DME Basics Part 1: Background Knowledge

Transcription

1 DME Basics Part 1: Background Knowledge Presented by Noridian DME Outreach and Education May

2 Disclaimer This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website and the CMS website. The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. Noridian Medicare Website ( CMS Website ( May 2016 Noridian DME Outreach and Education 2 2

3 Workshop Protocol Attendee lines are muted upon entry Questions Written questions in Q & A section Verbal questions at the conclusion of the material Certificate of Completion CEUs are NOT offered for this course 1 AAPC CEU is offered for this course Certificate of Completion ed to all attendees with 2-3 business days following the workshop May 2016 Noridian DME Outreach and Education 3 3

4 Please Sign into Audio Using Either Method Call Me Option Enter your contact phone number You will receive a call that connects you Call Using Computer Option Ensure you have mute off on your Computer and Headphones May 2016 Noridian DME Outreach and Education 4 4

5 Sync Your Phone with Your Name Click on Event Info Tab Verify Identity code Enter # your number # May 2016 Noridian DME Outreach and Education 5 5

6 How to Ask a Written Question Click on the Q and A tab Address All Panelists Type your question into the box Limit 256 characters Be concise May 2016 Noridian DME Outreach and Education 6 6

7 Acronyms CMS: Centers for Medicare & Medicaid Services IOM: Internet Only Manual IRP: Inexpensive or Routinely Purchased LCD: Local Coverage Determination LPM: Liters Per Minute NCD: National Coverage Determination PA: Policy Article SNF: Skilled Nursing Facility May 2016 Noridian DME Outreach and Education 7 7

8 Agenda Comprehensive Error Rate Testing PECOS Contractors General Coverage Benefit Categories Fee Schedule Categories Medical Policies Resources and Reminders May 2016 Noridian DME Outreach and Education 8 8

9 Comprehensive Error Rate Testing (CERT) 9

10 CERT 2015 Improper Payment Rates CERT Improper Payment Rate webpage ( and-systems/monitoring-programs/medicare- FFS-Compliance-Programs/CERT/index.html) Service Type Improper Error Rate Improper Payment Amount (2) Inpatient Hospitals 6.2% $7.0 Billion Durable Medical Equipment 39.9% $3.2 Billion Physician/Lab/Ambulance 12.7% $11.5 Billion Non Inpatient Hospital Facilities 14.7% $21.7 Billion Overall 12.1% $43.3 Billion May 2016 Noridian DME Outreach and Education 10 10

11 CERT Address Customize the location for possible CERT letters Call CERT Documentation Contractor (Livanta) at or, Update this information at: o.aspx?contractorid=&providerid *This only changes the address for CERT inquires *Changes to a suppliers physical address should go to the National Supplier Clearinghouse (NSC) May 2016 Noridian DME Outreach and Education 11 11

12 CERT Randomly select submitted claims Request medical records from provider/supplier that submitted claim Review claims and medical record for compliance with Medicare to include: Coverage Coding Billing rules May 2016 Noridian DME Outreach and Education 12 12

13 CERT Error Categories Insufficient documentation No documentation Service incorrectly coded Medically unnecessary service Other May 2016 Noridian DME Outreach and Education 13 13

14 Decrease CERT Errors Educate staff Train coders/billers Submit correct information Beneficiary name, social security number, Medicare number, date of service Submit legible and complete records Dates, required signatures, etc. Send CERT Inquiries May 2016 Noridian DME Outreach and Education 14 14

15 CERT Inquiries should include: CERT Claim Identification (CID) In Subject Line Supplier name and address Telephone number Explanation of the issues, concern or question DO NOT send Protected Health Information (PHI) Response within 2 business days May 2016 Noridian DME Outreach and Education 15 15

16 Provider Enrollment Chain and Ownership System (PECOS) 16

17 PECOS Requirement Claims may be denied if: The ordering physician is NOT in PECOS The ordering physician is not of the specialty to order If the physician's name submitted on the claim does not match their name in PECOS PECOS Edit ( aims-appeals/claim-submission/pecos-edits) View the PECOS DME on Demand ( qykbpz87umz0) May 2016 Noridian DME Outreach and Education 17 17

18 PECOS Educational Tools ucation/event-materials Web-Based Workshop Presentation Self-Paced Tutorial (DME on Demand) Q&A Session Consolidated Resources May 2016 Noridian DME Outreach and Education 18 18

19 Contractors 19

20 Primary DME Contractors Durable Medical Equipment Medicare Administrative Contractor (DME MAC) National Supplier Clearinghouse (NSC) Pricing, Data Analysis and Coding (PDAC) Common Electronic Data Interchange (CEDI) Competitive Bid Implementation Contractor (CBIC) Review Contractors (RA, CERT, SMRC, ZPIC) May 2016 Noridian DME Outreach and Education 20 20

21 DME MAC Process claims according to where beneficiary resides Based on Social Security Administration address on file (where social security benefits are received) Types of claims processed by DME MACs Durable Medical Equipment Prosthetics Orthotics Supplies May 2016 Noridian DME Outreach and Education 21 21

22 Noridian s DME MAC Role Noridian s role: Process Medicare claims Communicate Medicare guideline changes Noridian does not: Establish Medicare rules and regulations CMS determines rules and regulations Legislation Determine beneficiary eligibility Social Security Administration May 2016 Noridian DME Outreach and Education 22 22

23 NSC National Supplier Clearinghouse Supplier enrollment CMS 855-S application Changes to enrollment must go through NSC Medicare DMEPOS Supplier Standards Can also be found in chapter 2 of our supplier manual Verifies Accreditation requirement Verifies Surety Bond requirement Contact information or May 2016 Noridian DME Outreach and Education 23 23

24 PDAC Pricing, Data Analysis and Coding Proper use of HCPCS Assist CMS with DMEPOS fee schedules DMECS HCPCS information Modifiers Fee schedules DMEPOS product classifications Contact information or May 2016 Noridian DME Outreach and Education 24 24

25 Common Electronic Data Interchange Single front end electronic solution Free Software Front end error report manual CEDI CEDI works closely with: DME MAC software venders Billing services Clearinghouses Trading partners Contact Info: Website: Phone: May 2016 Noridian DME Outreach and Education 25 25

26 CBIC Competitive Bid Implementation Contractor Application assistance Contracting process, contract changes and terminations Questions/complaints concerning policy and/or program regulations Report concerns about a supplier/referral agent, quality of service, suspected fraud Obtain assistance locating a supplier Clarify guidelines on a particular policy Educational material or programs May 2016 Noridian DME Outreach and Education 26 26

27 CBIC Contact Information Contact information Cat/Home Payment/DMEPOSCompetitiveBid/index.html a.m. and 5:30 p.m. prevailing Eastern Time, M-F May 2016 Noridian DME Outreach and Education 27 27

28 Review Contractors Improper payment identified by: Recovery Auditor (formerly known as RAC) Comprehensive Error Rate Testing (CERT) Medical Review Special Study (SMRC) Suspected fraud identified by: Zone Program Integrity Contractors (ZPICs) May 2016 Noridian DME Outreach and Education 28 28

29 General Coverage 29

30 General Coverage Criteria All DMEPOS must be: Eligible for a defined Medicare benefit category Reasonable and Necessary Diagnosis or treatment of illness or injury; or Improve the functioning of a malformed body member Meet Medicare guidelines Statutory and regulatory requirements Prescribed by physician or other qualified medical professional prior to claim submission May 2016 Noridian DME Outreach and Education 30 30

31 Noncovered Items Wigs Hot water bottles Disposable underpads Toilet rails Tub stool or bench Bed board Noncovered items listing: oncovered-items May 2016 Noridian DME Outreach and Education 31 31

32 DME MAC Covered Drugs Oral anticancer Oral antiemetic Nebulizer Immunosuppressive External infusion pump drugs Insulin infusion through pump May 2016 Noridian DME Outreach and Education 32 32

33 Mandatory Assignment on Medicare Covered Drugs Assigned claim only Unassigned drug or biological claim processed as assigned May 2016 Noridian DME Outreach and Education 33 33

34 Benefit Categories 34

35 Benefit Categories Durable Medical Equipment Withstand repeated use Used to serve medical purpose Not useful in absence of illness or injury Appropriate for use in home Prosthetic Devices Replace all or part of function of permanently inoperative or malfunctioning body part May 2016 Noridian DME Outreach and Education 35 35

36 Braces (Orthotics) Benefit Categories (2) Rigid or semi-rigid device Supports weak or malformed body member Restrict or eliminate motion in diseased or injured part of body Surgical Dressings Therapeutic and protective coverings applied to surgical or debrided wounds Includes primary and secondary dressings Therapeutic Shoes for Persons with Diabetes Custom molded or extra-depth shoes and inserts May 2016 Noridian DME Outreach and Education 36 36

37 Benefit Categories (3) Immunosuppressive Drugs For transplant purposes only Oral Anticancer Drugs Must have same chemical composition and indications as parenteral form of drug Oral Antiemetic Drugs When used as full replacement for IV form during chemotherapy treatment May 2016 Noridian DME Outreach and Education 37 37

38 Fee Schedule Categories 38

39 Fee Schedule Payment Categories Most DMEPOS fall into one of the following categories: Inexpensive or Other Routinely Purchased DME (IRP) Items Requiring Frequent and Substantial Servicing Customized Items Prosthetic and Orthotic Devices Capped Rental Items Oxygen and Oxygen Equipment May 2016 Noridian DME Outreach and Education 39 39

40 Inexpensive or Other Routinely Purchased DME (IRP) Inexpensive DME Purchase price does not exceed $ Routinely Purchased DME Purchased at least 75% of time Rental or lump sum purchase Total rental payment can not exceed actual purchase price Pricing Modifiers: NU, UE, RR Must advise beneficiary of rent or purchase option, per supplier standard #5 May 2016 Noridian DME Outreach and Education 40 40

41 Frequent and Substantial Servicing Rental only Modifier: RR Payment based on monthly fee schedule amount until medical necessity ends Supplies and accessories included May 2016 Noridian DME Outreach and Education 41 41

42 Customized Items Individual consideration based on medical need Physician must prescribe customized equipment and provide information regarding physical and medical status Items needed for coverage to be considered Detailed description Feature description making item unique Acquisition or production cost Lump sum payment Date of service = date of delivery May 2016 Noridian DME Outreach and Education 42 42

43 Prosthetics and Orthotics All prosthetic and orthotic devices excluding: Items requiring frequent and substantial servicing Certain customized items Transcutaneous electrical nerve stimulators (TENS) Parenteral/enteral nutritional supplies and equipment Intraocular lenses Lump sum payment Date of service = date of delivery May 2016 Noridian DME Outreach and Education 43 43

44 Capped Rental Items Paid on monthly rental basis 13 month period Item is beneficiary owned after 13 months Modifiers: RR: Rental KH: Month 1 KI: Months 2-3 KJ: Months 4-13 May 2016 Noridian DME Outreach and Education 44 44

45 Capped Rental Purchase Option Complex rehab power wheelchairs only K0835 -K0864 Must give beneficiary option to purchase in first month First month claim must include one of the following modifiers: BR Beneficiary has elected to rent BP Beneficiary has elected to purchase May 2016 Noridian DME Outreach and Education 45 45

46 Complex Rehabilitative Power Wheelchair Accessories April 1, 2014 Complex rehabilitative power wheelchair base codes and options/accessories Payable under the lump sum purchase method Suppliers give beneficiary's option of purchasing accessories at the time they are furnished Beneficiary declines purchase option Items paid under Capped Rental rules May 2016 Noridian DME Outreach and Education 46 46

47 Oxygen and Oxygen Equipment Rental only 36 month cap Modifiers RR: Rental QE: prescribed oxygen < 1 LPM QF: prescribed oxygen > 4 LPM & portable prescribed QG: prescribed oxygen > 4 LPM QH: Conserving device used with delivery system May 2016 Noridian DME Outreach and Education 47 47

48 Determining the Fee Schedule Payment Category May 2016 Noridian DME Outreach and Education 48 48

49 PDAC Website Search May 2016 Noridian DME Outreach and Education 49 49

50 PDAC Website Search Results May 2016 Noridian DME Outreach and Education 50 50

51 Medical Policies 51

52 National Coverage Determination (NCD) Medicare coverage database: Internet-Only Manual Publication : Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS html NCD Major sections Indications & Limitations of Coverage and/or Medical Necessity Nationally Covered and Non-covered Indications General and other May 2016 Noridian DME Outreach and Education 52 52

53 LCD and Policy Article Both documents together constitute a medical policy Policy Article can be accessed at bottom of LCD Available on the Noridian DME website at: May 2016 Noridian DME Outreach and Education 53 53

54 LCDs & Policy Articles Combined documents To view: Click the title of the medical policy May 2016 Noridian DME Outreach and Education 54 54

55 Local Coverage Determination (LCD) Major sections Indications and Limitations of Coverage and/or Medical Necessity Defines coverage criteria based on determination of whether item is reasonable and necessary Includes information on NCDs when applicable Item does not meet criteria, denies not medically necessary HCPCS modifiers and codes Diagnosis that support medical necessity Documentation requirements Standard Documentation Language Revision history May 2016 Noridian DME Outreach and Education 55 55

56 Major sections Policy Article (PA) Nonmedical necessity coverage and payment rules Items that do not meet statutory definition of benefit category Items not separately payable Items not in DME MACs jurisdiction Coding Guidelines Proper use of modifiers Further definitions codes May 2016 Noridian DME Outreach and Education 56 56

57 CMS IOM Internet-Only Manuals (IOM) Program issuances Operating instructions Policies Procedures Statutes Regulations Guidelines Models Directives May 2016 Noridian DME Outreach and Education 57 57

58 Internet-Only Manuals (2) Only-Manuals-IOMs.html May 2016 Noridian DME Outreach and Education 58 58

59 Resources and Reminders 59

60 Resources LCD/Policy Article ( olicies/lcd/active) Noridian Supplier Manual ( ducation/supplier-manual) Dear Physician Letters ( olicies/physician-resources) May 2016 Noridian DME Outreach and Education 60 60

61 Resources (cont.) Documentation Checklists ( olicies/documentation-checklists) Acronyms Noridian Acronym List ( cronyms-glossary) CMS Acronym List ( May 2016 Noridian DME Outreach and Education 61 61

62 2016 MSI Survey Your feedback matters! Coming in May the 2016 MSI The MAC Satisfaction Indicator (MSI) is coming May You will have opportunity to take this 10 minute survey administered by the Centers for Medicare & Medicaid Services (CMS). Watch for the survey on our website to participate. We re looking forward to hearing your experiences about the services we provide to you. May 2016 Noridian DME Outreach and Education 62 62

63 New Supplier Education Curriculum General and policy specific Short presentations grouped by relevance Quiz at conclusion with certificate Great for new and existing suppliers Suppliers encouraged to view both general and policy specific curriculum New Supplier Education Curriculum Webpage ( medicare.com/web/jd dme/topics/welcome) May 2016 Noridian DME Outreach and Education 63 63

64 Denial Code Guidance Each denial code webpage includes: Claim adjustment reason code and description Claim adjustment remark code and description Common reason why Noridian uses that reason/remark code Next step (re-file, redetermination, reopening, etc.) How to avoid these types of denials Applicable resources Denial Code Guidance Pages ( opics/ra/denial-guidance) May 2016 Noridian DME Outreach and Education 64 64

65 PECOS Requirement Claims may be denied if: The ordering physician is NOT in PECOS The ordering physician is not of the specialty to order If the physician's name submitted on the claim does not match their name in PECOS PECOS Edit ( aims-appeals/claim-submission/pecos-edits) View the PECOS DME on Demand ( qykbpz87umz0) May 2016 Noridian DME Outreach and Education 65 65

66 ICD-10 Questions? ICD-10 Implementation took place 10/1/15 ICD-10 Resources Noridian Medicare ICD-10 Webpage ( cd-10) CMS ICD-10 Webpage ( ml) Road to 10 Website ( May 2016 Noridian DME Outreach and Education 66 66

67 Tuesday and Friday Latest updates and announcements Customizable Sign-up in the lower right corner of our website Click subscribe Updates May 2016 Noridian DME Outreach and Education 67 67

68 Website Survey Your feedback is valuable Click Yes, I ll give feedback May 2016 Noridian DME Outreach and Education 68 68

69 Electronic Submission of Medical Documentation (esmd) Transmit documentation electronically for review Who accepts documentation via esmd? DME MAC (Noridian) Complex Medical Review and PMD PAR CERT Recovery Auditor ZPIC CMS esmd Webpage ( Statistics-Data-and-Systems/Computer-Dataand-Systems/ESMD/index.html?redirect=/esmd) May 2016 Noridian DME Outreach and Education 69 69

70 MREP Medicare Remit Easy Print Free software! View, search and print remits Print and export reports CMS Brochure ( reremit_0408.pdf) MREP Software ( dicareremiteasyprint.asp) May 2016 Noridian DME Outreach and Education 70 70

71 Medicare Learning Network (MLN) Guides Articles Educational Tools Booklets Brochures Fact Sheets Training Presentations Web-Based Training And more! MLN Webpage ( ch-and- Education/Medicare- Learning-Network- MLN/MLNGenInfo/ind ex.html) May 2016 Noridian DME Outreach and Education 71 71

72 Noridian Medicare Portal Will replace Endeavor Same functionality as Endeavor Endeavor to be decommissioned May 1, 2016 Five roles: Provider Administrator Must register first Provider End User Vendor Administrator Vendor End User Dual Role More information including training and registration: Noridian Medicare Portal webpage ( medicare.com/web/jd dme/topics/nmp) May 2016 Noridian DME Outreach and Education 72 72

73 We Are Coming To You! Catch the JD Express to Medicare Success Half day Sessions Register online In-Person Seminars ( medicare.com/web/jd dme/education/inperson-seminars) Locations and Dates: To Be Determined Fall Seminar locations to be announced this summer! May 2016 Noridian DME Outreach and Education 73 73

74 Education Opportunities Web-Based Workshops Q & A Sessions 2nd Monday of each 3 p.m. CT DME On Demand Education Request Ask the Contractor Teleconference (ACT) Education and Outreach Webpage ( ducation) May 2016 Noridian DME Outreach and Education 74 74

75 Single Toll Free Line Interactive Voice Response (IVR) Supplier Contact Center Telephone Reopenings Monday Friday 8 a.m. 6 p.m. CT May 2016 Noridian DME Outreach and Education 75 75

76 Beneficiary Contact Information Beneficiaries who need assistance can be directed to: Medicare ( ) Question on claims and coverage of equipment Social Security Administration ( ) Update name/address, questions on premiums, Medicare entitlement Benefits Coordination Recovery Center ( ) Primary insurance information update May 2016 Noridian DME Outreach and Education 76 76

77 Have a Verbal Question? Audio Conference Steps: Dial the phone number provided Enter the access number provided Enter your attendee ID provided Failure to follow these steps may disable some audio features May 2016 Noridian DME Outreach and Education 77 77

78 Asking a Verbal Question To ask verbal question: Click on the Participant tab at the top Click on the hand image at the bottom The telephone handset or computer headset must be present beside your name May 2016 Noridian DME Outreach and Education 78 78

79 How to Ask a Written Question Click on the Q and A tab Address All Panelists Type your question into the box Limit 256 characters Be concise May 2016 Noridian DME Outreach and Education 79 79

80 Questions? 80

81 Thank you for attending! 81