dme: do you have the right documentation? - amazon web...
TRANSCRIPT
DISCLAIMER• ALL MATERIAL IS PUBLIC ACCESSABLE
• ALWAYS VERIFY YOUR STATE LAWS, PAYOR POLICIES,
CONTRACTS,
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
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
ACRONYMS
• CMN – CERTIFICATE OF MEDICAL NECESSITY
• DIF - DME INFORMATION FORM
• POV – POWER OPERATED VEHICLE
• PMD – POWER MOBILITY DEVICES
5
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.
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.
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
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
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
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)
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)
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
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
• 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
CERTIFICATE OF MEDICAL NECESSITY (CMN)
AND DME INFORMATION FORM (DIF)
15
ACCEPTABLE CMN’S – ITEMS REQUIRING CMN
16
DME MAC FORM CMS FORM ITEMS ADDRESSED
484.03 after 10/1/2015 484.3 484 Oxygen
04.04B 846Pneumatic Compression
Devices
04.04C 847 Osteogenesis Stimulators
06.03B 848Transcutaneous Electrical
Nerve Stimulators (TENS)
07.03A 849 Seat Lift Mechanisms
11.02 854 Section C Continuation Form
ACCEPTABLE DIF’S – FOR ITEMS REQUIRING DIF
17
DME MAC FORM CMS FORM ITEMS ADDRESSED
09.03 10125 External Infusion Pumps
10.03 10126Enteral and Parenteral
Nutrition
• 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
VALID VS INVALID CMN’S OR DIF’S
18
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
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
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
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
CONTINUED NEED CONTINUED USE
• 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
• 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
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
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
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
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
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
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
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
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
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
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,
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
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
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
RESOURCES• DME FEE SCHEDULE JULY UPDATE
• HTTPS://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FOR-
SERVICE-PAYMENT/DMEPOSFEESCHED/DMEPOS-FEE-
SCHEDULE.HTML
• COMPETITIVE BIDDING PROGRAM
• HTTP://WWW.DMECOMPETITIVEBID.COM/PALMETTO/CBIC
.NSF/DOCSCAT/HOME
• CMS DME MANUAL
• HTTPS://WWW.CMS.GOV/CENTER/PROVIDER-
TYPE/DURABLE-MEDICAL-EQUIPMENT-DME-
CENTER.HTML
RESOURCES• NORIDIAN MAC DOCUMENTATION CHECKLIST
• https://med.noridianmedicare.com/web/jddme/policies/docume
ntation-checklists
• MEDICARE PDAC SYSTEM
• MAC’S BY STATES
• PROGRAM INTEGRITY MANUAL CHAPTER 5 DME
• https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/pim83c05.pdf.
• CMN AND DIF FORMS AND HOW TO FILL THEM OUT
• https://med.noridianmedicare.com/web/jddme/topics/documen
tation/cmn-dif