External Breast Prosthesis Copyright, CGS Administrators, LLC.

Transcription

1 External Breast Prosthesis 1

2 Agenda Coverage Criteria Modifier Use Documentation Cert Findings Cert Requirements Jurisdiction C Resources 2

3 Coverage 3

4 Coverage Criteria A breast prosthesis can be made from silicone, foam, rubber/latex, fabric, or other material A breast prosthesis is covered for a patient who has had a mastectomy ICD-9-CM diagnosis codes V10.3 V45.71 The ICD-9 diagnosis code must be included on each claim for the prosthesis or related items 4

5 Coverage L8020: Breast prosthesis mastectomy form L8030: Breast Prosthesis, silicone or equal L8039: Breast prosthesis, not specified When billing for this code additional information will be required: Product name Manufacturer s Name and suggested price Documentation of patients medical necessity for item 5

6 Coverage Medicare will pay for only one prosthesis per side In situations of bilateral mastectomy one prosthesis per side will be allowed More than one per side will be denied as not medically necessary 6

7 Coverage External prosthesis garment with mastectomy form L8015 will be covered when: Patient is in postoperative period prior to a permanent prosthesis or As an alternative to mastectomy bra and breast prosthesis 7

8 Mastectomy Bras L8000: is covered for a patient who has a covered mastectomy form either L8020 or L8030 when the pocket of the bra is used to hold the prosthesis adjacent to the chest wall. L8001: breast prosthesis, unilateral mastectomy bra with integrated breast prosthesis form L8002: breast prosthesis, bilateral mastectomy bra with integrated breast prosthesis forms 8

9 Coverage (Non-Covered) The Mastectomy sleeve (L8010) does not meet the definition of a Prosthesis therefore will be denied as non-covered. 9

10 Coverage (Non-Covered) If an L8031 breast prosthesis, silicone or equal, with integral adhesive or L8035 custom fabricated breast prosthesis is provided It will be denied as not medically necessary Refer to Use of Upgrade Modifiers when billing for this code. Resources:» Supplier Manual Chapter 6 (ABNs for Upgrades)» (DME Upgrades ABN and Claims Modifiers Chart) 10

11 Replacement A prosthesis of the same type can be replaced at any time if it is lost or irreparably damaged. A different type may be covered at any time if there is a change in the patient s medical condition RA modifier (DME replacement) should be appended to HCPCS (for replacement guidelines see Supplier Manual Chapter 5 pg. 22) 11

12 Useful Lifetime Expectancy L8030: Silicone or equal Breast Prosthesis 2 years L8020: Fabric, Foam or Fiber filled Breast Prosthesis 6 mos. L8015: Camisole type garment with integrated form- 6 mos. L8032: Nipple Prosthesis 3 months 12

13 Modifiers RT (Right) and LT (Left) modifiers must be used with all breast prosthesis codes When two prostheses are billed (bilateral mastectomy) on the same date, the RT and LT (RTLT) will be used on the same claim line with two units of service Claims will be denied if modifiers are used incorrectly or omitted 13

14 Advanced Beneficiary Notices When an upgrade is within a single code the upgrade item must include feature that exceed the official code descriptor for that item. An upgrade is an item that goes beyond what is medically necessary 14

15 How to File Claim Example 1 Scenario Request from beneficiary Supplier provides upgraded item with no additional charge 03/23/11-03/23/11 12 L8031 LTGZ /23/11-03/23/11 12 L8030 LTGK The supplier bills the GZ modifier and the HCPCS code that describes the item that was provided on the first line. On the next line the supplier bills the GK modifier and the HCPCS code that describes the item that is covered based on the LCD. 15

16 How to File Claim Example 2 Scenario Supplier wants to collect from beneficiary for upgraded item Properly completed ABN obtained 03/23/11-03/23/11 12 L8035 LTGA /23/11-03/23/11 12 L8030 LTGK The supplier bills the GA modifier and the HCPCS code that describes the item that was provided on the first line. On the next line the supplier bills the GK modifier and the HCPCS code that describes the item that is covered based on the LCD. 16

17 Documentation Requirements 17

18 Documentation Dispensing Order The provider must have a dispensing order prior to providing the item to the patient The order may be faxed, pen and ink, or verbal The dispensing order must include: A description of the item ordered The beneficiary s name The date of the order The ordering Physicians name and signature (if written) NOTE if a verbal dispensing order is provided the supplier s signature is required 18

19 Documentation Detailed Written Order A detailed written order is required for all items and services submitted for claims to the DME MAC They must be on file before the claim is submitted The detailed written order may take the form of a faxed copy, a photocopy, the original written document, or electronically maintained May be produced by someone other than physician Physician must review the content and sign and date (concurrence ) 19

20 Documentation Detailed Written Order The date of the order The beneficiary s name The Physician s name The Physician s signature and the date A description of the item Including options or additions ICD-9 diagnosis must be included on each claim (can be included on the order) 20

21 Documentation Reminders If Change in Medical Condition New order submitted by physician Explanation of need for different type of prosthesis on the order Supplier-produced records, even if signed by the ordering physician, and attestation letters are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, are subject to corroboration with information in the medical record. 21

22 Refill Requirements CMS Program Integrity Manual, Internet-Only Manual, Pub , Chapter 5, Section Must be based on prospective, not retrospective use To ensure items remain reasonable and necessary To confirm any changes or modifications to the order Supplier must not deliver refills without a refill request form from the beneficiary Supplier must not dispense a quantity of supplies exceeding a beneficiary s expected utilization 22

23 Refill Requirements Non-Consumable Supplies (supply items that are more durable in nature, but may require periodic replacement) The supplier should assess whether the item remains functional Replacement should be provided only when the item is no longer functional The supplier should document the condition of the item being replaced in sufficient detail to indicate why the replacement is necessary at that time. 23

24 Refill Requirements A routine refill prescription is not needed. A new prescription is needed when: There is a change of supplier There is a change in the item(s), frequency of use, or amount prescribed There is a change in the length of need or A previously established length of need expires State law requires a prescription renewal 24

25 Continued Use Any of the following may serve as continued use documentation: Timely documentation in the beneficiary s medical record showing usage of the item, related options/accessories and supplies Supplier records documenting the request for refill/replacement of supplies in compliance with the refill request documentation requirements Supplier records documenting confirmation of continued use of a item Timely documentation is a record in the preceding 12 months unless otherwise specified in the applicable policy 25

26 Continued Need The following may serve as documentation justifying continued medical need: A recent order by the treating physician for refills A recent change in prescription Timely documentation in the beneficiary's medical record showing usage of the item. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy. 26

27 Proof of Delivery Direct to patient: Date of service is date of delivery Delivery slip must include: The beneficiary s name; The quantity delivered, A detailed narrative description of the item,» The brand name (manufacturer),» The model name or number (if applicable), and» The serial number (if available). Beneficiary s signature and date 27

28 Proof of Delivery Delivery service tracking slip: Each beneficiary s package Delivery address Package identification number (tracking number) Date delivered Supplier Shipping Invoice Beneficiary s name Quantity and detailed description of items Brand name and serial number Delivery service identification number 28

29 Proof of Delivery Skilled Nursing Facility: Date of service is shipping date Inventory control: Document receipt of supplies Identify use by specific patient Used by designated patient only Obtain documentation from SNF 29

30 Delivery Exceptions Exceptions: Patient is being discharged from a hospital or nursing facility Supplier may deliver up to two days prior to discharge Supplier should bill date of service as date of discharge Place of service is patient s home (12) 30

31 Documentation Reminders Before billing the DME MAC, you should have: Dispensing order Detailed written order Assignment of Benefits (AOB) Proof of Delivery Advance Beneficiary Notice (ABN) (where applicable) Information required for use of specific modifiers Clinical documentation to support the medical need and continued use Documentation must be maintained for at least 7 years! 31

32 Comprehensive Error Rate Testing (CERT) 32

33 CERT Findings Reasons for errors No documentation of use by beneficiary No documentation of clinical management No documentation of mastectomy status Over utilization No documentation to support need to replace Documentation not authenticated 33

34 CERT Overview The CERT Documentation Contractor (CDC) requests documentation from suppliers on randomly selected submitted claims each month. The CERT Review Contractor (CRC) determines whether documentation submitted supports coverage criteria is met. Any claims identified by the CRC as paid in error are adjusted to deny by CGS. Suppliers are notified of overpayments 34

35 CERT The CERT contractor s medical review specialists review each claim and determine the following: Does the item/equipment fit a Medicare benefit category Is the item/equipment statutorily excluded Is the item/equipment medically reasonable and necessary Is the item/equipment coded and billed correctly 35

36 CERT Error Rates What contributes to error rates? Supplier Non-Response Insufficient Documentation Coding Errors Medically Unnecessary Items/Service Written Order Error Other Errors 36

37 CERT: Importance of Responding Suppliers who do not return requested information are considered as non-responders. Non-response is an error and an overpayment will be collected. Failure to respond increases possibility of future expanded audit. CGS actively participates in alerting and assisting suppliers who have received a CERT request. 37

38 CERT Responses There are two ways to respond to a request from the CERT contractor. Fax: This is the preferred method. Mail: CERT Documentation Office Attn: CID # xxxxx 9090 Junction Dr., Suite 9 Annapolis, MD, Extension Requests:

39 CERT Legible Records: Make sure all records are legible. Appeal Rights: All appeals are to be filed with CGS, not the CERT contractor. This is done through the normal channels, starting with a Redetermination request: CGS PO Box Nashville, TN

40 Jurisdiction C Resources 40

41 Jurisdiction C Resources ANSI Denial Guide Interactive Voice Response (IVR): Customer Service: Beneficiary Inquiries: MEDICARE ( ) Telephone Re-openings: Re-openings Fax:

42 Jurisdiction C Resources Redeterminations: CGS Attn: Appeals PO Box Nashville, TN Redeterminations Fax: Paper Claim Submission, Adjustment Requests (Reopenings), EFT Form Submission, and Written Inquiries: CGS PO Box Nashville, TN

43 Jurisdiction C Resources PDAC formerly SADMERC National Supplier Clearinghouse CEDI NGS.CEDIHelpdesk@wellpoint.com 43

44 CGS ListServ To receive the most current news and Medicare updates, enroll in the Jurisdiction C ListServ To enroll, go to our website at: click on the ListServ link; enter supplier information; and click the submit button. Verify that your will accept s from CGS 44

45 Questions? 45

46 Disclaimer This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees; agents, including CGS and its staff; and CMS staff make no representation, warranty, or guarantee that this compilation of Medicare information is error free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. 46