Oxygen. 1554_0714_oxygen.pptx. Billing, Common Audit Errors and Tips to Avoid Them

Transcription

1 Oxygen 1554_0714_oxygen.pptx Billing, Common Audit Errors and Tips to Avoid Them

2 Today s Presenters Charity Bright Provider Outreach and Education Consultant Stacie McMichel Provider Outreach and Education Consultant 2 National Government Services, Inc.

3 Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and 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 material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at 3 National Government Services, Inc.

4 No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events This applies to our webinars, teleconferences, live events, and any other type of National Government Services educational event 4 National Government Services, Inc.

5 Acronyms ABG arterial blood gas ABN Advance Beneficiary Notice of Noncoverage ACA Affordable Care Act ADL activities of daily living AHI apnea-hypopnea index CERT Comprehensive Error Rate Testing CMN Certificate of Medical Necessity CMS Centers for Medicare & Medicaid Services DME MAC Durable Medical Equipment Medicare Administrative Contractor HCPCS Healthcare Common Procedure Coding System HG Mercury IDTF Independent Diagnostic Testing Facility 5 National Government Services, Inc.

6 Acronyms IOM Internet-only manual LCD local coverage determination MR Medical Review MU Medicare University NPI National Provider Identifier OSA obstructive sleep apnea PAP positive airway pressure PSG polysomnogram RDI Respiratory disturbance index RUL reasonable useful lifetime SAT saturation WOPD written order prior to delivery 6 National Government Services, Inc.

7 Objectives To provide an understanding of the coverage criteria, documentation requirements, and billing guidelines for oxygen and oxygen equipment. 7 National Government Services, Inc.

8 Agenda Coverage Criteria Overview Testing Requirements Certificate of Medical Necessity Documentation Billing Common Audit Errors Resources 8 National Government Services, Inc.

9 Coverage Criteria Overview

10 Coverage Criteria For Home Oxygen Therapy Supporting documentation must be patient s medical record, all criteria must be met for coverage consideration. Severe lung disease or hypoxia related symptoms; and Beneficiary s blood gas study meets specific criteria; and Blood gas study performed by physician or a qualified provider or supplier of laboratory services; and 10 National Government Services, Inc.

11 Coverage Criteria For Home Oxygen Therapy Blood gas study performed under specific conditions; and Alternative treatments ineffective medical and physical therapy directed at secretions, bronchospasm and infection 11 National Government Services, Inc.

12 Home Oxygen Therapy Not Reasonable And Necessary Angina pectoris in the absence of hypoxemia Dyspnea without cor pulmonale or evidence of hypoxemia Severe peripheral vascular disease in absence of systemic hypoxemia Terminal illnesses that do not affect the respiratory system 12 National Government Services, Inc.

13 Group I ABG at or below 55 mm Hg or SAT at or below 88% At rest, or During exercise (3 tests) During sleep (at least 5 minutes) During sleep (signs of hypoxemia) Decrease in ABG more than 10 mm Hg or a decrease in SAT more than 5% from baseline for at least 5 minutes taken during sleep Initial coverage is limited to 12 months 13 National Government Services, Inc.

14 Group II ABG between mm Hg or SAT at 89% Same testing requirements as Group I Beneficiary must have one of the following conditions Dependent edema, suggesting congestive heart failure; or Pulmonary hypertension or cor pulmonale; or Erythrocythemia with a hematocrit greater than 56% Initial coverage is limited to three months 14 National Government Services, Inc.

15 Group III ABG at or above 60 mm Hg or SAT at or above 90% For these patients there is a rebuttable presumption of noncoverage 15 National Government Services, Inc.

16 Portable Oxygen Systems Covered if Patient is mobile within the home, and Qualifying blood gas study was performed while at rest (awake), or during exercise 16 National Government Services, Inc.

17 Testing Requirements

18 Blood Gas Study Qualifying test covered under Medicare Part A or B Test must be performed by a qualified testing provider Blood gas studies performed by a supplier are not acceptable Qualifying blood gas studies may not be paid for by any supplier 18 National Government Services, Inc.

19 Testing Types of qualifying tests ABG below 60 mm Hg SAT below 90% Most recent study prior to CMN initial date (within 30 days) Study can be performed At rest During sleep During exercise 19 National Government Services, Inc.

20 Exercise Testing Can be formal exercise or exertion while performing ADLs Three separate tests must be performed during same testing session At rest breathing room air During exercise breathing room During exercise while on oxygen Record result taken during exercise breathing room air on CMN 20 National Government Services, Inc.

21 Sleep Oximetry Studies Oximeter must be Stand-alone overnight pulse oximetry Tamper proof Capable of downloading date that allows documentation of duration of O2 desaturation below specified value Home-based oximetry tests Performed under direction of Medicare enrolled IDTF Can be delivered by supplier or shipping entity if Ordered by physician Test results accessible only by IDTF CMN Q1(b) = lowest value during five-minute qualifying period 21 National Government Services, Inc.

22 Overnight Oximetry, OSA And PSG Testing must be performed in chronic stable state Both oxygen LCD and PAP LCD must be followed OSA sufficiently treated and lung disease unmasked 22 National Government Services, Inc.

23 Overnight Oximetry, OSA And PSG Overnight oximetry during home sleep test not eligible to be used for oxygen certification Testing may only occur during a titration study and Minimum two hours During titration specific reduction in AHI/RDI criteria met Only performed after optimal PAP settings determined Nocturnal oximetry conducted during PSG shows < 88% for five minutes 23 National Government Services, Inc.

24 Certificate Of Medical Necessity

25 Initial CMN First claim to DME MAC Break in need during 36-month rental period Testing and physician evaluation within 30 days of initial date Replacement due to RUL No new testing or new physician visit required Replacement due to irreparable damage, theft, or loss of the originally dispensed equipment No new testing or new physician visit required 25 National Government Services, Inc.

26 Recertification Group I: twelve months after initial Most recent qualifying test prior to 13th month Group II: three months after initial Most recent qualifying test between 61st 90th day Other requirements Re-evaluation within 90 days prior to recertification Recertification for replacement equipment Same timeframes apply Repeat testing and reevaluation not required Use most recent qualifying value and test date 26 National Government Services, Inc.

27 Revised CMN Change in flow rate category Less than 1 LPM 1 4 LPM Greater than 4 LPM Length of need expired Equipment added New treating physician oxygen order is the same New supplier does not have prior CMN Revised CMN does not change recertification schedule 27 National Government Services, Inc.

28 Making Changes To A CMN Two options Draw line through error Treating physician must initial and date correction Must have similar capability for electronic CMN Complete a new CMN Whiteout or correction tape is not acceptable 28 National Government Services, Inc.

29 Documentation

30 Preliminary Dispensing Order E1390 may be dispensed based on a verbal/preliminary written order E1390 provided based on a dispensing order must be followed up with a completed detailed written order Dispensing order must include Beneficiary s name Physician s name Description of item Date of order Signature 30 National Government Services, Inc.

31 Written Order Prior To Delivery Face-To-Face Encounter Affected DME requires Ordering physician to conduct a face-to-face evaluation within six months prior to WOPD Or sooner if required by LCD NPI must be included on WOPD Effective July 1, 2013 Enforced January 1, National Government Services, Inc.

32 Oxygen HCPCS Affected By ACA 6407 E0424 E0431 E0433 E0441 E0442 E0443 E0439 E0434 E National Government Services, Inc.

33 Continued Use/Continued Need Continued use describes ongoing utilization by a beneficiary Must be periodically documented in either the beneficiary s medical records or supplier records to confirm the item continues to be used by the beneficiary Continued medical need justifies the item remains reasonable and necessary 33 National Government Services, Inc.

34 Billing

35 Oxygen Payment Policy 36-Month Rental Period 36-month rental period Modifier RR Modifiers QE QH, if applicable 35 National Government Services, Inc.

36 Oxygen Payment Policy After 36-Month Rental Period After 36-month rental period Bill for contents (stationary/portable liquid and gaseous equipment only) No modifier Bill for maintenance and servicing (stationary/portable concentrator, transfilling equipment only) MS modifier 36 National Government Services, Inc.

37 Relocation And Travel Months 1 36 Supplier responsible for providing equipment for remainder of current rental month Months Home supplier required to provide or make arrangements for another supplier to provide equipment and all related items/services Beneficiary responsible for airline oxygen services and services provided outside the United States 37 National Government Services, Inc.

38 Change In Modality Switching modalities is prohibited unless one of the following exceptions apply Supplier replaces the equipment with the same or equivalent item Physician orders different equipment Beneficiary chooses to receive an upgrade and signs an ABN CMS or the DME MAC determines that a change in equipment is warranted 38 National Government Services, Inc.

39 After The RUL Is Met Beneficiary may elect to receive new equipment New 36-month rental payment period New 5-year RUL Supplier must actually deliver new equipment Proof of delivery required Follow guidelines for billing replacement of oxygen after RUL 39 National Government Services, Inc.

40 After The RUL Is Met If beneficiary does not elect to receive new equipment Supplier is under no obligation to continue furnishing oxygen equipment Supplier may choose to continue providing oxygen equipment May bill only for contents for stationary and portable liquid or gaseous 40 National Government Services, Inc.

41 Replacement Lost, stolen, irreparably damaged Narrative explaining reason for replacement RUL New initial CMN Initial date should be date of delivery Narrative description of reason for replacement Date of delivery of original equipment Example: RUL RA modifier Submit on first months claim for replacement 41 National Government Services, Inc.

42 Common Audit Errors

43 Documentation Compliance Review Initiated due to high volume of errors identified by CERT for missing and/or incomplete documentation DMEPOS suppliers were notified in October 2011 via an Update Audits will continue until further notice 43 National Government Services, Inc.

44 Top Documentation Compliance Review Error 30-day inperson visit Visit > 30 days Not provided Not signed by the physician or equivalent O2 Testing Only found on the order Doesn t match the date/value on the CMN Not provided Proof of delivery More than two days prior to DOS Not provided Resolution 1. Contact physician to see if another visit took place within the policy guidelines 2. Obtain a signed copy of the medical record 3. Obtain a physician s attestation or signature log 1. Obtain a copy of the actual test report and submit upon appeal. 2. Request the physician correct the information on the CMN to correlate with the medical record with the physician annotating the change and submit upon appeal. 1. Correct date of service if incorrect 2. Submit proof of delivery if available 44 National Government Services, Inc.

45 Top Medical Review Errors Error No records submitted Medical record does not corroborate information on CMN No documentation in chart to indicate beneficiary is mobile within the home- for portable equipment Resolution Establish a process with your referring providers to ensure that documentation is received timely when claims are subject to audit. Utilize the resources available to educate your referring providers on Medicare guidelines to ensure that the medical record supports the claim. There must be evidence in the medical record to confirm that the beneficiary is not confined to one room within their place of residence. 45 National Government Services, Inc.

46 Top CERT Errors Error No documentation of the qualifying blood gas study/saturation test results. Medical records fail to support that the treating physician continues to manage the condition for which the oxygen is ordered. Recertification CMN did not reflect the most recent qualifying blood gas study/oximetry prior to 13th month of therapy. Resolution 1. Obtain a copy of the actual test report or request the physician correct the information on the CMN to correlate with the medical record with the physician annotating the change and submit upon appeal 1. Request medical records within 12 months from the DOS that support physician oversight. 2. An appeal may be requested for the denied services. 1. For patients initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the recertification CMN. 2. If another test was conducted and not reported, the recertification CMN must be corrected to report the most recent qualifying test. The physician must annotate the change on the recertification CMN and this document may be submitted with a request for an appeal. 46 National Government Services, Inc.

47 Resources

48 Resources National Government Services website Medical Policy Center Local medical policy for oxygen and oxygen equipment Policy Education Page: Oxygen Jurisdiction B DME MAC Supplier Manual Self-Service Center MR Denial Reason Tool CERT Denial Reason Finder NGSConnex 48 National Government Services, Inc.

49 Resources CMS website CMS IOM Publication , Chapter 1 49 National Government Services, Inc.

50 CERT Denial Reason Finder 50 National Government Services, Inc.

51 CERT Denial Reason Finder 51 National Government Services, Inc.

52 Medical Review Denial Tool 52 National Government Services, Inc.

53 Updates Subscribe to receive the latest, up-to-date Medicare information. 53 National Government Services, Inc.

54 Website Survey This is your chance to have your voice heard Say yes when you see this pop-up so National Government Services can make your job easier! 54 National Government Services, Inc.

55 Medicare University Interactive online system available 24/7 Educational opportunities available Computer-based training courses Teleconferences, webinars, live seminars/face-to-face training Self-report attendance 55 National Government Services, Inc.

56 Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at Topic = Medicare University Credits (MUCs) = 8 Catalog Number and Course Code = To Be Given During Live Presentation For step-by-step instructions on self-reporting please visit the Accessing the Self-Reporting Tool page on the NGSMedicare.com website 56 National Government Services, Inc.

57 Thank You! 57 National Government Services, Inc.