Diabetic Services, Supplies and Documentation. Presented by Medicare Part B and DME MAC Provider Outreach and Education (POE) January 2016

Transcription

1 Diabetic Services, Supplies and Documentation Presented by Medicare Part B and DME MAC Provider Outreach and Education (POE) January 2016

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 CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at 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. All rights reserved. Applicable FARS/DFARS apply. January

3 Agenda Diabetic Overview & Screening Diabetic Self Management Training (DSMT) Medical Nutritional Treatment (MNT) Glucose Monitors & Testing Supplies Therapeutic Shoes for Persons with Diabetes External Insulin Infusion Pump Documentation Requirements Reminders and Resources January

4 Objective To assist providers and suppliers with a better understanding of the Noridian Medicare Part B and Durable Medical Equipment (DME) roles in providing Diabetic billing, coverage, documentation and supplies. January

5 ACRONYM ABN CDE DMEPOS E/M FQHC IOM MLN MPFS PTAN RD RHC DESCRIPTION Advance Beneficiary Notice of Non Coverage Certified Diabetic Educator Durable Medical Equipment, Prosthetics, Orthotics & Supplies Evaluation and Management Service Federally Qualified Health Center Internet Only Manual Medicare Learning Network Medicare Physician Fee Schedule Provider Transaction Access Number Registered Dietician Rural Health Clinic January

6 Diabetic Overview and Screening January

7 Diabetes Overview Diabetes is 7th leading cause of death in USA Diabetes can lead to severe complications: Glaucoma (significant risk factor) Heart disease Kidney failure Stroke Medicare provides several diabetes-related preventive services for eligible beneficiaries January

8 Glucose Screening Risk Factors Risk Factors for Diabetes: Hypertension High Cholesterol Obesity Elevated impaired fasting glucose/glucose intolerance Previous Identification With any two following risk factors: Overweight Body Mass Index (BMI) > 25 Family history of diabetes Age 65 or older Gestational diabetes history or delivery of baby over 9 lbs Coinsurance/Deductible waived January

9 Glucose Screening Lab Codes CPT Descriptors Glucose; quantitative, blood (except reagent strip) Glucose; post glucose dose (includes glucose) Glucose; tolerance test (GTT), three specimens (includes glucose) Diagnosis Z13.1 Non Pre-diabetes, Z13.1 diagnosis Covered one per 12 month period Pre-diabetes, Z13.1, modifier TS (follow-up) Covered twice/12 month period January

10 Glaucoma Screening Covered for high risk groups Individuals with Diabetes Mellitus Glaucoma family history individuals African-Americans over 50 Hispanic-Americans age 65 or older Glaucoma screening includes Dilated eye exam (intraocular pressure measurement) Direct ophthalmoscopy exam or slit-lamp bio microscopic exam Recommended once every 12 months Coinsurance/Deductible apply January

11 Glaucoma Screening Codes HCPCS Descriptors G0117 Glaucoma screening for high risk patients furnished by optometrist/ophthalmologist G0118 Glaucoma screening for high risk patients furnished under direct supervision of optometrist/ophthalmologist Diagnosis Z13.5 Special screening for neurological, eye, and ear diseases, glaucoma January

12 Hyperbaric Oxygen (HBO) Therapy Modality in which entire body exposed to oxygen under increased atmospheric pressure Administered in a one-person chamber Covered conditions* include diabetic wounds of lower extremities meeting the following: Patient has type I or type II diabetes and has a lower extremity wound due to diabetes; Has wound classified as Wagner grade III or higher; and Has failed adequate course of standard wound therapy Explained in next slide *Not all inclusive conditions January

13 Standard Wound Therapy First Standard wound therapy includes: Assessment of vascular status and correction Optimization of nutritional status and glucose control Debridement Maintenance with appropriate moist dressings Appropriate off-loading Treatment to resolve infection Failure occurs when no measureable signs for at least 30 days HBO allowed for adjunctive therapy only - after failure of above Evaluation every 30 days during HBO No coverage if measurable signs of healing within 30 days January

14 HBO Therapy Coverage IOM , Chapter 1, Part 1, Section Type I / Type II diabetes with lower extremity wound due to diabetes Physician attendance and supervision, per session (adjunctive therapy only, after no measurable signs of healing at least 30 days of treatment) Diagnoses Refer to CR9087 for complete table of ICD-10 codes A Diabetes code plus a Wound code (a code from Group 1 & Group 2) must be used together to satisfy medical necessity G0277 Hyperbaric oxygen under pressure, full body chamber, per 30 min. January

15 Diabetic Self-Management Training (DSMT)

16 DSMT Coverage Program educates self-monitoring: Blood Glucose Diet and Exercise Education Insulin Treatment Plan Physician must refer and certify plan of care with: Number of sessions, frequency, duration State whether individual or group DSMT service Signed statement of need January

17 Eligible DSMT Programs DSMT programs accredited by diabetes selfmanagement education American Diabetes Association (ADA) and/or American Associate of Diabetes Educators (AADE) Special diabetes education training to teach beneficiaries ADA/AADE credentials DSMT programs, not individuals If program credentialed, MD/DO/NPP accredited Not credentialing individual providers January

18 Eligible DSMT Practitioners Covered if treating physician or qualified non-physician practitioner (NPP) certifies services needed Must maintain plan of care Certified program usually provided by team of individuals Ordering physicians MUST sign and date themselves MD/DO/NPPs do NOT require specific provider accreditation or certification Since DSMT is not a separately recognized provider type, providers can not enroll in Medicare for sole purpose of providing DSMT Considered additional service No supervision requirements For RNs, CDE, RDs or pharmacists January

19 Eligible DSMT Practitioners (2) May be furnished by Certified Diabetic Educator (CDE), Registered Dietician (RD), Registered Nurse (RN) or pharmacist with accreditation/certification CDE/RD able to bill direct with their own NPI/PTAN Can not be sole provider of DSMT; except in rural areas Pharmacists/RNs can not bill and receive payment directly Team up with certified provider (bills on their behalf) Accept claim assignment RNs/pharmacists furnish training ONLY Can NOT bill direct Certified provider bills on their behalf January

20 DSMT Coding Physician must refer/certify with plan of care Includes # of sessions, frequency and duration G0108 (individual session, 30 minutes) G0109 (group session, 2 or more, 30 minutes) 2-20 individuals not all need to be Medicare beneficiaries Hour session = 2 (Item 24G/electronic equivalent) DSMT may be provided before E/M billed by physician Coinsurance/Deductible apply January

21 DSMT Coding (2) Initial: Up to 10 hours for continuous 12-months First hour individual; other 9 hours group Subsequent: If eligible, another two hours of group sessions the follow-up/year covered with additional physician s written order Special individual training covered if no group sessions available within 2 months of physician order Physician documents special physical needs like hearing or vision impaired and language limitations Physician may order additional insulin training January

22 DSMT Documentation Provider maintains documentation including Original order/training plan with instructions No specific diagnosis needed Any instructions by ordering provider Any changes to training plan Signed by ordering provider with separate referral Kept in DSMT program records and provider s office Session includes (nutrition, exercise, insulin, etc.) Number of sessions Individual or group January

23 Post Pay Review Requirement Evidence the education plan was collaboratively developed between beneficiary and instructor Educational goal(s) is identifiable and plan content identified Plan tailored to meet any unique needs of the individual Education services provided/revised according to plan Who provides what services Achievement of learning objectives identified Follow-up assessment occurred Personalized follow-up plan for on-going selfmanagement support developed in collaboration with beneficiary January

24 ABN Reminder Beneficiary liable for denials Over DSMT limited hours Provider liable if not valid ABN (dated 03/11) ABN should not be issued for covered services provided by dietitians or nutrition professionals qualified to render service in their state, but did not enroll/obtain PTAN IOM , Chapter 18, Section January

25 Medical Nutrition Therapy (MNT) January

26 MNT Coverage Covered services for disease management: Initial nutrition and lifestyle assessment Nutrition counseling Managing lifestyle factors affecting diet Follow-up sessions to monitor progress All other nutritional services never covered ABN not needed National Coverage Determination (NCD) policy titled Medical Nutrition Therapy (MNT) January

27 Differences DMST/MNT MNT = nutritional, diagnostic, therapeutic and counseling services provided by registered dietitian or nutrition professional for purpose of managing: Diabetes Renal disease Kidney transplant within last three years DSMT = overall guidance related to all aspects of diabetes self-management and glycemic control Designed to increase patient s knowledge/skill about the disease and promote behaviors for self-management of their health January

28 Who Can Treat MNT? Physician prescribes services performed by registered dietician (RD) or other nutritional professionals (e.g. CDE) 900 hours supervised dietetics and licensed/certified Bachelor s degree in dietetics/nutrition program Provided by individual or team with certification Must accept claim assignment Physician does not need to be present during services Acquire NPI and enroll with Medicare Specialty 71 January

29 MNT Requirements MNT coverage when conditions met: Diagnosed with diabetes and/or renal disease ESRD without dialysis Chronic renal insufficiency Received kidney transplant within last 3 years Therapy initial calendar year 3 hours one-on-one counseling (no annual carryover) Subsequent years (with physician referral) 2 hours/year New physician referral needed annually January

30 MNT Billing/Coverage Treating/referring physician lists diabetes/renal disease diagnosis on referral No particular diagnosis needed on claim Bill either 97802, 97803, 97804, G0270 or G0271 Not payable from Part B for POS Hospital inpatient, hospice, NH/SNF Coinsurance/Deductible waived January

31 Miscellaneous Podiatry Treatments One exam every 6 months With diabetes-related nerve damage to either foot Hemoglobin A1c Lab Test Measures blood glucose levels over past 3 months Ordered by physician for diabetic patients DSMT/MNT not covered for pre-diabetes Important: Face-to-face physician encounter requirements to order all DME items Effective 2013 per Section 6407 of Affordable Care Act January

32 CMS Telehealth Booklet 6 pages Dec 2014 Originating site (Q3014) Several CPT/HCPCS codes/special modifier GT (interactive audio/ video telecommunications) GQ (AK/HI asynchronous telecommunications system) IOM , Chapter 15, Section January

33 Telehealth Both DSMT/MNT Must meet telehealth rules of beneficiary originating sites Rural health professional shortage area (HPSA) or County outside of Metropolitan Statistical Area (MSA) DMEPOS suppliers, pharmacies and RNs can not bill direct DSMT individual and group training G0108/G0109/97802 MNT individual/group therapy assess/re-assessment services 97802/97803 (individual; 15 min.) and (group) G0270/G0271 (subsequent re-assessment) Group health/behavior assessment and intervention (HBAI) (group) and (family-with patient present) January

34 Glucose Monitor and Testing Supplies Local Coverage Determination (LCD) - L33822 Policy Article (PA) - A52464 January

35 Basic Coverage Criteria Beneficiary must meet the following criteria: Beneficiary has diabetic diagnosis (ICD-10 listed in LCD) Beneficiary or caregiver has sufficient training using the device As evidenced by providing prescription Blood glucose monitor (E0607) and supplies will deny not reasonable and necessary if this basic coverage criteria not met January

36 Accessories and Supplies Lancets (A4259) 1 unit = 100 Lancets Blood glucose test strips (A4253) 1 unit = 50 strips Glucose control solutions (A4256) Spring powered device (A4258) 1 per six month January

37 Usual Utilization Guidelines Patient not treated with insulin 100 test strips and 100 lancets or one lens shield every three months Patient being treated with insulin 300 test strips and 300 lancets or one lens shield every three months Oral medication is not insulin-treated January

38 High Utilization Guidelines Beneficiary who exceeds usual guidelines must meet all following criteria: a. Basic coverage criteria 1 and 2 met b. Treating physician seen and evaluated beneficiary s diabetes control within 6 months prior to ordering quantities above normal utilization and document specific reason in medical records for additional materials c. Refills of quantities exceeding utilization must have documentation in the physician s records that beneficiary is actually testing at a frequency that corroborates quantities dispensed Specific narrative statement in the medical record or copy of the testing logs indicating testing frequency New documentation every 6 months for beneficiaries regularly using above normal utilization January

39 Therapeutic Shoes for Persons with Diabetes LOCAL COVERAGE DETERMINATION (LCD) - L33369 POLICY ARTICLE (PA) - A52501 January

40 Coverage Criteria 1. Patient has diabetes mellitus 2. Patient has one or more following conditions: a. Previous amputation of other foot, or part of either foot, or b. History of previous foot ulceration of either foot, or c. History of pre-ulcerative calluses of either foot, or d. Peripheral neuropathy with evidence of callus formation of either foot, or e. Foot deformity of either foot, or f. Poor circulation in either foot; and Certifying physician, must be a MD or DO, has documented in the medical record of an in-person visit within 6 months prior to delivery of the shoes/inserts and prior to or on the same day as signing the certification statement; or Obtain, initial, date (prior to signing the certification statement), and indicate agreement with information from the medical records of an in-person visit with a podiatrist, other M.D or D.O., physician assistant, nurse practitioner, or clinical nurse specialist that is within 6 months prior to delivery of the shoes/inserts, and that documents one of more of criteria a f January

41 Coverage Criteria (2) 3. Signed certifying statement from physician, must be MD or DO Certified criteria 1 and 2 are met Treating patient under a comprehensive plan of care for diabetes In-person visit within 6 months prior to delivery of shoes/inserts; and Sign statement on or after date of in-person visit and within 3 months prior to delivery of shoes/inserts Shoes are needed January

42 Coverage Criteria (3) 4. Prior to selecting items, supplier must conduct and document in-person evaluation 5. At time of delivery supplier must conduct and document in-person visit with patient January

43 Allowance Per Calendar Year One pair of custom molded shoes (A5501) and two additional pairs of inserts (A5512 or A5513) OR One pair of depth shoes (A5500) and three pairs of inserts (A5512 or A5513) Not including non-customized removable inserts provided with shoes January

44 External Infusion Pump LOCAL COVERAGE DETERMINATION (LCD) - L33794 POLICY ARTICLE (PA) - A52507 January

45 Insulin Infusion Pump E0784 Insulin J1817 IV. Subcutaneous insulin for diabetes mellitus Refer to Diagnosis Codes Group 1 supporting Medical Necessity in LCD Criterion A or B AND criterion C or D a. C-peptide testing requirement 1. < 110% of the lower limit of normal of the laboratory s measurement method; OR 2. Patients with renal insufficiency and creatinine clearance < 50 ml/minutes, a fasting C-peptide < 200% of lower limit of normal of the laboratory s measurement method; AND 3. Fasting blood sugar obtained same time as C-peptide is < 225 mg/dl b. Beta cell autoantibody test is positive January

46 Insulin Infusion Pump E0784 Insulin J1817 (2) IV. Continued criterion C or D c. Completed comprehensive diabetes education program, multiple daily injections of insulin with frequent selfadjustments at least 6 month prior to insulin pump, documented self-testing at least 4 X per day 2 months prior to insulin pump and one or more of the following 1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 2. History of recurring hypoglycemia 3. Wide fluctuations in blood glucose before mealtime 4. Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dl 5. History of severe glycemic excursions d. On external insulin pump prior to Medicare enrollment and testing at least 4 X per day the month prior to Medicare enrollment January

47 Continued Coverage for Insulin Pump Patient must be seen and evaluated by treating physician at least every 3 months Physician who orders and follows up must manage multiple patients on continuous subcutaneous insulin infusion therapy Physician works closely with a knowledgeable team Nurses Diabetic educators Dieticians January

48 Documentation Requirements

49 Authorized to Order DMEPOS Treating Physician, MD, or DO Nurse Practitioner or Clinical Nurse Specialist Treating patient for condition for which item is needed Practicing independently of physician Bill Medicare for other covered services using own NPI Permitted to do in state where services are rendered Physician Assistant Meet definition of physician assistant found in Section 1861(aa)(5)(A) of Social Security Act Treating beneficiary for condition for which item is needed Practice under supervision of MD or DO Have own NPI Permitted to perform services in accordance with state law January

50 Preliminary/Dispensing Order Some DMEPOS may be dispensed based on verbal/preliminary order Items provided based on a dispensing order must be followed up with a completed detailed written order Description of Item Physician s Name Signature Beneficiary s Name Date of Order November 2015 Noridian Jurisdiction D DME MAC 50

51 Detailed Written Orders Required prior to claim submission Append EY modifier if not received Basic elements Beneficiary s name Detailed description of item All options or additional features Physician s signature Date order is signed Initial date if provided based on dispensing order January

52 Additional Elements For items provided on a periodic basis, the written order must include: Item to be dispensed Dosage or concentration Route of administration Frequency of use Duration of infusion Quantity to be dispensed Number of refills January

53 Acceptable Detailed Written Order May be completed by someone other than physician Treating physician must review, sign, and date Acceptable orders Fax Photocopy Electronic Original pen and ink January

54 Written Order Prior to Delivery and Face-to-Face Encounter Affected DME requires: Face-to-face evaluation within six months prior to order Not currently enforced by DME MACs Is currently enforced by CERT WOPD Currently enforced by DME MACs and CERT Implemented 7/1/13 August 2015 Noridian Jurisdiction D DME MAC 54

55 Date and Timing Requirements F2F Evaluation On or before date on the order No older than 6 months prior to order Must be on or before delivery of DME Date stamp (or equivalent) WOPD On or before delivery of DME Date stamp (or equivalent) DME supplier must receive both F2F and WOPD prior to delivery of DME August 2015 Noridian Jurisdiction D DME MAC 55

56 Written Order Prior to Delivery Basic elements Beneficiary s name Physician s name (WOPD) Date of the order and the start date, if start date is different from the date of the order Detailed description of the item(s) Physician signature and signature date Physician NPI Only needed for those items that require a face-to-face per MM8304-Revised November 2015 Noridian Jurisdiction D DME MAC 56

57 When is a New Order Required? New supplier New physician Changes to order, i.e. equipment, accessory, supply Equipment reaches reasonable useful lifetime Lost, stolen, or irreparable damage due to specific incident State licensure or regulations January

58 Relevant Medical Records Examples of relevant medical records include: Physician notes Non-physician clinical notes Non-physician clinical evaluations January

59 Supplementary Documentation Other types of information not sufficient by themselves to document coverage criteria Even if signed or initialed by treating physician Not considered part of patient s medical record Will be given consideration if corroborated by medical record Applies to documents created before delivery of item(s) January

60 Reminders and Resources January

61 Medicare Benefit Policy Manual IOM Publication Chapter 15 Guidance/Guidance/Manuals/Downloads/bp102c15.pdf 110 (Durable Medical Equipment) 140 (Therapeutic Shoes for Individuals with Diabetes) (Glaucoma Screening) (Coverage Requirements) (Who Provides DSMT) (Training Frequency) (Outpatient Diabetes Self-Management Training) January

62 Medicare Claims Processing Manual IOM Preventative and Screening Services, Chapter 18 Guidance/Guidance/Manuals/Downloads/clm104c18.pdf IOM Durable Medical Equipment, Prosthetics, Orthotics and Supplies, Chapter 20 Guidance/Guidance/Manuals/Downloads/clm104c20.pdf IOM Medicare National Coverage Determinations Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html January

63 National Coverage Decision (NCD) Policies NCD Title NCD # Blood Glucose Testing Diabetics Outpatient Self-Management Training & Medical Nutrition Treatment (MNT) Diagnosis/Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS) Glyclated Hemoglobins/Proteins HBO Therapy Home Blood Glucose Monitors 40.2 Home Health Visits to a Blind Diabetic Infusion Pumps Surgery for Diabetes January

64 January

65 Questions? Thank You for Attending Today s Workshop! January