will determine if the submitted documentation supports Medicare’s coverage criteria and reasonable and necessary requirements for nebulized drugs.", "codes_text": "J2545, J7605, J7606, J7608, J7611, J7612, J7613, J7614, J7620, J7626, J7631, J7639, J7644, J7669, J7677, J7682, J7686, Q4704, K0730, E0574, Q0513, Q0514", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable Medical Equipment: Scope and Conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §200.2- Nebulized Beta-Adrenergic Agonist Therapy for Lung Diseases 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 01/01/2024 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33370: Nebulizers; Effective 10/01/2015; Revised 02/01/2026 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52466: Nebulizers- Policy Article; Effective 10/01/2015; Revised 02/01/2026 24. HCPCS level II Codebook", "codes": [ "E0574", "J2545", "J7605", "J7606", "J7608", "J7611", "J7612", "J7613", "J7614", "J7620", "J7626", "J7631", "J7639", "J7644", "J7669", "J7677", "J7682", "J7686", "K0730", "Q0513", "Q0514", "Q4704" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "490a9f7e164d73f458fca2ff618d0f5e0d1ead0c9b41338e8c6b3a9e86fa06ab", "raw_sha256": "0c804234fad46c8c0f1d49b85d17567f0c4c4d5136d3e382b7dd085966568c2e", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0028", "issue_number": "0028", "title": "0028 - Annual Wellness Visit: Excessive Units", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-03-29", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0028-annual-wellness-visits-awv", "source_id": "cms-rac-approved", "description": "Claims for HCPCS code G0438 billed more than once in a lifetime will be denied. HCPCS code G0438 (Annual wellness visit; includes a personalized prevention plan of service (PPS), initial visit) is a \"one time\" allowed Medicare benefit per beneficiary.", "codes_text": "G0438", "policy_text": "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. 42 Code of Federal Regulations (CFR) §410.15-Annual wellness visits providing Personalized Prevention Plan Services: Conditions for and limitations on coverage 8. 42 Code of Federal Regulations (CFR) §411.15(a)(1)- Particular services excluded from coverage (a) -Routine physical checkups (1)- Examinations performed for a purpose 9. 42 Code of Federal Regulations (CFR) §411.15(k)(15)- Particular services excluded from coverage (k)- Any services that are not reasonable and necessary (15)- In the case of additional preventive services not otherwise described in this title, subject to the conditions and limitation specified in § 410.64 of this chapter. 10. Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), §280.5- Annual Wellness Visit (AWV) Providing Personalized Prevention Plan Services (PPPS) 11. Medicare Claims Processing Manual, Chapter 18 (Preventive and Screening Services), §140- Annual Wellness Visit 12. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1-3.6.6 13. HCPCS Level II Codebook", "codes": [ "G0438" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "716ed4d35256af75ef33bef3c38c5af7ed62a3c2e563fe0c13db0acf8b333ee5", "raw_sha256": "b5be51c9d62a8efdb43a4de2acecc6da84c19fe8eac653c8fcfd8c02ab999956", "texas": "national", "specialties": [ "Primary care" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Check beneficiary eligibility, prior IPPE/AWV history, and the earliest eligible date. Do not substitute a blanket 365-day scheduling rule for Medicare eligibility verification.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0043", "issue_number": "0043", "title": "0043 - New Patient Visits: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-03-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0043-new-patient-visits", "source_id": "cms-rac-approved", "description": "A new patient is one who has not received any professional services, [e.g., E/M service or other face-to-face service (e.g., surgical procedure)] from the physician or physician group practice (same physician specialty) within the previous 3 years.", "codes_text": "92002, 92004, 99202, 99203, 99204, 99205, 99341, 99342, 99344, 99345", "policy_text": "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 12: Physicians/Non-physician Practitioners, §30.6.1.1 - Initial Preventive Physical Examination [IPPE] and Annual Wellness Visit [AWV] 8. Medicare Claims Processing Manual, Chapter 12: Physicians/Non-physician Practitioners, §30.6.7.A-Definition of New Patient for Selection of E/M Visit Code 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. AMA CPT Codebook 11. HCPCS Level II Codebook", "codes": [ "92002", "92004", "99202", "99203", "99204", "99205", "99341", "99342", "99344", "99345" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "30d3b1ecf746bfa6442603f2fae606881f538f9769903fd9be017ed8c217d840", "raw_sha256": "36b9e9114510d27df6a9f708f76b52f86447f407de974951097a307c8ab2949a", "texas": "national", "specialties": [ "Primary care" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0042", "issue_number": "0042", "title": "0042-Evaluation and Management Services for Office or Other Outpatient Visit Billed for Hospital Inpatients: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-03-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/httpswwwcmsgovresearch-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance/0042-evaluation-and-management-services-office-or-other-outpatient-visit-billed-hospital-inpatients", "source_id": "cms-rac-approved", "description": "Office or other outpatient visits for evaluation and management services may not be billed for patients while admitted to a hospital setting.", "codes_text": "99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215", "policy_text": "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", "codes": [ "99202", "99203", "99204", "99205", "99211", "99212", "99213", "99214", "99215" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "4d64a2bd58ea8543cc8220d777908d28f164d7e0e98532356f5b3c776f4023fb", "raw_sha256": "95856b3961e788d3b1e6d00554cc9a250428027a66831001822af1b90ba066d0", "texas": "national", "specialties": [ "Primary care", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0039", "issue_number": "0039", "title": "0039 - Ophthalmology Codes for New Patient: Incorrect Coding", "review_type": "Automated", "provider_type": "Physician; Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-03-09", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery/60487232/0039-ophthalmology-codes-new-patient-incorrect-coding", "source_id": "cms-rac-approved", "description": "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 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", "codes_text": "92002, 92004", "policy_text": "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 10. AMA CPT Codebook", "codes": [ "92002", "92004" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "5896ef2b32da9c9e1d70d8bfe1824314b296c86cd57cae3148b5d03c385c2dba", "raw_sha256": "6f890c30be73611cb8a255cafff6479faa4f2f067ba6ee8d2a456878bb52e6aa", "texas": "national", "specialties": [ "Primary care", "Ophthalmology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0047", "issue_number": "0047", "title": "0047 - Panretinal (Scatter ) Laser Photocoagulation: Excessive Frequency", "review_type": "Automated", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "J6, JK, J15", "source_date": "2017-02-23", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0047-panretinal-scatter-laser-photocoagulation-excess-frequency", "source_id": "cms-rac-approved", "description": "Claims billed more frequently than once per eye within the global surgery period will be denied.", "codes_text": "67228", "policy_text": "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 Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 8. CGS Administrators, Local Coverage Determination (LCD) L34064- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 03/02/2023 9. NGS, Local Coverage Determination (LCD) L33628- Panretinal (Scatter) Laser Photocoagulation; Effective 10/01/2015; Revised 9/19/2019 10. CGS Administrators, Local Coverage Article A56594- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 10/03/2019; Revised 03/02/2023 11. NGS, Local Coverage Article A56550- Billing and Coding: Panretinal (Scatter) Laser Photocoagulation; Effective 8/1/2019; Revised 9/19/2019 12. AMA CPT Codebook", "codes": [ "67228" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "7586bb2053133e306e45f6bad9503b772112e871057d10668f7bd818a5dc6e84", "raw_sha256": "509b16624115225a4cf301a46dcefcefbedcedafe567177c7b499546822d731d", "texas": "not-listed", "specialties": [ "Ophthalmology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0038", "issue_number": "0038", "title": "0038 - Visits to Patients in Swing Beds: Incorrect Coding", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-02-23", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0038-visits-to-patients-in-swing-beds", "source_id": "cms-rac-approved", "description": "If the inpatient care is billed by the hospital as inpatient hospital care, the hospital care codes apply. If the inpatient care is billed by the hospital as nursing facility care, then the nursing facility codes apply. Hospital care codes billed while in a swing bed will be recovered.", "codes_text": "99221-99223; 99231-99233; 99238-99239", "policy_text": "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 12- Physicians/Nonphysician Practitioners, §30.6.9. D - Visits to Patients in Swing Beds 8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 9. AMA CPT Codebook", "codes": [ "99221", "99223", "99231", "99233", "99238", "99239" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "aa3a913f7409ef17fd54465d7219fef6d649f7951af1134bd8688cdb67357b72", "raw_sha256": "d68bf0b36f24d28b3f468c2e166024f86a1d4df562b56a207a5b4365bd07ce60", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0037", "issue_number": "0037", "title": "0037 - Hospital Services: Excessive Units", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-02-23", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0037-excessive-units-of-hospital-services", "source_id": "cms-rac-approved", "description": "Both Initial Hospital Care (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 or physicians of the same specialty from the same group practice.", "codes_text": "99221-99223; 99231-99233", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits 2. 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 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 12- Physicians/Nonphysician Practitioners, §30.6.9- Payment for Inpatient Hospital Visits- General, Effective: 01-01-23 8. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.1- Payment for Initial Hospital Inpatient or Observation Care Services (Including Admission and Discharge Services), Effective: 01-01-23 9. Medicare Claims Processing Manual, Chapter 12- Physicians/Nonphysician Practitioners, §30.6.9.2- Subsequent Hospital Inpatient or Observation Care Visit and Hospital Inpatient or Observation Discharge Day Management (Codes 99231 - 99239), Effective: 01-01-23 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. AMA CPT Codebook", "codes": [ "99221", "99223", "99231", "99233" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "018f95ef72bf927a63ef2db9081c45fe8b2bbc30794b6419ab483caf857af71f", "raw_sha256": "cabc44ccbbf8117fbb061e2135b2e21f6822c82d811176f622dd880494a513da", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0030", "issue_number": "0030", "title": "0030 - Osteogenesis Stimulators: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0030-osteogenesis-stimulators-medical-necessity", "source_id": "cms-rac-approved", "description": "This review will determine if an Osteogenesis Stimulator is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "E0747, E0748, E0760", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare National Coverage Determinations (NCD) Manual, Ch. 1, Part 2, §150.2 Osteogenic Stimulators 15. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 16. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 17. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 18. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Determination L33796: Osteogenesis Stimulators; Effective 10/1/2015, Revised 01/01/2024 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC , Local Coverage Article A52513: Osteogenesis Stimulators - Policy Article; Effective 10/1/2015, Revised 07/02/2023 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024", "codes": [ "E0747", "E0748", "E0760" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "cff286e37937868beea75f0e5a52eeb03db5fb8a95c5beb47d801824996a3183", "raw_sha256": "ef104bb87724ee294aa50a6195fc3a2ace0a73dd575205c26a395d699bbd24c1", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0023", "issue_number": "0023", "title": "0023 - High Frequency Chest Wall Oscillation Devices: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0023-chest-wall-oscillation-devices-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "This review will determine if a High Frequency Chest Wall Oscillation Device is reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "E0483", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 19. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 20. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCD L33785- High Frequency Chest Wall Oscillation Devices; Effective 10/01/2015; Revised 10/01/2022 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC LCA A52494- High Frequency Chest Wall Oscillation Devices- Policy Article; Effective 10/01/2015; Revised 10/01/2025", "codes": [ "E0483" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "3c53ce422f2f0a33143dca80928cf86a21d54b99ab4395ebbfd60ef06b5af1bb", "raw_sha256": "2a0006e5f2f6b78a2d8b687586df22f4ebbe4e17d28972c87e241e0f316bb265", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0022", "issue_number": "0022", "title": "0022 - Inpatient Psychiatric Admission Billed without Source of Admission Equal to \"D\"", "review_type": "Automated", "provider_type": "Inpatient Hospital; Inpatient Psychiatric Facility (IPF)", "jurisdiction": "All A/B MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0022-inpatient-psychiatric-admission-billed-without-source-of-admission-equal-to-%25252522d%25252522", "source_id": "cms-rac-approved", "description": "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.", "codes_text": "Claims without Source of Admission Code D", "policy_text": "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 12. CMS Inpatient Psychiatric Facility Prospective Payment System (IPF PPS) Addendum A, applicable to the claim date of service.", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "bd5ed921342331a7e97590030f475b72fbef1c325f6c320d4562ed113ed83edd", "raw_sha256": "e115af0f6969e28026f32cf04ad490db36af494d1ba8225c95b862481e3ac0d7", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0021", "issue_number": "0021", "title": "0021 - Tracheostomy Suction Pumps and Suction Catheters: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0021-trach-suction-catheters-", "source_id": "cms-rac-approved", "description": "his review will determine if tracheotomy suction pumps and suction catheters are reasonable and necessary for the patient’s condition based on the documentation in the medical record.", "codes_text": "A4605, A4624, A4628, E0600", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items; §1834(m)- Payment for Telehealth Services 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 7. 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 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §410.78- Telehealth Services 11. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 12. 42 CFR §414.234(b)- Master List of Items Potentially Subject to Face-To-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. 13. 42 CFR §414.65- Payment for Telehealth Services 14. Medicare Benefit Policy Manual, Ch. 15- Covered Medical and Other Health Services, §110.2(C)- Repairs, Maintenance, Replacement, and Delivery 15. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 16. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 17. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests, §3.3.1.1(B)- Medical Record Review; §3.3.2.1- Documents on Which to Base a Determination; §3.3.2.1.1- Progress Notes and templates; §3.3.2.1.2- DMEPOS Orders; §3.3.2.2- Absolute Words and Prerequisite Therapies; §3.3.2.4- Signature Requirements; §3.3.2.5- Amendments, Corrections and Delayed Entries in Medical Documentation §3.5- Postpayment Medical Record Review of Claims; §3.6.2.1- Coverage Determinations; §3.6.2.2- Reasonable and Necessary Criteria; and §3.6.2.4- Coding Determinations 18. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements (*Historical, for claims with Dates of Service prior to 10/12/2021) 19. Medicare Program Integrity Manual, Ch. 4- Program Integrity, §4.7.3.1- Supplier Proof of Delivery Documentation Requirements 20. Medicare Program Integrity Manual, Ch. 5- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Items and Services Having Special DME Review Considerations, §5.1-Home Use of DME, Prosthetics, Orthotics, and Supplies; §5.2- Rules Concerning DMEPOS Orders/Prescriptions; §5.2.1- Standard Written Order/ Prescription (SWO); §5.2.2- Required Elements of a SWO; §5.2.3- Who can complete a SWO; §5.2.4- Timing of the Order/Prescription; §5.2.5- When a New Order/Prescription is Required; §5.2.6- Refills of DMEPOS Items Provided on a Recurring Basis; §5.3- Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and WOPD and/or Prior Authorization Requirements; §5.4- Face-to-Face Encounter Definition; §5.4.1- Timing of the Face-to-Face Encounter; §5.4.2- Documentation from the Face-to-Face Encounter; §5.5- Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs); §5.7- Nurse Practitioner or Clinical Nurse Specialist Rules Concerning Orders and CMNs; §5.8- Physician Assistant Rules Concerning Orders and CMNs; §5.9- Documentation in the Patient’s Medical Record; §5.10- Supplier Documentation; and §5.11- Evidence of Medical Necessity 21. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33612: Suction Pumps; Effective 10/01/2015; Revised 04/01/2023 22. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52519: Suction Pumps- Policy Article; Effective 10/01/2015; Revised 04/01/2023 23. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 4/6/2020 (*Historical, for claims with Dates of Service prior to 01/01/2023) 24. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2023", "codes": [ "A4605", "A4624", "A4628", "E0600" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "c3c56b33c33cdbff5f9b108d5368885df7e237f753a74991cb986c24adbc3a3f", "raw_sha256": "b57f93e798c54196fd781c1523183a2fcdbcb6f01719e10fe3f8f4595dee5ad4", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0019", "issue_number": "0019", "title": "0019 - Durable Medical Equipment Billed while Inpatient: Unbundling", "review_type": "Automated", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0019-durable-medical-equipment-billed-while-inpatient", "source_id": "cms-rac-approved", "description": "A supplier (includes physician furnishing DME) may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to two (2) days prior to the patient's anticipated discharge to their home. The supplier should bill the date of service on the claim as the date of discharge and shall use the place of service (POS) as 12 (patient's home). The item must be for subsequent use in the patient's home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.", "codes_text": "E0100 -E8002; K0001 -K0899; L0112 -L4631; V2020 -V2786; A4206 -A9999; B4034 -B9999; and J and Q codes", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII, §1861(n)- Durable Medical Equipment 5. 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 6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions 7. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834 (2)(B); (3)(A); (5)(A); (7)(A)(i)(1); (7)(C)(ii)(1)- Special Payment Rules for Particular Items and Services 8. Social Security Act, Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies 9. 42 CFR §405.929- Post-Payment Review 10. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 11. 42 Code of Federal Regulations (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 12. 42 CF §405.986- Good Cause for Reopening 13. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 14. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 15. 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges 16. 42 CFR §424.57(c)- Application Certification Standards 17. Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General 18. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 19. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §10.2- Coverage Table for DME Claims, §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 20. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §110.3.2- Date of Service for Pre-Discharge Delivery of DMEPOS 21. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §210 - CWF Crossover Editing for DMEPOS Claims During an Inpatient 22. Medicare Claims Processing Manual, Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS), §211- SNF Consolidated Billing and DME Provided by DMEPOS Suppliers 23. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 24. Medicare Program Integrity Manual, Chapter 4- Benefit Integrity, §4.7.3.1.2 – Exceptions 25. Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.15 Incurred Expenses for DMEPOS 26. CMS SNF Consolidated Billing- https://www.cms.gov/Medicare/Billing/SNFConsolidatedBilling 27. HCPCS level II Codebook", "codes": [ "A4206", "A9999", "B4034", "B9999", "E0100", "E8002", "K0001", "K0899", "L0112", "L4631", "V2020", "V2786" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "fe767063525cdc32d80e15350f68fe3761b1ce28ff5ab3cecc89d1c6adc2ac02", "raw_sha256": "74446b19e96cf73aa5c796daa1faae81b5bbf41fcab66fb96c52d8e7a80e194e", "texas": "national", "specialties": [ "DME & supplies", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0018", "issue_number": "0018", "title": "0018 - Spring-Powered Devices: Excessive Units", "review_type": "Automated", "provider_type": "DME Physician/ DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systemsmonitoring-programsmedicare-ffs-compliance-programsrecovery/0018-spring-powered-devices-excessive-units", "source_id": "cms-rac-approved", "description": "More than one spring powered device per 6 months is not reasonable and necessary.", "codes_text": "A4258", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 CFR §405.929- Post-Payment Review 6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request42 CFR §405.929- Post-Payment Review 7. 42 Code of Federal Regulations (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 Party42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 11. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §40.2- Home Blood Glucose Monitors 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 04/01/2024 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464- Glucose Monitor- Policy Article; Effective 10/01/2015; Revised 04/01/2024 17. HCPCS Level II Codebook", "codes": [ "A4258" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "4d68e1524864d2c349b64eb002931034303bf32b3201d5120995f37d908d15d2", "raw_sha256": "e13e304c6ef761a6c30f62994544a1168e1ac7399815b27ad1fa5308f23301bb", "texas": "national", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0016", "issue_number": "0016", "title": "0016 - Continuous Passive Motion Billed without Total Knee Replacement or Total Knee Revision", "review_type": "Automated", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0016-continuous-passive-motion-billed-without-total-knee-replacement", "source_id": "cms-rac-approved", "description": "Continuous Passive Motion devices are not covered if billed for more than three weeks following a qualified knee surgery or for patients who have not received a total knee replacement or revision.", "codes_text": "E0935- Continuous passive motion exercise, device for use on knee only", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR §414.210(f)- Payment for Replacement of Equipment 11. National Coverage Determination Manual, Chapter 1, Part 4, §280.1- Durable Medical Equipment Reference List 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Claims Processing Manual Chapter 20, 30.2.1 - Daily Payment for Continuous Passive Motion (CPM) Devices 15. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 16. HCPCS Level II Codebook", "codes": [ "E0935" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "75ecc1c0cd12810a29fbd190cd8a731dc4c1e1fe9c9af42ebc463beae58459e0", "raw_sha256": "661f37866265e5c156d789ae2f2a5255fd5c8f7b7aa35e54613fe52899375cb2", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0014", "issue_number": "0014", "title": "0014 - Glucose Monitor Supplies Billed With Same Dates of Service as Glucose Monitor: Unbundling", "review_type": "Automated", "provider_type": "DME Physician/DME Supplier", "jurisdiction": "All DME MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0014-automated-glucose-monitor-when-billed-with-same-date-of-services-as-glucose-monitor-supplies-unbundling", "source_id": "cms-rac-approved", "description": "When a glucose monitor is provided, the glucose monitor supplies are included in the allowance for the glucose monitor and are not separately payable.", "codes_text": "A4233, A4234, A4235, A4236", "policy_text": "1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits 2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items 3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B 4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer 5. 42 Code of Federal Regulations (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 §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 42 CFR §405.986- Good Cause for Reopening 9. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions 10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment 11. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §40.2- Home Blood Glucose Monitors 12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare 13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies 14. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 04/01/2024 16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464: Glucose Monitor- Policy Article; Effective 10/02/2015; Revised 04/01/2024 17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs; Effective 01/01/2017; Revised 01/01/2024 18. HCPCS Level II Codebook", "codes": [ "A4233", "A4234", "A4235", "A4236" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "ccd7d4371110f9a9fc01d32552985a0b31467879b871913a3c633c7891169d66", "raw_sha256": "f7f0d1b808eb8502edc644a2caa5e8911c8d3f4ed3f62fcb553acb375016afd8", "texas": "national", "specialties": [ "DME & supplies" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0011", "issue_number": "0011", "title": "0011 - Inappropriate Billing of Home Visit Professional Service Evaluation and Management Codes During Hospital Inpatient Stay", "review_type": "Automated", "provider_type": "Professional Services", "jurisdiction": "All A/B MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0011-inappropriate-billing-of-home-visit-professional-service-evaulation-and-management-codes-during-inpatient", "source_id": "cms-rac-approved", "description": "Home 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.", "codes_text": "CPT Codes 99341, 99342, 99343, 99343, 99344, 99345, 99347, 99348, 99349, and 99350", "policy_text": "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 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 or Residence Services (Codes 99341-99350); Effective: 01-01-2023 9. AMA CPT Codebook", "codes": [ "99341", "99342", "99343", "99344", "99345", "99347", "99348", "99349", "99350" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "6270027b079af39f9140580a8c1e617db5c0218619629ca72b0995e37c13c82a", "raw_sha256": "dede22fd68aaac1f9f24859d68ab47baea1d625122ccf7510caca5ba1c2356ca", "texas": "national", "specialties": [ "Primary care", "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Start with the claims relationship at issue, such as units, dates, modifiers, setting, or duplicate services, before assuming a documentation defect.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0010", "issue_number": "0010", "title": "0010 - Cardiac Positron Emission Tomography Scans: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Outpatient Hospital; Professional Services", "jurisdiction": "JN, JL", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0010-cardiac-positron-emission-tomography-scans-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "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.", "codes_text": "78459, 78491, 78492, A9526, A9555, A9552, A9597, A9598", "policy_text": "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 1834 (e)(1)(B)- Advanced Diagnostic Imaging Services Defined 4. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1862 (a)(7) – Exclusions from Coverage and Medicare as Secondary Payer 5. Social Security Act (SSA), Title XVIII – Health Insurance for the Aged and Disabled, Section 1861(s)(3) – Medical and Other Health Services 6. 42 CFR §405.929- Post-Payment Review 7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request 8. 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 9. 42 CFR §405.986- Good Cause for Reopening 10. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, Section 220.6.1- PET for Perfusion of the Heart 11. Medicare National Coverage Determination (NCD) Manual: Chapter 1, Part 4- Coverage Determinations, §220.6.8- FDG PET for Myocardial Viability 12. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §50- Nuclear Medicine (CPT 78000 – 79999) 13. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60- Positron Emission Tomography (PET) Scans- General Information 14. Medicare Claims Processing Manual, Chapter 13 – Radiology Services and Other Diagnostic Procedures, § 60.4 – PET Scans for imaging of the Perfusion of the Heart Using Rubidium 82 (RB 82) 15. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.9- Coverage of PET Scans for Myocardial Viability 16. Medicare Claims Processing Manual, Chapter 13- Radiology Services and Other Diagnostic Procedures, §60.11- Coverage of PET Scans for Perfusion of the Heart Using Ammonia N-13 17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, § §3.1-3.6.6 18. Medicare Program Integrity Manual, Chapter 13- Local Coverage Determinations, §13.5.4- Reasonable and Necessary Provisions in LCDs 19. First Coast LCD L38396 – Cardiology Non-emergent Outpatient Stress Testing, Effective 03/15/2020; Revised 4/25/2021 20. First Coast LCA A56952 – Billing and Coding: Cardiology – Non-emergent Outpatient Stress Testing, Effective 03/16/2020, Revised 01/01/2026 21. Novitas LCD L35083 – Cardiology Non-emergent Outpatient Stress Testing, Effective 10/02/2015, Revised 04/25/2021 22. Novitas LCA A56423 – Billing and Coding: Cardiology Non-emergent Outpatient Stress Testing, Effective 03/28/2019, Revised 01/01/2026 23. AMA CPT Codebook 24. HCPCS Level II Codebook", "codes": [ "78459", "78491", "78492", "A9526", "A9552", "A9555", "A9597", "A9598" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "3ca45b86cec2a51df4e1a3396c42ead11770b05a13c942d925e4d9e8fe9422cb", "raw_sha256": "2b292cbc7d4750a89e31b59d3fcf0e9543607ca43e045deab325dc8aa1cc9fea", "texas": "not-listed", "specialties": [ "Cardiology", "Diagnostics & laboratory" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0008", "issue_number": "0008", "title": "0008 - Bariatric Surgery-Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Inpatient Hospital; Outpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0008-bariatric-surgery-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "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 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.", "codes_text": "43770, 43644, 43645, 43845, 43846, 43847, 43775", "policy_text": "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 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 8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, Section 150- Billing Requirements for Bariatric Surgery for Treatment of Morbid Obesity 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. First Coast LCD L33411- Surgical Management of Morbid Obesity; Effective 10/1/2015; Revised 10/01/2019 11. Palmetto GBA LCD L34576- Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 10/1/2015; Revised 01/11/2024 12. Novitas LCD L35022- Bariatric Surgical Management of Morbid Obesity; Effective 10/01/2015; Revised 05/13/2021 13. NGS LCA A52447- Laparoscopic Sleeve Gastrectomy (LSG)- Medical Policy Article; Effective 10/01/2015; Revision 10/01/2021 14. Noridian LCA A53026- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2024 15. Noridian LCA A53028- Billing and Coding: Bariatric Surgery Coverage; Effective 10/01/2015; Revised 10/01/2024 16. Novitas LCA A56422- Billing and Coding: Bariatric Surgical Management of Morbid Obesity: Effective 03/28/2019; Revised 10/01/2024 17. WPS LCA A54923- Billing and Coding: Bariatric Surgery for Treatment of Co-Morbidities Conditions Related to Morbid Obesity; Effective 3/01/2016; Revised: 10/01/2024 18. Palmetto GBA LCA A56852- Billing and Coding: Laparoscopic Sleeve Gastrectomy for Severe Obesity; Effective 08/15/2019; Revised 10/01/2024 19. First Coast LCA A57145- Billing and Coding: Surgical Management of Morbid Obesity; Effective 10/03/2018; Revised 10/01/2024 20. First Coast LCA A55930- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 3/15/2018, Retired 10/15/2021 21. First Coast LCA A56182- Surgical Management of Morbid Obesity Revision to the Part A and Part B LCD; Effective 11/06/2018, Retired 10/15/2021 22. AMA CPT Codebook 23. AHA ICD-10-CM Diagnosis Codebook 24. AHA ICD-10-PCS Procedure Codebook", "codes": [ "43644", "43645", "43770", "43775", "43845", "43846", "43847" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "2053bbc7d0c403069cb72359d165b7dcc19060f5b95b4d2cfed9fe0ff8d67a12", "raw_sha256": "81c3f0e88b6eae2746fdbcb10fe6fee3f04cbd1f62aefbb6c40197d89d29d8a1", "texas": "national", "specialties": [ "Orthopedics & surgery" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0003", "issue_number": "0003", "title": "0003 - Sacral Neurostimulation: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Inpatient Hospital; Outpatient Hospital; Professional Services", "jurisdiction": "Urinary Incontinence- All A/B MACS, Fecal Incontinence- CGS, Noridian, Palmetto (for services after 11/05/23)", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0003-sacral-neurostimulation-medical-necessity-and-documentation-requirements-", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if sacral nerve stimulation for urinary or fecal incontinence meets Medicare coverage criteria, and/or is medically reasonable and necessary.", "codes_text": "64561, 64581, 64590", "policy_text": "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 National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, §230.18- Sacral Nerve Stimulation for Urinary Incontinence 8. Medicare Claims Processing Manual, Chapter 32- Billing Requirements for Special Services, §40- Sacral Nerve Stimulation 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. Noridian Healthcare Solutions, LLC, LCA A53017- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Retired 10/02/2025 11. Noridian Healthcare Solutions, LLC, LCA A53359- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 10/01/2015; Revised 04/06/2026 12. CGS Administrators, LLC, LCA A55835- Billing and Coding: Sacral Nerve Stimulation for Urinary and Fecal Incontinence, Effective 2/01/2018; Revised 03/05/2026 13. Palmetto, LCD L39543 – Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence, Effective 11/05/23 14. Palmetto, LCA A59332 – Billing and Coding: Sacral Nerve Stimulation for the Treatment of Urinary and Fecal Incontinence, Effective 11/05/2023, Revised 06/17/2025 15. AMA CPT Codebook 16. HCPCS Level II Codebook", "codes": [ "64561", "64581", "64590" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a39aac3e08231de4b5c0c0413f946b291d175023581371a74e762a608123e91b", "raw_sha256": "94c1b3fe27757c77f2265857f6eb2bba5512977bd29a4b5456403d861b6f8024", "texas": "conditional", "specialties": [ "Other / multispecialty" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0002", "issue_number": "0002", "title": "0002 - Cataract Removal: Medical Necessity and Documentation Requirements", "review_type": "Complex", "provider_type": "Ambulatory Surgical Center (ASC); Outpatient Hospital", "jurisdiction": "CGS, First Coast, NGS, Noridian, Novitas, Palmetto, WPS (for DOS on/after 2/11/2024)", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0002-cataract-removal-medical-necessity-and-documentation-requirements", "source_id": "cms-rac-approved", "description": "Documentation will be reviewed to determine if Cataract Surgery meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary.", "codes_text": "66830, 66840, 66850, 66852, 66920, 66930, 66940, 66982, 66983, 66984, 66987, 66988 Palmetto and WPS only- 66989, 66991", "policy_text": "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 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 8. Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §80- Eye, §80.10- Phaco-Emulsification Procedure - Cataract Extraction; §80.12- Intraocular Lenses (IOLs) 9. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 10. CGS LCD L33954- Cataract Extraction; Effective 10/01/2015; Revised 01/04/2024 11. CGS LCA A56453- Billing and Coding: Cataract Extraction; Effective 10/01/2016; Revised 10/01/2025 12. NGS LCD L33558- Cataract Extraction; Effective 10/1/2015; Revised 09/19/2019 13. NGS LCA A56544- Billing and Coding: Cataract Extraction; Effective 08/01/2019; Revised 10/01/2025 14. Noridian LCD L34203- Cataract Surgery in Adults; Effective 10/01/2015; Revised 09/11/2025 15. Noridian LCD L37027- Cataract Surgery in Adults; Effective 10/10/2017; Revised 09/11/2025 16. Noridian LCA A57195- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Revised 10/01/2025 17. Noridian LCA A57196- Billing and Coding: Cataract Surgery in Adults; Effective 10/01/2019; Retired 09/11/2025 18. Palmetto LCD L34413- Cataract Surgery; Effective 10/01/2015; Revised 11/21/2024 19. Palmetto LCA A56613- Billing and Coding: Cataract Surgery; Effective 06/13/2019; Revised 04/30/2023 20. Palmetto LCA A53047- Complex Cataract Surgery: Appropriate Use and Documentation; Effective 10/01/2015; Revised 01/01/2022 21. Novitas LCD L35091- Cataract Extraction (including Complex Cataract Surgery); Effective 10/01/2015; Revised 07/11/21 22. Novitas LCA A56615- Billing and Coding: Cataract Extraction (including Complex Cataract Surgery); Effective 06/13/2019; Revised 10/01/2025 23. First Coast LCD L33808- Cataract Extraction; Effective 10/01/2015; Retired 10/29/2019 24. First Coast LCD L38926- Extraction (including Complex Cataract surgery); Effective 07/11/2021 25. First Coast LCA A58592- Cataract Extraction (including Complex Cataract Surgery); Effective 07/11/2021 26. WPS LCD L39716- Cataract Extraction; Effective 2/11/2024; Retired 10/13/2024 27. WPS LCA A59556- Billing and Coding: Cataract Extraction: Effective 2/11/2024; Retired 10/13/2024 28. WPS LCD L39905- Cataract Surgery; Effective 10/13/2024 29. WPS LCA A59805- Billing and Coding: Cataract Surgery; Effective 10/13/2024; Revised 11/14/2024 30. AMA CPT Codebook", "codes": [ "66830", "66840", "66850", "66852", "66920", "66930", "66940", "66982", "66983", "66984", "66987", "66988", "66989", "66991" ], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "714be709cc926fd9dfce54d65cae18f4fd7691c61724f0f76042ff105c8dc8d2", "raw_sha256": "6f8e701848d45cb8cf429f4e10179c317991bed239dc3dcd0c378b5414a98cb7", "texas": "conditional", "specialties": [ "Ophthalmology" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] }, { "id": "rac-0001", "issue_number": "0001", "title": "0001 - Inpatient Hospital MS - DRG Coding Validation", "review_type": "Complex", "provider_type": "Inpatient Hospital", "jurisdiction": "All A/B MACs", "source_date": "2017-02-01", "rac_status": "Approved", "source_url": "https://www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/approved-rac-topics-items/0001-inpatient-hospital-ms-drg-coding-validation", "source_id": "cms-rac-approved", "description": "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.", "codes_text": "All MS-DRGs (001-999)", "policy_text": "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 §424.5(a)(6)- Sufficient information 7. 42 CFR §405.986- Good Cause for Reopening 8. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §20- Payment Under Prospective Payment System (PPS) Diagnosis Related Groups (DRGs) 9. Medicare Claims Processing Manual, Chapter 3- Inpatient Hospital Billing, §§20.1.2.4. B & C, 40.2.4 10. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6 11. Medicare Program Integrity Manual, Chapter 6- Medicare Contractor Medical Review Guidelines for Specific Services, §6.5.3- DRG Validation Review, §6.5.4 – Review of Procedures Affecting the DRG 12. Inpatient Prospective Payment System (IPPS) Final Rule and Correcting Amendment Tables: Acute Inpatient PPS | CMS 13. ICD-10 Clinical Modification (ICD-10-CM) and ICD-10- Procedural Coding System (PCS) (ICD-10-PCS) Coding Manual, Official Guidelines for Coding and Reporting, and Addendums 13. AHA Coding Clinic for ICD-10", "codes": [], "verified_at": "2026-09-15T05:59:49Z", "detail_status": "verified", "effective_date": null, "fingerprint": "a952b7dc6a017756772f48a3098a34622d454becc2fd2bc71954cb12f4478e6e", "raw_sha256": "a416ff25708759919f8d4bec85002be32ffaed2081c5b6d43e92f9af41808981", "texas": "national", "specialties": [ "Hospital & post-acute" ], "first_seen_at": "2026-09-11T01:32:32Z", "listing_status": "listed", "self_check": [ "Confirm whether your organization bills the exact services, codes, setting, and jurisdiction described in the CMS topic.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ] } ], "signals": [ { "id": "novitas-jh-f24774dfea1449b4", "source_id": "novitas-jh", "source_family": "Novitas JH / TPE", "title": "Targeted Probe and Educate (TPE) round results evaluation & management (E/M) services: Established office/outpatient visits", "source_date": "2026-09-14", "effective_date": null, "signal_class": "confirmed", "current_status": "Published Novitas JH TPE item", "summary": "Targeted Probe and Educate (TPE) round results...and JL TPE reviews that have been...contact the nurse reviewer assigned to your review for additional information...Additional rounds of review will be utilized when the targeted topic demonstrates a...continued need for review with newly identified...the following: • Medical necessity o The...does not support medical necessity as listed", "source_url": "https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00284381", "jurisdiction": "Novitas Jurisdiction H (Texas); some shared JH/JL education may also appear.", "texas": "texas", "provider_type": "See Novitas source", "review_method": "Targeted Probe and Educate", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "Targeted Probe and Educate", "rac_status": "Published Novitas JH TPE item", "description": "Targeted Probe and Educate (TPE) round results...and JL TPE reviews that have been...contact the nurse reviewer assigned to your review for additional information...Additional rounds of review will be utilized when the targeted topic demonstrates a...continued need for review with newly identified...the following: • Medical necessity o The...does not support medical necessity as listed", "policy_text": "", "codes": [], "issue_number": "f24774dfea14", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. 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Read the transmittal before treating it as a change in audit intensity.", "source_url": "https://www.cms.gov/medicare/regulations-guidance/transmittals/2026-transmittals/r13652demo", "jurisdiction": "National CMS program guidance", "texas": "national", "provider_type": "Varies by transmittal", "review_method": "Policy / program-integrity update", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "source_content_hash": "8d8d959b980d72a51452525a48eff246be9a22a969b4567973333e5a160b082e", "record_type": "signal", "review_type": "Policy / program-integrity update", "rac_status": "CMS transmittal issued", "description": "CMS policy/procedure change relevant to program integrity or medical review. Read the transmittal before treating it as a change in audit intensity.", "policy_text": "", "codes": [], "issue_number": "ef48bb5bace1", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "722d7dbb80e3370796f5995bba5b5ced8b84ee53b4f1a708a6e8a908dd69fe87", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "oig-medicare-669c42eb60635796", "source_id": "oig-medicare", "source_family": "OIG", "title": "Medicare Home Health Agency Provider Compliance Audit: Alternate Solutions Homecare of Dayton", "source_date": "2026-02-19", "effective_date": null, "signal_class": "early", "current_status": "OIG Medicare oversight finding", "summary": "OIG Medicare A/B report. Lookout treats an OIG finding as an early-warning signal unless a review contractor separately confirms a review focus.", "source_url": "https://oig.hhs.gov/reports/all/2026/medicare-home-health-agency-provider-compliance-audit-alternate-solutions-homecare-of-dayton/", "jurisdiction": "National oversight finding; recommendations and contractor actions vary.", "texas": "national", "provider_type": "See OIG report", "review_method": "OIG audit/evaluation", "codes_text": "", "specialties": [ "Hospital & post-acute" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "OIG audit/evaluation", "rac_status": "OIG Medicare oversight finding", "description": "OIG Medicare A/B report. 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An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "a17c27b71309fb1d190025eef1dd43a686cf3c2f2d73bcdd50193779dd3a3823", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "smrc-01-157", "source_id": "cms-smrc", "source_family": "SMRC", "title": "01-157 Patient Lifts Notification of Medical Review", "source_date": "2026-02-12", "effective_date": null, "signal_class": "confirmed", "current_status": "Current SMRC medical review project", "summary": "View review reasons, documentation requirements and resources to consult when submitting claims.", "source_url": "https://noridiansmrc.com/current-projects/01-157/", "jurisdiction": "SMRC is nationwide; this project has source-specific selection criteria.", "texas": "national", "provider_type": "See SMRC project", "review_method": "Medical record review", "codes_text": "", "specialties": [ "DME & supplies" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "source_content_hash": "1c80c0dca36104067c564bf0c2b9c369c808d90874ed52704c20eab0b57994ba", "record_type": "signal", "review_type": "Medical record review", "rac_status": "Current SMRC medical review project", "description": "View review reasons, documentation requirements and resources to consult when submitting claims.", "policy_text": "", "codes": [], "issue_number": "157", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "b71c6658b45b802f2c147f2740fb5a3014cfe7fa71ff2f6eca0302c0c2308aa3", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "cms-program-445a6bf83bac7a98", "source_id": "cms-program", "source_family": "CMS Program Integrity", "title": "R13625OTN: Reporting of All Recovery Auditor-Initiated Claim Adjustments and their Subsequent Adjustments for Periodic Interim Payment (PIP) Facilities", "source_date": "2026-02-06", "effective_date": "2026-04-06", "signal_class": "update", "current_status": "CMS transmittal issued", "summary": "CMS policy/procedure change relevant to program integrity or medical review. 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Read the transmittal before treating it as a change in audit intensity.", "policy_text": "", "codes": [], "issue_number": "445a6bf83bac", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "b5ffed76c4c03ffd5fee8c72fa150e581c986cf53e24cf826991be0ae6a75d44", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "cms-program-3b33af774e61aea7", "source_id": "cms-program", "source_family": "CMS Program Integrity", "title": "R13595PI: Updates of Chapters 3, 4, and Exhibits in Publication (Pub.) 100-08, Including Updates to the Provider Notification Process and Vetting with the CMS Process.", "source_date": "2026-01-26", "effective_date": "2026-02-26", "signal_class": "update", "current_status": "CMS transmittal issued", "summary": "CMS policy/procedure change relevant to program integrity or medical review. 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An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "aceef1b4c9bae208a60a01a8422fba89ef942c02e3bcbe6b4f2b2a5d3b6980d5", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "cert-e2d5cb2b37f69c9d", "source_id": "cert", "source_family": "CERT", "title": "2025 Medicare Fee-for-Service Supplemental Improper Payment Data", "source_date": "2026-01-24", "effective_date": null, "signal_class": "update", "current_status": "CERT improper-payment report published", "summary": "CERT identifies measured Medicare FFS payment vulnerabilities; publication alone is not a contractor audit announcement.", "source_url": "https://www.cms.gov/data-research/monitoring-programs/improper-payment-measurement-programs/comprehensive-error-rate-testing-cert/cert-reports/2025-medicare-fee-service-supplemental-improper-payment-data-2", "jurisdiction": "National Medicare FFS measurement program", "texas": "national", "provider_type": "Medicare FFS", "review_method": "CERT improper-payment measurement", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "CERT improper-payment measurement", "rac_status": "CERT improper-payment report published", "description": "CERT identifies measured Medicare FFS payment vulnerabilities; publication alone is not a contractor audit announcement.", "policy_text": "", "codes": [], "issue_number": "e2d5cb2b37f6", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "8469a15f9b5145d95ccde85aaf6472698df4a759166edb34d364a363d9523363", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "smrc-01-155", "source_id": "cms-smrc", "source_family": "SMRC", "title": "01-155 CGMs After the PHE Notification of Medical Review", "source_date": "2026-01-16", "effective_date": null, "signal_class": "confirmed", "current_status": "Current SMRC medical review project", "summary": "View review reasons, documentation requirements and resources to consult when submitting claims.", "source_url": "https://noridiansmrc.com/current-projects/01-155/", "jurisdiction": "SMRC is nationwide; this project has source-specific selection criteria.", "texas": "national", "provider_type": "See SMRC project", "review_method": "Medical record review", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "source_content_hash": "38d8fcd02afeafa79418930cdd3181c25833186f58c615bb0c0b3caffc6f1e08", "record_type": "signal", "review_type": "Medical record review", "rac_status": "Current SMRC medical review project", "description": "View review reasons, documentation requirements and resources to consult when submitting claims.", "policy_text": "", "codes": [], "issue_number": "155", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "0cf8851cf1c38d6efca948becaf6d6ba355a5b0f838438c342d3b6368138674d", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "novitas-jh-cb02623f2b1ca9bb", "source_id": "novitas-jh", "source_family": "Novitas JH / TPE", "title": "Targeted Probe and Educate (TPE) Education: Debridement", "source_date": "2026-01-16", "effective_date": null, "signal_class": "update", "current_status": "Published Novitas JH TPE item", "summary": "Debridement This is a central location for all Debridement educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication number 100- 08 Medicare P...", "source_url": "https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00223503", "jurisdiction": "Novitas Jurisdiction H (Texas); some shared JH/JL education may also appear.", "texas": "texas", "provider_type": "See Novitas source", "review_method": "Targeted Probe and Educate", "codes_text": "", "specialties": [ "Dermatology & wound" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "Targeted Probe and Educate", "rac_status": "Published Novitas JH TPE item", "description": "Debridement This is a central location for all Debridement educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication number 100- 08 Medicare P...", "policy_text": "", "codes": [], "issue_number": "cb02623f2b1c", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "9bb5f56e028c8ee58653213108aa37c5e77875225fe7e26f9db49187256a1650", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "cms-program-1f08a58d9efce8d8", "source_id": "cms-program", "source_family": "CMS Program Integrity", "title": "R13581DEMO: Implementation of Wasteful and Inappropriate Service Reduction (WISeR) Model Prior Authorization and Medical Review Process and Establishment of New Quarterly Change Request (CR) Process for Possible Future Changes to Information Included in Attachments A, B, C, D, E, and F.", "source_date": "2026-01-13", "effective_date": "2025-09-30", "signal_class": "update", "current_status": "CMS transmittal issued", "summary": "CMS policy/procedure change relevant to program integrity or medical review. Read the transmittal before treating it as a change in audit intensity.", "source_url": "https://www.cms.gov/medicare/regulations-guidance/transmittals/2026-transmittals/r13581demo", "jurisdiction": "National CMS program guidance", "texas": "national", "provider_type": "Varies by transmittal", "review_method": "Policy / program-integrity update", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "source_content_hash": "d5503ce0c68eab21bac9e62db2e9341e80ec95505534913d433987e40a0657d9", "record_type": "signal", "review_type": "Policy / program-integrity update", "rac_status": "CMS transmittal issued", "description": "CMS policy/procedure change relevant to program integrity or medical review. Read the transmittal before treating it as a change in audit intensity.", "policy_text": "", "codes": [], "issue_number": "1f08a58d9efc", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "ad26aba71cd83c742805691b2a66c24584c8ffb5e68e5e7ff82d2ce41c0dec20", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "novitas-jh-dd4f2a24e0636ed8", "source_id": "novitas-jh", "source_family": "Novitas JH / TPE", "title": "Targeted Probe and Educate (TPE) Education: Severe Malnutrition", "source_date": "2026-01-08", "effective_date": null, "signal_class": "update", "current_status": "Published Novitas JH TPE item", "summary": "Severe Malnutrition This is a central location for all Severe Malnutrition educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication number 100...", "source_url": "https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00223508", "jurisdiction": "Novitas Jurisdiction H (Texas); some shared JH/JL education may also appear.", "texas": "texas", "provider_type": "See Novitas source", "review_method": "Targeted Probe and Educate", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "Targeted Probe and Educate", "rac_status": "Published Novitas JH TPE item", "description": "Severe Malnutrition This is a central location for all Severe Malnutrition educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication number 100...", "policy_text": "", "codes": [], "issue_number": "dd4f2a24e063", "self_check": [ "Confirm whether your organization bills or provides the services described in this public-source signal, including the relevant codes, setting, contractor, and dates.", "Confirm that the submitted record supports the service, medical necessity, required orders or certifications, and billed units where applicable.", "Identify the clinicians or facilities involved and establish recent claim counts and allowed amounts using an appropriate lookback.", "Compare utilization only within similar specialties, settings, and patient populations. An outlier is a review lead, not proof of improper billing.", "Review a focused sample against the policy version applicable to each date of service; document findings and assign follow-up as appropriate." ], "fingerprint": "92eae8e826e4cb2d66c55c6a8aee5e07502289497bae0c86d80204225ec7c8bc", "first_seen_at": "2026-09-14T15:06:25Z", "historical_import": false }, { "id": "novitas-jh-1b83ee36a70d1589", "source_id": "novitas-jh", "source_family": "Novitas JH / TPE", "title": "Targeted Probe and Educate (TPE) Education: Intravenous Immune Globulin (IVIG)", "source_date": "2026-01-08", "effective_date": null, "signal_class": "update", "current_status": "Published Novitas JH TPE item", "summary": "Intravenous Immune Globulin (IVIG) This is a central location for all IVIG educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. Centers for Medicare & Medicaid Services (CMS) Internet Only Manual (IOM) Publication number 100...", "source_url": "https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00223506", "jurisdiction": "Novitas Jurisdiction H (Texas); some shared JH/JL education may also appear.", "texas": "texas", "provider_type": "See Novitas source", "review_method": "Targeted Probe and Educate", "codes_text": "", "specialties": [ "Other / multispecialty" ], "verified_at": "2026-09-15T05:59:49Z", "listing_status": "listed", "record_type": "signal", "review_type": "Targeted Probe and Educate", "rac_status": "Published Novitas JH TPE item", "description": "Intravenous Immune Globulin (IVIG) This is a central location for all IVIG educational information, including links to related Centers for Medicare & Medicaid Services (CMS) resources and references. 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