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Face to Face and
Documentation Review:
How Do You Get It All?
Ronda Buhrmester, CRT
VGM / US Rehab
O: 888-665-6518
F: 855-262-3821
Learning Objectives:
1. Identify documentation that is required to be in the
patient’s file prior to delivery of equipment and prior to
claim submission.
2. Discuss the face-to-face requirements related to the ACA
6407.
3. Identify the difference between orders and what
information is necessary.
4. Discuss recommendations for educating the referral sources
on documenting in the medical record.
Documentation Review,
What is Needed?
Basic coverage for Medicare
BASIC coverage determination for all audit entities:
Must not bill Medicare more than you would any other
entity
Item must be Medically Necessary for use within the
home
Medicare will pay for least costly alternative
Must provide the item prior to billing
An item is considered as DME if--
1. It can withstand repeated use, and
2. Is primarily and customarily used to serve a medical
purpose, and
3. Generally is not useful to a person in the absence of an
illness or injury;
4. Is appropriate for use in the home.
Program Integrity Manual (on line only manual) www.cms.hhs.gov/pim
Who can order DME? The ordering practitioner can be:
• Physician
• Nurse practitioner
• Physician assistant
• Clinical nurse specialist
BUT: Must have own NPI & must be allowed to practice medicine in the state they are treating the patient for the condition the item is being provided for.
AND: They are practicing under the supervision of a doctor of medicine or doctor of osteopathy
Supplier Standards • Must meet to receive and maintain billing privileges
• Became effective December 11, 2000
• DMEPOS suppliers have the option to disclose the following statement in order
to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a
copy of the standards to the beneficiary.
“The products and/or services provided to you by supplier legal business name or
DBA are subject to the supplier standards contained in the Federal regulations
shown at 42 Code of Federal Regulations Section 424.57(c). These standards
concern business professional and operational matters (e.g., honoring warranties
and hours of operation). The full text of these standards can be obtained at
http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the
standards.”
• Make sure all staff has read and understands the Supplier Standards
---review annually
Most LCD policies now contain this notice
For any item to be covered by Medicare, it must 1) be eligible for a
defined Medicare benefit category, 2) be reasonable and necessary for
the diagnosis or treatment of illness or injury or to improve the
functioning of a malformed body member, and 3) meet all other
applicable Medicare statutory and regulatory requirements. For the
items addressed in this local coverage determination, the criteria for
"reasonable and necessary", based on Social Security Act §
1862(a)(1)(A) provisions, are defined by the following coverage
indications, and limitations and/or medical necessity.
PIM 5.7- Documentation
“For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type & quantity of items ordered & for the frequency of use or replacement (if applicable). ----- However, neither a physician’s order nor a CMN nor a DIF nor a physician attestation statement by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. ----”
Changes to the PIM regarding documentation
• On March 15, 2013, Section 3.3.2.1(C) of the amended PIM states that “physicians/LCMPs [licensed/certified medical professionals] who fail to submit documentation upon a supplier’s request may trigger increased MAC or RAC review of the physician/LCMP’s evaluation and management services”
Intake and Assessment • Need a strong, knowledge intake department
• Assures proper documentation is collected and meets coverage requirements
• Make sure understand what is required
• Encourage them to ask questions
• Make sure the date of the F2F is on the intake sheet or part of the intake questionnaire:
When did you see your ordering practitioner for this item being billed to your insurance?
Make sure it’s within the last 6 months—If applicable, Oxygen (E1390, E1392, K0738) are still at 30 days or 2 days prior to discharge
• Use documentation checklists and Dear Physician letters available: Jurisdiction C: www.cgsmedicare.com
Jurisdiction D: www.noridianmedicare.com
VGM & US Rehab websites
Know your policies
• HOSPITAL BED: In order for a hospital bed to be covered by Medicare there are certain specific details that are required in the patients’ medical record.
• For a fixed height hospital bed: Pt requires positioning of the body in ways that can not be accomplished with a regular bed ie: needs head of bed elevated greater than 30 degrees (CHF / Respiratory cond./ aspiration problems ) – pillows or wedges must have been considered and ruled out. *** Removed: August 2013****
• Requires positioning to alleviate pain which can not be done with ordinary bed – (arthritis/ CA etc) or pt needs traction which can only be attached to a hospital bed
• The variable height is covered if meets one of above and needs the variation in height to effect transfer to chair/ wheelchair or standing position --- The semi-electric – same as above but requires “frequent changes and or has an “immediate” need for change in body position; such as the patient who has the upper respiratory problems or acute discomfort and would require more frequent changes in position.
• The information can be a simple statement such as : _______ is in need of a semi electric hospital bed because she has had a stroke with dysphasia and requires elevation of bed greater than 30 degrees to prevent aspiration and needs frequent repositioning to alleviate pain and discomfort and prevent skin breakdown. Pillows/wedges were considered and ruled out.
• This information can be in discharge summaries from nursing homes, hospitals, home health notes and any other type of clinical records. The ordering practitioner needs to be aware of the equipment being ordered for their patient.
Documents needed in patient’s file What do I need??
What is needed “in your files”?
• Patient Profile: Order Intake Form • Verification of current & permanent address • Representative information if patient did not sign
• Attending physicians full name, address, NPI
• Assignment of Benefits (AOB) • Release of Information form
• HIPAA • Privacy rules
• Certificate of Medical Necessity (CMN), if applicable
• DME Information Form (DIF) and/or Physician Order, if applicable
• Detailed written order
• Medical records notes, and any other necessary supporting documentation
Documents needed in patient’s file
Patient Profile / Intake
Verification of insurance benefits and address
Release of information form
-- HIPAA / Privacy rules
Dispensing / Verbal Order
Detailed Written Order
F2F notes,
Physicians address, NPI
Assignment of Benefits
Representative information,
if patient did not sign
Documentation showing patient has received education on equipment by supplier
ABN, if applicable
Proof of capped rental notification, or purchase option letter
Proof of warranty provided to patient
Proof Supplier Standards were explained
CMN, if applicable
Proof of Delivery
Initial Claim ---
Proof of Delivery
Method 1 and Method 2 POD records
require: Beneficiary’s name Delivery address
Address of where items were delivered to or picked up
Sufficiently detailed description of the item(s) being delivered (e.g., brand name, serial number, narrative description)
Quantity delivered Date delivered Remember those lots numbers—for recall
purposes
In addition, Method 1 requires: Beneficiary (or designee) signature and date of
signature Suppliers signature and date
In addition, Method 2 requires: Delivery service’s package identification number,
supplier invoice or alternative method that links the supplier’s delivery documents with the delivery service’s records.
Evidence of delivery
Method 3 requires: If supplier delivers directly to nursing facility—
follow Method 1 When a delivery service/mail order is used to for
delivery---follow Method 2
Method 1 = Direct delivery to beneficiary by the supplier Method 2 = Delivery via shipping or delivery service directly to beneficiary Method 3 = Delivery to a nursing facility on behalf of a beneficiary
Who can sign POD record? A designee is defined as:
“Any person who can sign and accept the delivery of durable medical equipment on behalf of the
beneficiary.” • Legal guardian • Representative payee—a person designated by the Social Security Administration or other governmental
agency to receive an incapable beneficiary’s monthly cash benefits • Authorized representative—acts on behalf and in best interest of the beneficiary and is usually a parent,
legal guardian of minor, or legal guardian of an adult who has been declared incompetent • Designee • Relative • Friend • Representative of an institution providing care or support • Governmental agency providing assistance
The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier.
The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.
Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary.
Proof of Delivery
• Documentation must be maintained for 7 years
• Delivery date is bill date
• Tracking slip should reference each individual package if sent to a facility with multiple beneficiaries
• Note you should down load the delivery document from your delivery service for proof of delivery – The delivery companies usually keep for 1 year—after that—GONE!
Service Date • Hospital/SNF/Rehab discharge date is date of service
• Shipping - date of service is the actual shipping date • The date of service can not be earlier than date of delivery • Delivery can be up to two days prior to discharge if it is for
the ***benefit of *** fitting or training, date of discharge is the date of service
Warranty Information Form • Warranty Information Form ABC Company Anywhere USA • Every DME product sold or rented by our company that carries a warranty
will be identified by our staff and beneficiaries will be notified of warranty coverage. ABC company will honor all warranties under applicable law.
• _____________ will repair or replace, free of charge, parts for Medicare covered equipment that is under warranty. Labor is not included in most manufacturers warranties. You will receive information relating to the applicable warranty on products you receive from our company.
• ABC company is not responsible for any repairs/replacement of equipment due to user neglect or abuse. If continued neglect/abuse of equipment is noted the supplier may pick up the equipment and refer the user to another supplier and the information will be reported to the appropriate insurance carrier.
• I have been instructed and understand the warranty coverage on the _________ I have received.
• Beneficiary’s Signature _______________ Date: ______
Capped Rental 13 Months A 2 Z Medical Supply Dear ____________ • As of January 1, 2006 CMS has changed their policy in the way they pay for
some types of Durable Medical Equipment. The ________ that has been provided (will be provided) to you is now paid under a capped rental format.
• Previously you would have the choice to continue to rent or to purchase this item in the 10th month. Medicare will now pay for rental for 13 months and than the ________ becomes yours.
• This means that during the 13 months you/or your secondary will be responsible for 20% co-pay monthly until the cap has been reached. A 2 Z Medical is responsible for maintenance and service needed during the 13 months. Once the 13 months payment is completed it will than become your equipment & Medicare will pay for repairs of patient owned equipment as long as it remains medically necessary.
• I have read and understand the above explanation of payment for the ___________ I have (am being) been provided.
• Beneficiary Signature ______________________ Date _________ • (Authorized Representative) {why patient unable to sign}
What does KX Mean:
• When you add a KX modifier on a line item you are telling Medicare that you “KNOW” this patient meets criteria for the item you are billing.
• Documentation has to be in clinical notes – hospital discharge- progress notes – SNFs, Hospitals, Home Health Chart (notes) IMPORTANT FOR SUPPORT SURFACES E0277s
• PT/OT evaluations/clinical /dieticians/ Prosthetist/Orthotist/lab tests, sleep studies
LCDs With a KX Modifier Requirement Orthopedic Footwear
Patient Lifts
Pneumatic Compression Devices
Positive Airway Pressure Devices
Power Mobility Products
Pressure Reducing Support Surfaces
Refractive Lenses
Respiratory Assist Devices
Speech Generating Devices
Therapeutic Shoes for Persons with Diabetes
Transcutaneous Electrical Nerve Stimulators
Urological Supplies
Walkers
Wheelchair Options and Accessories
Wheelchair Seating
Ankle-Foot/Knee-Foot Orthosis
Automatic External Defibrillators
Cervical Traction Devices
Commodes
External Infusion Pumps
Glucose Monitors
High Frequency Chest Wall Oscillation Devices
Hospital Beds
Immunosuppressive Drugs
Knee Orthoses
Manual Wheelchair Bases
Nebulizers
Negative Pressure Wound Therapy Devices
Oral Antiemetic Drugs
Oral Appliances for OSA
COMMON ERRORS
COMMON ERRORS- illegible • Illegible medical records
• Illegible physician signatures
– Signature attestations
– Signature logs
– “I, ____________________[print full name of the physician/practitioner], hereby attest that the medical record entry for _________[date of service] accurately reflects signatures/notations that I made in my capacity as _______[insert provider credentials, e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”
• Stamped signatures
• Invalid electronic signatures
• Missing patient identification on multiple pages of medical or supplier records without indication of page numbers
• If you can’t read a note, more than likely no one else can either---ask physician to transcribe note, the nurse is able to transcribe as well—have physician sign and date transcription
Top Denial Reasons for PAPs (E0601) & RADs (E0470)
Medical record provided did not include documentation of F2F clinical evaluation by treating physician prior to sleep study assessing for OSA
DWO was on a blanket order form that did not allow ordering physician to individualize the equipment & supplies being ordered
Signature was missing or illegible
Sleep study not interpreted by physician with correct credentials
Proof of delivery was not provided or incomplete
Item delivered before receiving dispensing order
Diagnostic sleep study not provided
Supplier records did not document beneficiary/caregiver received instruction in proper care of device and accessories
Date of service submitted on claim did not match the date the beneficiary signed for delivery
No clinical evaluation by treating physician for those seeking replacement equipment following the 5 year RUL or when requesting coverage upon entering Medicare FFS
Clinical re-evaluation failed to demonstrate improvement in OSA symptoms and receiving continued benefit for therapy
DWO was missing and DWO was prior to the sleep study
Example 1
Unacceptable Blanket Order Does not provide a detailed list of each separately billed item and the replacement instructions are non-specific
Example 2
Unacceptable Blanket Order Order form lists supplies and accessories in a way that does not allow the physician to pick and choose the specific items being ordered for this beneficiary
Example 3
Acceptable order Order form lists supplies and accessories in a way that the physician can pick and choose the specific items being ordered for this beneficiary. Note: NPI needs to be on order.
Patient: John Doe
Start Date: 08/01/2011
Length of Need - Lifetime (99) CPAP Device at 10 cmH20
Heated Humidifier Bi-Pap Equipment (mask, accessories, disposable and reusable filters) - replace as needed
Charles Smith
August 15,2011 Charles Smith, M.D.
Patient: John Doe
Start Date: 08/01/2011
Length of Need - Lifetime (99) Bi-Pap w/o BU - IPAP 12 cm H20, EPAP 10 CM H20
Heated Humidifier PAP Oral Interface
Repl Exhalation Port for PAP Combi Oral/Nasal Mask 1/3 Mo
Full Face Mask 1/3 Mo
Replacement Face Mask 1/1 Mo
Nasal Application Device 1/3 Mo
PAP Headgear 1/6 Mo
PAP Chinstrap 1/6 Mo
PAP Tubing 1/3 Mo
PAP Non-disposable Filter 1/6 Mo
Humidifier Chamber 1/6 Mo
Oral Cushion 2/1 Mo
Repl Nasal Pillow Comb Mask 2/1 Mo
Replacement Nasal Cushion 2/1 Mo
Replacement Nasal Pillows 2/1 Mo
PAP Disposable Filter 2/1 Mo
Charles Smith
August 15,2011 Charles Smith, M.D.
Patient: John Doe
Start Date: 08/01/2011
Length of Need - Lifetime (99) CPAP Device at 11cmH20
Heated Humidifier Mask - Nasal Pillow 1/3 Mo
Mask - Full Face 1/3 Mo
Oral Mask Interface 1/3 Mo
Nasal Mask cushion 2/1 Mo
Full Face Mask Cushion 1/1 Mo
Nasal Pillows 2/1 Mo
Tubing 1/3 Mo
Chinstrap 1/6 Mo
Headgear 1/6 Mo
Filter, Disposable 2/1 Mo
Filter, Non-Disposable 1/6 Mo
Humidifier Chamber 1/6 Mo
Other ____________________
Charles Smith
August 15,2011 Charles Smith, M.D.
NPI: 1234567890
Valid Physicians order
Good Diagnosis---OSA 327.23
F2F prior to sleep study
Correct Sleep study---diagnostic (PSG) signed
Documentation of medical necessity in medical record
F2F—if needed to meet F2F ruling
Completed DWO
Proof of delivery
Summary of Documentation for PAP
• The actual oxygen saturation test indicated on the CMN must be provided in an audit. Although it can be indicated on the order, must be supported in the medical record.
• The date of the physician’s signature on the CMN/order is after the date of service on the claim and the verbal/dispensing order was not provided.
• The POD is prior to the date of service on the claim or the POD submitted is invalid.
• Documentation was not provided to support that alternative treatment measures have been tried or considered and deemed clinically ineffective.
• Documentation was not provided to support that the treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy
Top Denial Reasons for Oxygen
Dispensing Order vs Detailed Written Order O2
Dispensing Order: • Can be either written or verbal • If verbal make sure to include the name and title of the person giving the order and the name
of the person at your office taking the order
Detailed Written Order: • Must include the following information:
Patient’s name Narrative of items being ordered (any billable items—such as O2 Content) Date of order, and start date if different than order date Liter flow Frequency of use Method of delivery Length of need Ordering practitioner’s printed name Ordering practitioner’s signature and signature date Ordering practitioner’s NPI
• CMN can serve as DWO if contains all necessary information in section C—such as method of delivery and frequency of use
Summary of Documentation for O2 Valid Physicians order
Diagnosis needs to be severe lung disease or hypoxia related symptom
Qualifying Testing: Done while in CSS or 2 days prior to discharge
Documentation of medical necessity in medical record
Completed CMN and DWO
Is portable ordered—make sure documentation includes patient mobile in home
Have alternative treatments been tried/considered and rule out
Proof of delivery
Release on 8/28/14 from Jur. A : E0464 (non-invasive) under prepayment review
Documentation must include the following:
1. Physician order for the item
2. Information from the medical record that demonstrates the reasonable and
necessary coverage criteria for the item(s) are met.
3. Proof of delivery.
4. Any other pertinent information that would justify payment for the item(s) provided.
5. Advanced Beneficiary Notice (ABN) if one was obtained, this must be submitted
with the above requested documentation.
Be prepared!
Vents under Prepayment Review
Ventilators
• National Coverage Determination (280.1)
E0463/E0464
• Categorized as Frequent & Substantial Servicing
• Monthly rental includes payment for supplies and accessories
• Humidifiers are considered accessory; cannot be billed separately
• Monthly rental includes payment for repair and maintenance
• Supplier is required to have emergency plan, back up plan in the event primary ventilator breaks down
Generally Covered for Treatment of:
• Neuromuscular Disorders
• Thoracic Restrictive Diseases
• Chronic Respiratory Failure
Examples of diagnosis: ALS, MS, tracheostomy complication, COPD, etc.
Medical Record must state:
• Why the ventilator is medically necessary, and
• Why a CPAP/BiPAP is insufficient
Documentation
Orders Dispensing Order: Patient’s name Prescribing Physician’s name Date of order Description of the item Start date of the order, if different from date of the order Practitioner’s signature (if written order) or supplier signature (if verbal order)
Detailed Written Order: Patient’s name Treating Practitioner’s name (printed or typed) Start date of order – if start date is different than order date Order for ventilator with description/brand/model/ and settings Any other billable items Practitioner signature Practitioner signature date and NPI Length of need Frequency of use
Documentation to support medical necessity includes:
Valid Physicians order
Good Diagnosis
Documentation of medical necessity in medical record
Ventilator settings
Documentation of supplier’s back up plan
Proof of delivery
1. Federal Register Vol. 77 no. 146
• Proposed Rule: July 30, 2012
• Final Rule: November 16, 2012
2. Med Learn Matters #MM8304 dated May 31, 2013
• CR8304 in chapter 5 of PIM implements these changes
3. Revised MLN article released June 27, 2013 (MM8304) • Indicating enforcement delay until October 1, 2013
4. Announcement released Sept. 9th, now delayed until “a date” in 2014
5. Date is here: Announcement released December 19, 2013 that DME MACs will begin enforcement effective January 1, 2014
6. Release on August 20, 2014: F2F encounter-enforcement date delayed
until “a future date”
**This rule is separate from the F2F rules for Power Mobility Devices and O &P **
When Did This Start
What is happening?
Effective July 1, 2013
Medicare will require that specific items of DME will require:
1. Written Order Prior to Delivery (WOPD)
aka: Detailed Written Order Prior to Delivery
2. Face to Face (F2F) encounter completed by ordering practitioner
Key phrase is “PRIOR TO DELIVERY”
The days of delivering on a dispensing/verbal order are gone! (under the F2F rules)
What does this mean…
• A referral must document and communicate to the DME supplier that a F2F encounter with the beneficiary by the physician or NP or PA or CNS.
• Which means you have to have documentation that a face to face with the ordering practitioner occurred within 6 months prior to date of detailed order.
• If NP or PA or CNS does the F2F, the physician must sign off and date on their progress notes:
– will receive an additional payment for signing off (G0454)
– the physician does not have to sign the actual detailed order. This can be done by the NP or PA or CNS
As Stated in the Federal Register
During the F2F encounter the Physician, PA, NP, or CNS must have evaluated the beneficiary, conducted a needs assessment for the beneficiary, or treated the beneficiary for the medical condition that supports the need for each covered item of DME. The information would be part of medical record, which identifies the practitioner who provided the F2F assessment. We believe that requiring the F2F encounter that supports the need for the covered item of DME would reduce the risk of fraud, waste, and abuse since these visits would help ensure that a beneficiary’s condition warrants the covered item of DME.
List includes 166 HCPCS Codes requiring F2F encounter as of 7-1-2013
Some of the main items include: • Oxygen and related equipment • All Manual Wheelchairs & accessories • All Hospital Beds & accessories included heavy duty beds • Overlays • TENS Units • Rollabout Chairs • Blood Glucose Monitors • Traction-Cervical Equipment • Ventilators • PAP and RAD devices • All Nebulizers • Seat Lift Mechanisms • And other items
“The List”
Does NOT include stationary concentrator (E1390), Portable Concentrator (E1392), & Portable Gas System -home compressor for filling tanks (K0738)
Does include Stationary Liquid (E0439) and Stationary Compressed Gas (E0424) And includes portable liquid (E0434) and portable gas (E0431)
Remember, the oxygen policy states:
In-person visit with treating physician within 30 days before initial date of service, and
Qualifying test must have been within 30 days prior or within 2 days prior to discharge from a facility
PMD not included which already have existing F2F requirements
List will be updated annually
In the future will add to the list any item of DME that appears on the fee schedule with a
price ceiling at or greater than $1000.
More On “The List”
Type of Equipment HCPCSAutomatic External Defibrillator K0606
Cervical Traction Devices E8040, E0849, E0850, E0855, E0856
External Infusion Pumps E0782-E0784, E0786
High Frequency Chest Wall
Oscillation DeviceE0483
Home Blood Glucose Monitors E0607
Hospital Beds
E0250, E0251, E0255, E0256, E0260,
E0261, E0265, E0266, E0290-E0297, E0300-
E0304
Manual In-exsufflation Devices E0482
Manual Wheelchairs and Transport
Chairs
E1031, E1037-E1039, E1161, E1232-
E1238, E2227, K0001-K0007, K0009
Nebulizers E0570, E0575, E0580, E0585, K0730
Neuromuscular Stimulators E0744-E0745, E0764, E0765
Osteogenesis Stimulators E0747-E0749, E0760
OxygenE0424, E0431, E0433, E0434, E0439,
E0441-E0444
Patient Lifts E0636, E1035, E1036
Pelvic Floor Stimulator E0740
Pneumatic Compression DevicesE0650-E0652, E0655-E0657, E0660, E0665-
E0669, E0671-E0673, E0675
166 Codes requiring F2F encounter as of July 1, 2013
Positive Airway Pressure Devices E0601, E0470
Pressure Reducing Support Surfaces E0185, E0188, E0189, E0194, E0197-E0199
Respiratory Assist Devices E0470-E0472
Seat Lift Mechanisms E0627-E0629
Speech Generating Devices E2502, E2506, E2508, E2510
TENS Units E0720, E0730, E0731
Transcutaneous Electrical Joint
StimulatorE0762
Ventilators E0450, E0460, E0461, E0463, E0464
Wheelchair Options and Accessories
E0958-E0961, E0966-E0969, E0971,
E0973, E0974, E0978, E0980-E0986,
E0990, E0992, E0994, E1014, E1015,
E1020, E1030, E1227, E1228, E1296-E1298
Check Shell E0457
Chest Wrap E0459
Rocking Bed with or without side rail E0462
Percussor electric/pneumatic home
modelE0480
Oscillatory positive expirator device,
non-electricE0484
Whirlppol non-portable E1310
Type of Equipment HCPCS
166 Codes requiring F2F encounter as of July 1, 2013—continued…..
What we know as of today…..
1. There must be clear documentation of a face to face encounter which documents that the encounter included an evaluation or treatment for a condition that supports the item(s) of DME ordered.
2. This can be performed by a physician, a PA (physician assistant) NP (Nurse Practitioner) or CNS (Clinical Nurse Specialist ) BUT the physician must sign and date the progress note from the NP, PAs and CNS.
3. They can document for multiple items at same encounter but the encounter must occur within 6 months of detailed written order.
• Mentioned in Dear Physician Letter dated 5/29/2014
• Following 2 slides have HCPCS codes that will be updated once CMS
releases the revisions
Codes that have been deleted or that were made not valid for
Medicare
Codes with narrative changes
• Bottom line: keep an eye on the codes; watch for release from
CMS
Update to Codes
Codes that have been deleted or that were made not valid for Medicare:
E0968: Commode Seat, wheelchair
E0969: Narrowing device wheelchair
E0978: Manual W/C accessory positioning belt/safety belt/pelvic strap
E0980: Manual w/c accessory safety vest
E0994: Arm rest
E1227: Special height arm for w/c
E1228: Special back height for w/c
E1296: Special sized w/c seat height
E1297: Special sized w/c seat depth by upholstery
E1298: Special sized w/c seat depth and/or width by construction
Updates to Codes:
E0983: power add on to convert manual to motorized, joystick control
E0984: power add on to convert manual to motorized, tiller control
E0986: push activated power assist
E0990: elevating leg rest
E0992: elevating leg rest solid seat insert
E1028: manual swing away, retractable or removable mounting
hardware for joystick, other control interface or positioning
accessory
E1029: Ventilator tray
E1030: Ventilator tray, gimbaled
Manual wheelchair accessories: E0958: one-arm drive attachment
E0959: adapter for Amputee
E0960: shoulder harness/strap
E0961: wheel lock brake extension handle
E0966: headrest extension
E0967: hand rim with projections
E0971: anti-tipping device
E0973: adjustable height detachable armrest
E0974: anti-rollaback device
E0981: seat upholstery, replacement only
E0982: back upholstery, replacement only
Codes that have had narrative changes
Other codes: E1035: Multi-positional patient transfer system with integrated seat
operated by caregiver
E1036: Patient transfer system
E1038: Transport chair, adult size up to 300lb
E1039: Transport chair, adult size heavy duty >300lb
E1233: W/C, pediatric size, tilt-n-space, folding, adjustable without
seating system
E1310: whirlpool, non-adjustable
E2502: SGD, prerecord messages between 8-20 minutes
E2506: SGD, prerecord messages over 40 minutes
E2508: SGD, message through spelling, manual type
E2510: SGD, synthesized with multiple message methods
E2227: Rigid pediatric wheelchair adjustable
K0606: AED garment with electronic analysis
CMS –2 Updates Regarding the F2F Ruling sent May 29, 2014
1st Update:
• Face-to-Face encounter DOES NOT need to be the prescriber writing the DWO (WOPD)
• Prescriber of the DME item can be a different practitioner
• DOES state that the prescriber of the DME item must have knowledge and documentation of the F2F examination that was conducted
• Make sure there is communication between the prescribing practitioner and the practitioner that performed the F2F evaluation AND the DME supplier
• Should make hospital discharges more streamlined—be very cautious and make sure there is communication
CMS –2 Updates Regarding the F2F Ruling sent May 29, 2014
2nd Update:
• DME MACs currently are allowed to audit on WOPD but not the F2F encounter
• Enforcement of actively auditing on the WOPD effective January 1, 2014
• Now—RAC, ZPIC, and Program Safeguard Contractors NOT allowed to audit on F2F encounter retroactive July 1, 2013.
• This does not apply to CERT auditors
• Remember: CERT auditors are auditing the DME MACs
Supplier Manual updated….. ................................................................................................................
Written Orders Prior to Delivery (WOPD) A written order prior to delivery is required for:
• Any HCPCS Subject to the Affordable Care Act (ACA) Face-to-Face Requirement
• Negative Pressure Wound Therapy
• Seat Lift Mechanisms
• Support Surfaces
• TENS Units
• Power Mobility Devices (PMD)
• Wheelchair Options and Accessories used with a PMD
DME MACs may identify other items for which we will require a written order prior to delivery and
suppliers should confirm the requirements in the specific Local Coverage Determination (LCD). For
items requiring a WOPD, the supplier must have received a written order that has been both signed
and dated by the treating physician, and meets the requirements for written orders, before dispensing
the item. If a supplier bills for an item without a written order, when the supplier is required to have a
written order prior to delivery, the item will be denied as not meeting the benefit category and is
therefore not appealable by the supplier.
Medical Policies Updated—March 6, 2014
with effective date of July 1, 2013
The Detailed Order Must Contain: F2F July 1, 2013 Detailed Written Order Must contain:
At a minimum from Federal Register Nov. 16, 2012
• Patient name
• Item ordered
• Ordering Practitioner signature **signature must be dated**
• Ordering Practitioner NPI
• Date of order
May need to include additional information such as:
• Start Date, if different than order date
• Diagnosis related to condition requiring the item-- if the item is diagnosis driven
• Length of need ---if required per policy
• Method of usage, required on some items, such as Oxygen via nasal cannulas/mask
• Other items according the medical policy
The requirements listed in the F2F regulation do not supersede other CMS requirements for a DWO.
Detailed Order 1. All Medicare items require an order
2. Must be signed and dated by ordering practitioner & include NPI
3. F2F items require the order be completed “PRIOR” to delivery (WOPD)
4. Description of item can be narrative or brand name –
5. Make sure you date stamp the order and medical records
6. Go by date of order, when start date is different than date of order, DME MACs go by date of order.
Sometimes items require delivery prior to discharge so start date may be different, and date
order received by supplier will be different, but Medicare will go by date of order. For example, ventilators.
7. Once the detailed order is signed by the ordering practitioner, it cannot be altered by the supplier. If a correction is needed, the ordering practitioner needs to make correction and then initial/date that correction or get a new order.
The Supplier can complete the detailed written order, then have the ordering practitioner review, sign, and date.
Reminders
• If a new order is required, then a new face to face is required
• All of the HCPCS codes listed in the F2F rule (166 codes) fall into the definition of a WOPD as there are some items listed under this category such as TENS, Group Support Surfaces, Seat Lift Mechanisms, etc. Cannot deliver these items based on a dispensing/verbal order anymore.
• The law requires that at in person visit with the treating practitioner whom documents the need for the item. If a PT, OT, etc., recommends a piece of equipment that is on the list of codes, the treating practitioner CANNOT use these notes as the face to face visit. Can be used as supporting documentation, but the patient is required to have an in person visit with the ordering practitioner.
• Medical record information does not go on prescription, has to be in the normal charting format in the notes.
On August 7, 2014 a new update was released:
I. If errors in the WOPD are found prior to delivery, the supplier has two options:
A. The WOPD may be properly amended following the guidance in the Program
Integrity Manual (Internet-Only Manual, Publ. 100-08), Chapter 3, Section
3.3.2.5; or,
B. A new WOPD may be created and sent to the physician for signature and
date.
II. If errors in the WOPD are found after delivery of the item, the supplier has two
options:
A. If the error is discovered prior to claim submission, the original supplier
may recover the delivered item(s), obtain a compliant, complete WOPD and
then may re-deliver the item(s) to the beneficiary; or,
B. If the error is discovered after submitting a claim, the original supplier can
recover their items and a new supplier must complete the transaction after
complying with all requirements.
Written Order Prior to Delivery
New Order Required
• Change of supplier
• Change in the item (s), frequency of use, or amount prescribed
• Change in length of need or previously established length of need expires
• State law requires a prescription renewal
• Under the F2F ruling—supplier does not need to obtain a new F2F
evaluation
• From the ACT call with Jurisdiction A on 9-17-14
NOTE: When a new order is required, then a new face to face is required
TEMPLATES
• Although CMS does not prohibit the use of templates or check lists we will caution all of our suppliers that these are frequently denied in review.
• Templates tend to not cover the true needs of the individual patient and are not thorough enough to sufficiently determine coverage.
• Use of the DMEMAC physician educational letters has been found to be useful to many suppliers.
• We are confident that the DME Medical Directors will assist us on this educational effort as they have in the past with many difficult LCDs.
Education Hints • Make sure your entire staff understands the F2F requirements, including on-call staff
• Educate all referral sources: doctors, discharge planners, social workers, nurses, medical assistants, case management – anyone that is involved in that patient’s care
• Use “Dear Physician Letter”
• Remind referrals ---this is nothing new—documentation in medical records always required
• Use Documentation Checklist
• Make sure intake/staff reviews information upon receiving referral
• Review claim information before submitting the claim
• Use VGM/US Rehab Reimbursement Team to assist with educating
• Explain to referrals that information is needed PRIOR TO DELIVERY
• If information received after delivery, then cannot go start billing Medicare—patient will have to switch to another supplier
• Get the patient and/or their family members involved from the beginning
• Explain to them exactly what would be needed
• The first interview they get when they go into the clinic is the nurse. Use them to
assist with gathering information needed
• Have the patient state to the nurse exactly what they need and why
• The nurse would then put this information on the chart; and will give the
practitioner a head’s up for what is needed
• Example: the patient state they tried using cane and walker, but mobility is still
limited trying to get from bedroom to kitchen because of degenerative joint
disease in knees has caused them to fall and needs a wheelchair.
• Example: Patient inquiring about a hospital bed, mentions having problems
sleeping flat and has tried positioning in different ways; has a history of CHF—
needing a HB
• Remember this is a subjective statement and would need to be followed up with
objective measurements
Getting The Patient Involved:
Remember CMS is the one doing this however, it comes from direction they have received through the Affordable Care Act 6407.
Effective January 1, 2014 DME MACs are enforcing the WOPD (or DWO) under the F2F requirements. The actual F2F encounter is still under “delay of enforcement”, but we strongly encourage that suppliers get both the WOPD and medical records prior to delivery!
Which means the DME MACS are not to “actively audit” on the actual F2F encounter; however, the DME MACS are not only auditors in the industry.
Remember, the law was implemented July 1, 2013
Call your Congress!
Prevention • Education -- Compliance
• To staff – referral sources – beneficiaries
• Good order intake - CSRs
• Medical Records – Get them and READ THEM!
• Clinical documentation is important from all sources
• Use the documentation check off sheets that are provided by some DME MACs
• Have desk procedures and make sure they are followed; (compliance plans are important and will be required)
• Review medical policies (LCD) and articles
• Files need to be legible and in order
• ALL Signatures must be legible
• DATE STAMP when received
• Delivery tickets/name/model/serial #s LEGIBLE signatures—watch dates
• Self Audits are a must –do yourself or have outside party
INSUFFICIENT DOCUMENTATION
• Work with Office Managers/social workers/ discharge planners/ nurses and explain the need for the documentation to remain compliant in order for the patient to receive needed equipment
• Advise physician and their staff that without documentation, Medicare may deny the claim and the patient may be responsible for payment
• Get the patient involved and explain that they may be liable without physician records
• Use properly executed ABNs - do not use these as a “way out”
Documentation is key!!
How to respond to the Letter!
1. Read the letter carefully to know what they are asking for and due date. Also to know where to send the information. Respond only once – no duplications.
2. Gather all the documentation. Make sure you are sending the correct documentation and all related information. Review the information being sent using a checklist.
3. There will be a bar code cover sheet to use a first page when responding.
4. Number each page like 1 of 20, 2 of 20, etc
5. Do not highlight anything!! Documents are scanned and highlights will block out the information. Underline or use asterisks to indicate important notes.
6. Make sure signatures are legible. Can send attestation statement from physician.
7. Send each claim separately, do no bundle.
8. Copy everything being sent. Send only what is related to the item being reviewed.
How do I respond?
9. Clinical documentation is a must in all situations -If you do not send it you will get a denial. – don’t stop billing but adjust your work flow ---
10. Review all documentation (using a check off sheet) before sending
11. Check dates on documentation- has be prior to delivery of equipment –
12. Keep a contact log with all information –use a spreadsheet
13. Check address to send to and make sure you send copy of letter received back to contractor. If you do not have it all send what you have and keep researching for additional documentation. (Get a return receipt requested)
14. Make sure you know all physicians’ patient is seeing –
15. ON the High End Rehab make sure that if your claim was sent to ADMC that you include that response with your audit
16. If unfavorable response received, follow same appeals process.
Appeal Levels
Regardless of who denies the audit you still follow the same review process.
Education with Referral Sources
Medicare Quick Reference Guide:
• Tool created to assist with educating your referral sources
• The reimbursement team is available to partner with educating
your referral sources via webinar or on-site consulting
Resources Available Jur A: www.medicarenhic.com
Jur B: www.ngsmedicare.com
Jur C: www.cgsmedicare.com
Jur D: www.nordianmedicare.com
Competitive Bid: www.dmecompetitivebid.com
VGM: www.vgm.com www.usrehab.com www.dclink.com PDAC: www.dmepdac.com CMS: www.cms.hhs.gov PECOS: https://pecos.cms.hhs.gov NSC: www.palmettogba.com
Ronda Buhrmester
O: 888-665-6518
F: 855-262-3821
Thank you!