Presented by Noridian Provider Outreach and Education Jurisdiction D DME MAC January Disclaimer

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1 External Breast Prosthesis Presented by Noridian Provider Outreach and Education Jurisdiction D DME MAC January 2015 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 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 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. 2 1

2 Workshop Protocol Entering Workshop Attendee lines are muted upon entry Throughout Workshop Written questions in Q & A section Please do not use the chat feature Conclusion of Workshop: Q & A Session Use Raise Hand feature to ask questions aloud Certificate of Completion 1 AAPC CEU is offered for this course Certificate of Completion will be sent out to all attendees 2-3 days after workshop based on attendance report Presentation was sent via , is also available at 3 Education Opportunities Web-Based Workshops DME Basics External Infusion Pumps PMD Prior Authorization Enteral Nutrition Parenteral Nutrition Prefabricated Orthoses Surgical Dressings In-Person Seminars Coming this Spring DME On Demand New ones posted monthly Education Request (NEW!) ACT 4 2

3 Have a Verbal Question? Be sure that you have entered the Attendee ID # on this screen to ensure you are correctly connected to the phone lines, which h will allow you to ask verbal questions 5 Click on Participants tab at top right Asking a Verbal Question Must have a phone or headset by your name Click on Hand on bottom right 6 3

4 Click on Q&A Tab How to Ask a Written Question Address All Panelists Type your question into box 7 Agenda Acronyms Coverage Criteria and Coding Refills and Replacement Modifiers and Upgrades Documentation CERT Resources and Reminders 8 4

5 Acronyms ABN Advance Beneficiary Notice of Noncoverage DX Diagnosis DOS Date of service NOC Not otherwise classified code LCD Local Coverage Determination PA Policy Article CERT 2013 Improper Payment Rates Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports.html 10 5

6 Coverage Criteria and Coding Local Coverage Determination L11569 Policy Article L19833 Coverage Criteria Breast prosthesis and garments covered: Beneficiary who has had a mastectomy with diagnosis codes below If sufficient tissue loss a lumpectomy could be considered a partial mastectomy ICD-9 Diagnosis Codes Malignant Neoplasm codes Secondary Malignant Neoplasm of Breast Postmastectomy Lymphedema Carcinoma in Situ of Breast Syndrome V45.71 Acquired absence of breast and nipple V10.3 Personal History of Malignant Neoplasm of Breast 12 6

7 L8015 External Breast Prosthesis Garment L External breast prosthesis garment with mastectomy form, commonly referred to as a camisole. Covered for use in post-op period prior to permanent breast prosthesis, or As alternative to mastectomy bra and breast prosthesis Note: L8015 cannot be dispensed prior to the surgical procedure, as the medical need cannot be clearly established until AFTER the surgical procedure has been performed. Delivered to facility Delivered for the purpose of fitting/training 2 days prior to anticipated discharge from hospital or nursing facility DOS=Discharge Date Indicate in the narrative Provided 2 days prior to discharge 13 L8000-L8002 Mastectomy Bras L8000 covered if beneficiary has a covered mastectomy form or silicone breast prosthesis (L8020, L8030, L8031, L8035) L8001 and L8002 include integrated t breast prosthesis forms Mastectomy bras cannot be billed as an upgrade Physician indicates on order number and frequency for bra refills Should only bill 3 month supply at one time Does not require the LT or RT modifier Non-participating suppliers can recoup the cost of a more expensive bra by billing unassigned, as billing for an upgrade is not an option. Participating suppliers are not allowed to bill unassigned 14 7

8 L8020, L8030 Mastectomy Forms L8020, L Mastectomy Forms Covered if beneficiary has had a mastectomy and has one of the following diagnoses V10.3, V45.71, , , 233.0, or L8032 Nipple Prosthesis All codes above require the LT and/or RT modifier Reasonable Useful Lifetime (RUL) L8020 Fabric, foam or fiber filled = six months L8030 Silicone breast prosthesis = two years L8032 Nipple Prosthesis = three months 15 L8035 Custom Mastectomy Forms L8031 Silicone Prosthesis with Adhesive L8035 Custom mastectomy forms Silicone breast prostheses, RUL is 2 years Fabric, foam, or fiber filled breast prostheses, RUL is 6 months L8031 Silicone Prosthesis with integral adhesive, RUL is 2 years Deny as being not reasonable and necessary Can be billed as an upgrade Requires the RT and/or LT modifier 16 8

9 Refills & Replacements Supplies and Accessories Cannot dispense more than a 3-month quantity at one time Must contact the beneficiary prior to dispensing items provided on a recurring basis, i.e., bras Only exception is when beneficiary picks up the items at supplier s retail store. In this case the signed delivery ticket serves as sufficient documentation of a request for refill. It must be clear on the delivery ticket that the item(s) were picked up 18 9

10 Refill Requirements Request for refill when delivering or shipping items must include: Beneficiary s name Description of each item being requested Date of refill request Non-consumables (e.g., bras) Functional condition of the item being refilled to demonstrate the cause of the dysfunction that necessitates replacement. (i.e. elastic worn, etc.) 19 Replacement of Breast Prosthesis Replacements Lost, stolen or irreparably damaged Requires new order RA modifier required Narrative required on claim Change in medical condition Requires new order Narrative required on claim explaining why replacing prior to Reasonable Useful Lifetime (RUL) of previous prosthesis No RA modifier required Prosthesis reaches its Reasonable Useful Lifetime (RUL) Requires new order No RA modifier required 20 10

11 Modifiers and Upgrades Modifiers LT/RT - Left side/right side RA - Replacement due to loss, stolen or irreparable damage GA - Waiver of liability statement on file (ABN) GK - Reasonable and necessary item associated with GA or GZ GL - Medically unnecessary upgrade provided at no charge, no ABN GZ - Item or service expected to be denied as not reasonable or necessary EY - No physician or other licensed health care provider order for this item 22 11

12 Upgrades Mastectomy bras do not qualify for upgrades Breast prostheses do qualify for upgrades Codes L8031 (silicone prosthesis with adhesive) and L8035 (custom prosthesis) are both considered not reasonable and necessary, but can be billed as upgrades If denial received for not reasonable and necessary Resubmit the claim using the upgrade modifiers and the code for the covered medically necessary item 23 Upgrades

13 Upgrade Claim Example 25 Documentation 13

14 Standard Documentation Dispensing Order Documentation Detailed Written Order Beneficiary Authorization Proof of Delivery Medical Records Authenticated by the author ABN when applicable Do not use Medicare HCIN number on form 27 Intake Process Ask the right questions Be ethorough ooug Eligibility Same and similar (Can now obtain on Endeavor for A, L & V codes) endeavor_last_paid_supply_orthotic_prosthetic_vision_dat e_of_service.html Coverage criteria Medical records including testing requirements You are building your foundation

15 Authorized to Order Treating Physician, MD, or DO Nurse Practitioner or Clinical Nurse Specialist Treating beneficiary 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 29 Preliminary/Dispensing Order Some DMEPOS may be dispensed based Description Beneficiary s on verbal/preliminary of Item Name order Items provided based Signature on a dispensing order must be followed up with a completed Physician s Date of detailed written order Name Order 30 15

16 Detailed Written Order (DWO) Claim may not be submitted without a written order Unless submitted with an EY modifier 31 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 32 16

17 Detailed Written Order Elements Basic Elements Beneficiary s i name Physician s name 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 33 Detailed Written Order Additional Elements Item(s) to be dispensed Quantity to be dispensed (number of bras) Frequency Number of refills 34 17

18 Comparison Written Dispensing vs. Detailed Written Order Required Elements on Written Dispensing Order Beneficiary s name Physician s name Date of the order (which should be the date the supplier is contacted by the physician) Start date of the order if it is different from the date of the order. A description of the item Physician s signature Required Elements on Detailed Written Order for External Breast Prosthesis Beneficiary s name Physician s name 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 Item(s) to be dispensed d Quantity to be dispensed (number of bras) Frequency of use (how often) Number of refills (1 year, lifetime etc.) 35 Common Issues with Orders Missing signature or date of signature. Detailed Written Order is dated after Date of Service and prior to claim submission but no dispensing order was received. When requested, ensure sending the identifiable information for who received the order if the dispensing order is not a written order from the physician Detailed Written Order is missing i quantity of items to be dispensed, frequency or number of refills. No new order for replacement items

19 When is a new order Required? Change in Order When indicated in the Medical Policy State Licensure or Regulations Replacement Change in Supplier 37 Continued Use for External Breast Prosthesis Continued use describes ongoing utilization of items Suppliers responsible for monitoring utilization of DMEPOS supplies. Suppliers must discontinue billing Medicare when items are no longer being used by the beneficiary Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used by the beneficiary 38 19

20 Continued Use (2) The following may serve as documentation for continued use: Timely documentation in the beneficiary s medical record showing usage of the item, related option/accessories and supplies. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy. Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements. 39 Continued Medical Need For ongoing supplies: Information in the beneficiary s i medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review

21 Continued Medical Need (2) The following may serve as documentation justifying continued medical need for External Breast Prosthesis: 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 Must indicate mastectomy or absence of breast In the absence of evidence of reconstruction, the original mastectomy information is all that is required to show there was a mastectomy 41 Medical Records Program Integrity Manual (100-08, Chapter 5) *Must be available upon request 42 21

22 Proof of Delivery (POD) Supplier Standard 12 Signed POD required to verify beneficiary i received DMEPOS item Required to verify beneficiary received item Must be available upon request If not provided, claim denied, overpayment requested If no documentation provided on consistent basis, may be referred to Office of Inspector General (OIG) Maintain documentation for seven years 43 Common Issues with Proof of Delivery Missing delivery address POD signed prior to or after DOS on the claim Unable to link the supplier s record/invoice and the delivery service/shipping information Beneficiary's signature is not dated 44 22

23 Method 1- Direct Delivery Delivery directly to a beneficiary by a supplier The POD record must include: Beneficiary's name Delivery address Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description) Quantity delivered Date delivered Beneficiary (or designee) signature and date of signature Date of service = Date of delivery 45 Method 2 Delivery/Shipping Service Delivery to beneficiary via shipping service The POD record must include: Beneficiary's name Delivery address Delivery service's package ID number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records Detailed description identifying item(s) being delivered Quantity delivered Date delivered Evidence of delivery Date of service = shipping date 46 23

24 Method 3 Delivery to Nursing Facility Delivery to a nursing facility on the beneficiary s behalf The POD record must include: Beneficiary's name Delivery address Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description) Quantity delivered Date delivered Beneficiary (or designee) signature and date of signature Date of service = Date of delivery 47 POD Exception: Anticipation of Discharge Delivery to Facility Delivered for the purpose of fitting/training 2 days prior to discharge from hospital or nursing facility DOS=Discharge Date POS=12 (Beneficiary s Home) Add narrative indicating delivered 2 days prior to discharge Delivery to Home 2 days prior to discharge from hospital or nursing facility DOS=Discharge Date POS=12 (Beneficiary s Home) Add narrative indicating delivered 2 days prior to discharge If you receive a denial with reason code 109 and remark code N538, you may not have billed with the discharge date and will need to resubmit your claim with the correct date

25 Proof of Delivery Signature Proof of delivery can be signed by: Beneficiary Beneficiary s designee Relationship to beneficiary must be noted on delivery slip Proof of delivery cannot be signed by: Suppliers Employees of suppliers Anyone with financial interest in delivery of item *Required only for direct delivery method, shipping service uses tracking 49 Advance Beneficiary Notice of Noncoverage (ABN) What is an ABN ABN form CMS R 131 Written notice of non coverage Allows beneficiary to make informed decision Protects supplier from liability Mandatory Use Medical necessity denials Frequency limited items Denial of advance determination of Medicare coverage (ADMC) Certain instances of upgrades 50 25

26 Comprehensive Error Rate Testing g( (CERT) CERT Letter

27 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 53 CERT Contractors AdvanceMed Select random claim sample Review selected claims and medical documentation Verify claim was properly adjudicated Livanta Request documentation Provide website to update supplier address and contact information

28 Reasons for CERT Errors Insufficient documentation No documentation Service incorrectly coded Medically unnecessary service 55 Educate staff Decrease CERT Errors 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

29 Quick Look CERT Documentation Chart 57 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 t Health Information (PHI) Response within 2 business days 58 29

30 Resources and Reminders Have a Verbal Question? Be sure that you have entered the Attendee ID # on this screen to ensure you are correctly connected to the phone lines, which h will allow you to ask verbal questions 60 30

31 Click on Participants tab at top right Asking a Verbal Question Must have a phone or headset by your name Click on Hand on bottom right 61 Click on Q&A Tab How to Ask a Written Question Address All Panelists Type your question into box 62 31

32 LCD/Policy Article Resources com/dme/coverage/lcd Supplier Manual Dear Physician letters Documentation ti Checklist 63 Live Online Q&A Online question and answer sessions with members of the Education staff Verbal and Written questions One hour sessions May log on, ask question and log off Monday 3-4 CST

33 Online Q & A Sessions Effective March 2015 Will take place once per month Second Monday of each month Time will not change 3 p.m. 4 p.m. Central Time All Q & A Sessions will be general in nature to address all DMEPOS-related questions 65 Common Electronic Data Interchange (CEDI) Single front end electronic solution Free Software Front end error report manual Contact: ngs.cedihelpdesk@wellpoint.com CEDI works with: DME MAC software venders Billing services Clearinghouses Trading partners Manual (Chapter 5):

34 ICD-10: Are You Ready? What is ICD-10? More specific information about medical conditions Ability to create more new diagnosis codes Diagnosis codes consist of 3-7 digits Consistent with many other developed countries around the world mhtml m.html The Centers for Medicare & Medicaid Services is examining the implications of the ICD- 10 provision in the recently enacted Protecting Access to Medicare Act of 2014 and will provide guidance to providers and other stakeholders soon. 67 Written Order Prior to Delivery and Face-to-Face Encounter Affected DME requires: Face-to-face evaluation within six months prior to order Sooner if required by LCD May be performed by MD, DO, NP, PA or CNS Must be received by supplier prior to delivery of DME WOPD Detailed written order must be received by the supplier prior to delivery of DME NPI must be included on WOPD Implemented 7/1/13 MLN MM8304-Revised References posted 02/21/14 Dear Physician Letter Clarifying article DME MAC Joint Publication Corrections and Amendments to F2F and WOPD posted 8/28/14 ements_corrections_and_amendments_to_the_face_to_face_visit_and_writ ten_order_prior_to_delivery_wopd.html 68 34

35 Tuesday and Friday Updates Latest t updates and announcements Customizable Tutorial 69 Website Survey 70 35

36 esmd (Electronic Submission of Medical Documentation) esmd is the ability to transmit documentation electronically for review Who accepts documentation via esmd? DME MAC (Noridian) CERT Recovery Auditor ZPIC What types of requests can be sent via esmd? Complex Medical Review & PMD PAR Find out more: Systems/ESMD/index.html?redirect=/esmd 71 MREP Medicare Remit Easy Print Free software! View, search and print remits Print and export reports CMS Brochure mit_ 0408.pdf MREP Software RemitEasyPrint.asp 72 36

37 Medicare Learning Network (MLN) Guides Articles Educational Tools Booklets Brochures Fact Sheets Training Presentations Web-Based Training Special Initiatives Web Resources MLN/MLNGenInfo/index.html 73 Education Request 1 on 1 Training With a knowledgeable Noridian representative Customized Education Tell us what you d like to learn Convenient Scheduling We ll set up a time/date that works for you Submit an Education Request today!

38 Functions Eligibility Claim Status New - View claim processing comments /2014/08_aug/endeavor_now_offers_cla im_comments_as_part_of_claim_status _results.html Same or Similar (Including A, L, & V codes.) cs/2014/12_dec/endeavor_last_paid_supp ly_orthotic_prosthetic_vision_date_of_ser vice.html Claim-Specific Remittance Advices Overpayments Reopening/Redetermination Submission Status Inquiry PMD Prior Auth Request Status Endeavor Availability Eligibility 24 hours/day, 7 days/week All other functions 6 a.m. 8 p.m. CT, Mon. Fri. 7 a.m. 3 p.m. CT, Sat Education Opportunities Web-Based Workshops DME Basics External Infusion Pumps PMD Prior Authorization Enteral Nutrition Parenteral Nutrition Prefabricated Orthoses Surgical Dressings In-Person Seminars Coming this Spring DME On Demand New ones posted monthly Education Request (NEW!) ACT

39 Contact Information Supplier Contact Center 8:00 a.m. 6:00 p.m. CT M-F Interactive Voice Response (IVR) 24/7 Eligibility 6:00 a.m. 8:00 p.m. CT M-F for claim status Telephone Reopenings 8:00 a.m. 4:30 p.m. CT M-F Beneficiary Contact Information Suppliers please use Noridian Contact Center number for supplier inquiries only 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 78 39

40 Questions Thank you for attending! 40