DME: DO YOU HAVE THE RIGHT DOCUMENTATION?

Transcription

1 DME: DO YOU HAVE THE RIGHT DOCUMENTATION? RHONDA ZOLLARS, COC, CPC Copyright 2016 AAPC

2 DISCLAIMER ALL MATERIAL IS PUBLIC ACCESSABLE ALWAYS VERIFY YOUR STATE LAWS, PAYOR POLICIES, CONTRACTS,

3 OBJECTIVES UNDERSTAND DMEPOS UNDERSTAND THE REQUIREMENTS FOR ORDERING UNDERSTAND THE REQUIREMENTS OF MEDICAL DOCUMENTATION FROM PROVIDER AND DME COMPANY PROOF OF PURCHASE AND DELIVERY PDAC SYSTEM

4 ACRONYMS MSA (METROPOLITAN STATISTICAL AREA). DMEPOS- DURABLE MEDICAL EQUIPMENT PROSTHETICS, ORTHOTICS AND SUPPLIES CMS- CENTER FOR MEDICARE MEDICAID SERVICES DME DURABLE MEDICAL EQUIPMENT PDAC PRICING, DATA ANALYSIS AND CODING WOPD- WRITTEN ORDER PRIOR TO DELIVER F2F- FACE TO FACE

5 ACRONYMS CMN CERTIFICATE OF MEDICAL NECESSITY DIF - DME INFORMATION FORM POV POWER OPERATED VEHICLE PMD POWER MOBILITY DEVICES 5

6 GENERAL PAYMENT RULES DMEPOS ARE CATEGORIZED INTO ONE OF THE FOLLOWING PAYMENT CLASSES: INEXPENSIVE OR OTHER ROUTINELY PURCHASED DME; ITEMS REQUIRING FREQUENT AND SUBSTANTIAL SERVICING; CERTAIN CUSTOMIZED ITEMS; OTHER PROSTHETIC AND ORTHOTIC DEVICES; CAPPED RENTAL ITEMS; OR OXYGEN AND OXYGEN EQUIPMENT.

7 PHYSICIAN ORDERS THE SUPPLIER FOR ALL DURABLE MEDICAL EQUIPMENT, PROSTHETIC, AND ORTHOTIC SUPPLIES (DMEPOS) IS REQUIRED TO KEEP ON FILE A PHYSICIAN PRESCRIPTION (ORDER). A SUPPLIER MUST HAVE AN ORDER FROM THE TREATING PHYSICIAN BEFORE DISPENSING ANY DMEPOS ITEM TO A BENEFICIARY.

8 VERBAL & PRELIMINARY WRITTEN ORDERS THIS ORDER MUST INCLUDE: A DESCRIPTION OF THE ITEM, THE MEMBER'S NAME, THE PHYSICIAN'S NAME START DATE OF THE ORDER. SUPPLIERS MUST MAINTAIN WRITTEN ORDERS UPON REQUEST FOR REVIEWS IF SUPPLIER DOES NOT HAVE WRITTEN ORDER FROM TREATING PHYSICIAN BEFORE DISPENSING AN ITEM IT IS UNCOVERED!! SUPPLIER MUST OBTAIN A DETAILED WRITTEN ORDER BEFORE DISPENSING

9 FACE TO FACE TREATING PHYSICIAN MUST IN-PERSON EXAM WITH MEMBER WITH IN 6 MONTHS PRIOR TO WOPD EXAM DOCUMENTS THAT THE MEMBER WAS EVALUATED/TREATED FOR A CONDITION THAT SUPPORTS NEED FOR DME ITEM MUST BE ON OR BEFORE DATE OF WRITTEN ORDER < 6 MONTHS PRIOR DATE OF F2F MUST BE ON OR BEFORE DELIVERY SIGNED/STAMPED ON OR BEFORE DATE OF DELIVERY

10 WOPD-WRITTEN ORDER PRIOR TO DELIVERY 8 ITEMS MUST BE DOCUMENTED MEMBER S NAME PHYSICIAN S NAME DATE OF ORDER AND START DATE OF DME DETAILED DESCRIPTION OF ITEM(S) PRESCRIBING PHYSICIAN S NPI PHYSICIAN SIGNATURE SIGNATURE DATE DATE STAMP INDICATING SUPPLIERS DATE OF RECEIPT FOR WOPD ON OR BEFORE DATE OF DELIVERY

11 DISPENSING ORDER 5 ITEMS REQUIRED DESCRIPTION OF ITEM(S) MEMBER S NAME TREATING PHYSICIAN S NAME DATE OF ORDER AND START DATE PHYSICIAN SIGNATURE (IF WRITTEN ORDER) OR SUPPLIER S SIGNATURE (IF VERBAL ORDER)

12 DETAILED WRITTEN ORDER MEMBER S NAME PHYSICIAN NAME DATE OF ORDER AND START DATE (IF DIFFERENT FROM DATE OF ORDER) DETAILED DESCRIPTION OF ITEM(S) PHYSICIAN SIGNATURE AND SIGNATURE DATE ITEMS PROVIDED ON A PERIODIC BASIS ITEM(S) TO BE DISPENSED DOSAGE OR CONCENTRATION (IF APPLICABLE) ROUTE OF ADMINISTRATION (IF APPLICABLE) FREQUENCY OF USE DURATION OF INFUSION (IF APPLICABLE) QUANTITY TO BE DISPENSED NUMBER OF REFILLS (IF APPLICABLE)

13 REFILL REQUIREMENTS ITEMS BOUGHT IN PERSON AT A RETAIL STORE SIGNED DELIVERY/SALES RECEIPT ITEMS DELIVERED TO MEMBER DOCUMENTATION OF A REQUEST FOR REFILLS IS REQUIRED REFILL RECORD MUST INCLUDE MEMBERS NAME OR AUTHORIZED REPRESENTATIVE DESCRIPTION OF DME ITEM DATE OF REFILL

14 REFILL REQUIREMENTS CONT. REFILL RECORD CONSUMABLE SUPPLIES NUMBER OF EACH ITEM MEMBER HAS REMAINING NON-CONSUMABLE SUPPLIES FUNCTIONAL CONDITION OF DME ITEMS BEING REFILLED CONTACT WAS MADE WITHMEMBER/REPRESENTATIVE WITH IN 14 DAYS PRIOR TO DELIVERY/SHIPPING DATE ITEM(S) WERE DELIVERED NO SOONER THAN 10 DAYS TO THE END OF USAGE

15 CERTIFICATE OF MEDICAL NECESSITY (CMN) AND DME INFORMATION FORM (DIF) REQUIRED TO HELP DOCUMENT THE MEDICAL NECESSITY AND OTHER COVERAGE CRITERIA FOR SELECTED DMEPOS ITEMS CMN S SECTION A AND C COMPLETED BY THE SUPPLIER CMN S SECTION B AND D (SERVES AS PROVIDERS WOPD) COMPLETED BY THE PHYSICIAN WHO TREATED AND SEEN THE MEMBER DIF IS COMPLETED AND SIGNED BY THE SUPPLIER DOES NOT REQUIRE A NARRATIVE DESCRIPTION OF EQUIPMENT AND COST OR A PHYSICIAN SIGNATURE MUST BE MAINTAINED BY THE SUPPLIER AND AVAILABLE UPON REQUEST 15

16 ACCEPTABLE CMN S ITEMS REQUIRING CMN DME MAC FORM CMS FORM ITEMS ADDRESSED after 10/1/ Oxygen 04.04B 846 Pneumatic Compression Devices 04.04C 847 Osteogenesis Stimulators 06.03B 848 Transcutaneous Electrical Nerve Stimulators (TENS) 07.03A 849 Seat Lift Mechanisms Section C Continuation Form 16

17 ACCEPTABLE DIF S FOR ITEMS REQUIRING DIF DME MAC FORM CMS FORM ITEMS ADDRESSED External Infusion Pumps Enteral and Parenteral Nutrition 17

18 VALID VS INVALID CMN S OR DIF S VALID CMN IS ONE IN WHICH THE TREATING PHYSICIAN HAS ATTESTED TO AND SIGNED SUPPORTING THE MEDICAL NEED AND THE APPROPRIATE INDIVIDUALS HAVE COMPLETED THE MEDICAL PORTION OF THE CMN VALID DIF IS ONE IN WHICH THE SUPPLIER HAS ATTESTED TO AND SIGNED SUPPORTING THE MEDICAL NEED FAILURE TO HAVE A VALID CMN OR DIF ON FILE OR TO SUBMIT A VAILD FORM MAKES THE CLAIM INVALID INITIATES OVERPAYMENT ACTIONS NO DOCUMENTATION TO SUPPORT REASONABLE AND NECESSARY 18

19 SUPPLIER REQUIREMENTS BEFORE SUBMITTING A CLAIM TO THE DME MAC MUST HAVE DISPENSING ORDER DETAILED WRITTEN ORDER CMN OR DIF (IF APPLICABLE) INFORMATION FROM THE TREATING PHYSICIAN MEMBERS DIAGNOSIS MODIFIERS IF REQUIRED ATTESTATION STATEMENTS AS DEFINED IN CERTAIN DME MAC POLICIES SHOULD ALSO OBTAIN DOCUMENTATION F2F IF REQUIRED IF MEDICAL NECESSITY NOT SUPPORTED SUPPLIER IS LIABLE FOR DOLLAR AMOUNT UNLESS A PROPERLY EXECUTED ABN HAS BEEN OBTAINED. 19

20 PROOF OF DELIVERY METHOD 1 DIRECT DELIVERY TO MEMBER BY SUPPLIER DATE MEMBER/REPRESENTATIVE SIGNS FOR SUPPLIES IS TO BE THE DATE OF SERVICE MEMBERS NAME DELIVERY ADDRESS DETAILED DESCRIPTION OF DME BEING DELIVERED QUANTITY DELIVERED DATE OF DELIVERY MEMBER/REPRESENTATIVE SIGNATURE

21 PROOF OF DELIVERY METHOD 2 DELIVERY VIA SHIPPING OR DELIVERY SERVICE - SHIPPING DATE IS TO BE DATE OF SERVICE OF CLAIM MEMBERS NAME DELIVERY ADDRESS PACKAGE ID #/INVOICE # OR ALTERNATIVE METHOD MUST LINK DELIVERY DOCUMENTS TO DELIVERY SERVICE RECORDS DETAILED DESCRIPTION OF ITEM(S) DELIVERED QUANTITY DELIVERED DATE OF DELIVERY & EVIDENCE OF DELIVERY

22 PROOF OF DELIVERY METHOD 3 DELIVERY TO NURSING FACILITY ON BEHALF OF A MEMBER WHEN A SUPPLIER DELIVERS DIRECTLY TO NURSING FACILITY DOCUMENTATION REQUIREMENTS OF METHOD 1 IS REQUIRED WHEN DELIVERY SERVICE OR MAIL ORDER IS USED DOUCMENTATION MUST BE SAME AS METHOD 2 REGARDLESS THE METHOD OF DELIVERY TO THE MEMBER IN THE NURSING FACILITY INFORMATION FROM NURSING FACILITY NEEDS TO SUPPORT THAT THE ITEMS DELIVERED WERE ACTUALLY PROVIDED TO AND USED BY THE MEMBER THESE MUST BE ALL BE AVAILABLE UPON REQUEST

23 CONTINUED NEED RECENT ORDER BY TREATING PHYSICIAN FOR REFILLS OR RECENT CHANGE IN PRESCRIPTION OR COMPLETED CMN OR DIF WITH APPROPRIATE LENGTH OF NEED SPECIFIED OR TIMELY DOCUMENTATION IN MEMBER S MEDICAL RECORD SHOWING USAGE OF THE ITEM CONTINUED USE TIMELY DOCUMENTATION IN MEMBER S MEDICAL RECORD SHOWING USAGE OF THE ITEM, RELATED OPTIONS/ACCESSORIES OR SUPPLIES SUPPLIER RECORDS DOCUMENTING THE REQUEST FOR REFILLS/REPLACEMENT OF SUPPLIES IN COMPLIANCE WITH THE REFILL DOCUMENTATION REQUIREMENTS OR SUPPLIER RECORDS DOCUMENTING MEMBERS CONFIRMATION OF CONTINUED USE OF A RENTAL ITEM

24 MEDICAL RECORDS DOCUMENTATION NEEDS TO SUPPORT THAT ALL THE COVERAGE CRITERIA ARE MET MUST REFLECT NEED OF DME ITEM PHYSICIAN OFFICE RECORDS HOSPITAL RECORDS NURSING HOME RECORDS HOME HEALTH AGENCY RECORDS RECORDS FROM OTHER HEALTHCARE PROVIDERS TEST REPORTS THESE RECORDS AREN T ROUTINELY SUBMITTED BUT MUST BE AVAILABLE UPON REQUEST, ALTHOUGH NOT A REQUIREMENT, IT IS RECOMMENDED THAT SUPPLIERS OBTAIN AND REVIEW MEDICAL RECORDS AND MAINTAIN A COPY

25 MEDICAL NECESSITY EVIDENCE REPLACEMENT SUPPLIES FOR THERAPEUTIC USE OF PURCHASED DMEPOS TREATING PHYSICIAN MUST SPECIFY ON THE ORDER/CMN, TYPE OF SUPPLIES NEEDED AND FREQUENCY WITH WHICH THEY MUST BE REPLACED, USED OR CONSUMED PRN OR AS NEEDED IS NOT ACCEPTABLE MEDICAL NECESSITY DETERMINATIONS MAY ASK SUPPLIER TO OBTAIN DOCUMENTATION FROM TREATING PHYSICIAN TO ESTABLISH THE SEVERITY OF PATIENTS CONDITION AND IMMEDIATE AND LONG TERM NEED OF EQUIPMENT AND THERAPEUTIC BENEFITS THE PATIENT IS EXPECTED FROM USE

26 TENS UNITS ALL TENS (E0720, E0730) AND GARMENTS (E0731) F2F WRITTEN ORDER PRIOR TO DELIVERY ALL TENS SUPPLIES DETAILED WRITTEN ORDER REFILL REQUIREMENTS ALL TENS, GARMENTS, AND SUPPLIES MEMBER AUTHORIZATION POD CONTINUED NEED CONTINUED USE 26

27 TENS MEDICAL RECORDS TENS UNIT (E0720, E0730) TREATING PHYSICIAN ORDERS DISEASE OR CONDITION JUSTIFYING NEED OF TENS UNIT COVERAGE FOR TREATMENT OF MEMBERS WITH CHRONIC, INTRACTABLE PAIN OR ACUTE POST-OPERATIVE PAIN 27

28 TENS- ACUTE POST-OP PAIN LIMITED TO 30 DAYS FROM DAY OF SURGERY PAYMENT ONLY MADE AS A RENTAL DOCUMENTATION MUST INCLUDE DATE OF SURGERY NATURE OF SURGERY LOCATION AND SEVERITY OF THE PAIN OR CHRONIC PAIN OTHER THAN LOW BACK CHRONIC LOW BACK PAIN MUST MEET ALL THE REQUIREMENTS AS LISTED IN DOCUMENTATION CHECKLIST 28

29 CONDUCTIVE GARMENTS (E0731) ONLY COVERED IF ALL OF THE FOLLOWING REQUIREMENTS ARE MET: PRESCRIBED BY TREATING PHYSICIAN FOR USE IN DELIVERING TENS TREATMENT AND MEMBER MEETS ONE OF THE COVERED MEDICAL CONDITIONS MEMBER HAS DOCUMENTED MEDICAL CONDITION SKIN PROBLEMS THAT PRECLUDE APPLICATION OF ELECTRODES, ADHESIVE TAPES AND LEAD WIRES; OR BENEFICIARY REQUIRES ELECTRICAL STIMULATION BENEATH A CASE TO TREAT CHRONIC INTRACTABLE PAIN COVERED DURING RENTAL PERIOD REASONABLE AND NECESSARY FOR MEMBER 29

30 TENS BILLING REMINDERS E0731 MUST INCLUDE THE BRAND, NAME AND MODEL NUMBER OF THE CONDUCTIVE GARMENT KX MODIFIER MUST BE ADDED TO CODE IF COVERAGE CRITERIA HAS BEEN MET GA OR GZ MODIFIER IF EXPECTATION OF DENIAL ON VALID ABN Q0 MODIFIER MUST BE ADDED TO E0720 AND E0730 IF USED FOR CLBP ICD-10 CODES THAT JUSTIFY NEED FOR TENS WHEN USED IN CLINICAL TRIAL TO TREAT CLBP CLINICAL TRIAL IDENTIFIER NUMBER REQUIRED ON EACH CLAIM FOR MEMBERS ENROLLED IN CLINICAL TRIAL TREATMENT FOR CLBP CLINICALTRIALS.GOV 30

31 PATIENT LIFTS E0636, E1035, E1036 F2F REQUIREMENTS ON OR BEFORE DATE OF DELIVERY WRITTEN ORDER PRIOR TO DELIVERY KX MODIFIER MUST BE ADDED ALL OTHER EQUIPMENT AND SUPPLIES DISPENSING ORDER DETAILED WRITTEN ORDER BENEFICIARY AUTHORIZATION POD AS DISCUSSED EARLIER MEDICAL RECORD DOCUMENTATION

32 BILLING REMINDERS FOR LIFTS E0636 E1035 E1036 KX MODIFIER MUST BE ADDED TO THESE CODES THE ONLY PRODUCTS THAT CAN BE BILLED WITH THESE ARE THOSE THAT HAVE A WRITTEN CODING VERIFICATION REVIEW FROM PDAC CONTRACTOR MEDICAL NECESSITY DENIAL EXPECTATION GA MODIFIER IF VALID ABN OBTAINED GZ MODIFIER IF VALID ABN NOT OBTAINED IF UPGRADE IS PROVIDED GA, GK, GL AND/OR GZ MODIFIER MUST BE USED TO INDICATE UPGRADE HEAVY DUTY BARIATRIC LIFTS E0630-E0640

33 DMEPOS COMPETETIVE BIDDING PROGRAM STATUTE REQUIRES SINGLE PAYMENT AMOUNTS WHICH REPLACE THE CURRENT MEDICARE DMEPOS FEE SCHEDULE THERE ARE CURRENTLY COMPETITIVE BIDDING PROGRAMS IN 99 METROPOLITAN STATISTICAL AREAS (MSAS) THROUGHOUT THE UNITED STATES, INCLUDING HONOLULU, HAWAII JULY 2016 CMS SENT OUT A FACT SHEET REGARDING PAYMENT CHANGES,

34 ITEMS INCLUDED IN DMEPOS OXYGEN, OXYGEN EQUIPMENT, AND SUPPLIES CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICES AND RESPIRATORY ASSIST DEVICES (RADS) AND RELATED SUPPLIES AND ACCESSORIES HOSPITAL BEDS, COMMODE CHAIRS, PATIENT LIFTS, AND SEAT LIFTS INFUSION PUMPS SUPPORT SURFACES OR PRESSURE REDUCING MATTRESSES AND OVERLAYS ENTERAL NUTRIENTS, SUPPLIES, AND EQUIPMENT NEBULIZERS AND RELATED SUPPLIES NEGATIVE PRESSURE WOUND THERAPY (NPWT) PUMPS AND RELATED SUPPLIES AND ACCESSORIES STANDARD MOBILITY EQUIPMENT AND RELATED ACCESSORIES, INCLUDING WALKERS, STANDARD POWER AND MANUAL WHEELCHAIRS, SCOOTERS, AND RELATED ACCESSORIES GROUP 2 COMPLEX REHABILITATIVE POWER WHEELCHAIRS TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICES AND SUPPLIES

35 DMEPOS MANDATED BY CONGRESS THROUGH THE MEDICARE PRESCRIPTION DRUG, IMPROVEMENT AND MODERIZATION ACT OF 2003 COMPETITION AMONG SUPPLIERS SUPPLIERS ARE REQUIRED TO SUBMIT A BID FOR SELECTED PRODUCTS DOES NOT APPLY TO ALL PRODUCTS BIDS SUBMITTED ELECTRONICALLY BASED ON SUPPLIER S ELIGIBILITY, FINANCIAL STABILITY AND BID PRICE

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37 PDAC SYSTEM - NORIDIAN MAC RECEIVES, EVALUATES AND PROCESSES CODING VERIFICATION APPLICATIONS FOR DMEPOS ESTABLISHES, MAINTAINS AND UPDATES ALL CODING VERIFICATION DECISIONS ON THE PRODUCT CLASSIFICATION LIST THAT IS AVAILABLE ON DMECS PROVIDES CODING GUIDANCE FOR MANUFACTURERS AND SUPPLIERS ON THE PROPER USE OF THE HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) MAINTAINS AND PUBLISHES THE NDC/HCPCS CROSSWALK AND OACD PRICING FILES CONDUCTS DMEPOS DATA ANALYSIS

38 DME PDAC NORIDIAN MEDICARE

39 CPAP RESULTS ON PDAC

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45 RESOURCES DME FEE SCHEDULE JULY UPDATE SERVICE-PAYMENT/DMEPOSFEESCHED/DMEPOS-FEE- SCHEDULE.HTML COMPETITIVE BIDDING PROGRAM CMS DME MANUAL TYPE/DURABLE-MEDICAL-EQUIPMENT-DME- CENTER.HTML

46 RESOURCES NORIDIAN MAC DOCUMENTATION CHECKLIST ntation-checklists MEDICARE PDAC SYSTEM MAC S BY STATES PROGRAM INTEGRITY MANUAL CHAPTER 5 DME Guidance/Guidance/Manuals/downloads/pim83c05.pdf. CMN AND DIF FORMS AND HOW TO FILL THEM OUT tation/cmn-dif

47 CEU: THANK YOU! 47