Ankle-Foot/Knee-Ankle-Foot Orthosis (AFO/KAFO)

Transcription

1 Ankle-Foot/Knee-Ankle-Foot Orthosis (AFO/KAFO) Presented by Noridian DME Outreach and Education June

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 ( June 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 1 AAPC CEU is offered for this course Certificate of Completion ed to all attendees with 2-3 business days following the workshop June 2016 Noridian DME Outreach and Education 3 3

4 Acronyms ADR: Additional Documentation Request DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics and Supplies DOS: Date of Service DWO: Detailed Written Order LCD: Local Coverage Determination OIG: Office of Inspector General POD: Proof of Delivery POS: Place of Service WOPD: Written Order Prior to Delivery June 2016 Noridian DME Outreach and Education 4 4

5 Agenda Coverage Criteria Coding & Billing Reminders Repairs & Replacement Documentation Comprehensive Error Rate Testing (CERT) Resources & Reminders June 2016 Noridian DME Outreach and Education 5 5

6 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 June 2016 Noridian DME Outreach and Education 6 6

7 Coverage Criteria 7

8 Definition of a Brace Rigid or semi-rigid device Supporting weak or deformed body member or; Restricting or eliminating motion in diseased or injured part of body Must provide support and counterforce on limb or body part that it is being used to brace Items that do not meet the definition of a brace are noncovered June 2016 Noridian DME Outreach and Education 8 8

9 Types of Orthoses Prefabricated Orthosis (OTS or Custom Fitted) Manufactured in quantity without specific beneficiary in mind Custom-fabricated orthosis Individually made for specific beneficiary starting with basic materials (i.e. plastic, metal, leather, or cloth) Can be a molded-to-beneficiary-model orthosis June 2016 Noridian DME Outreach and Education 9 9

10 Coverage Criteria Ambulatory Beneficiaries AFOs & KAFOs used during ambulation AFOs: L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, L4387 and L4631 Covered if Beneficiary: Ambulatory (or plan to move to an ambulatory status must be in medical record) Weakness or deformity of the foot and ankle Require stabilization for medical reasons Have the potential to benefit functionally KAFOs: L2000-L2038, L2126-L2136 and L4370 Beneficiaries who meet coverage for AFO Require additional knee stability June 2016 Noridian DME Outreach and Education 10 10

11 Custom Fabricated Covered for ambulatory beneficiaries when basic coverage criteria met and one of the following criteria are met: Beneficiary could not be fit with prefabricated AFO, or Condition expected to be permanent or of longstanding duration, or Need to control the knee/ankle/foot in more than one plane, or Documented neurological/circulatory/orthopedic status, or Healing fracture which lacks normal anatomical integrity or anthropometric proportions Physician must document medical necessity for custom fabricated vs. pre-fabricated Must be corroborated by CPO functional evaluation records June 2016 Noridian DME Outreach and Education 11 11

12 AFO Not Used During Ambulation L4396 or L4397 used for an AFO when a beneficiary is nonambulatory, or minimally ambulatory and is covered if all criteria 1-4, or criterion 5 is met: Plantar flexion contracture of ankle with dorsiflexion on PROM testing of at least ten degrees (i.e., nonfixed contracture); and Reasonable expectation of ability to correct contracture; and Contracture is interfering or expected to interfere significantly with beneficiaries functional abilities; and Used as component of therapy program which includes active stretching of involved muscles and/or tendons OR Beneficiary has plantar fasciitis Code L4398 is also used for an AFO which is worn when a beneficiary is nonambulatory June 2016 Noridian DME Outreach and Education 12 12

13 L4398 AFO Not Used During Ambulation Designed to maintain the foot at a fixed position or zero degrees (i.e., perpendicular to the lower leg); and, Not designed to accommodate an ankle with a plantar flexion contracture; and, Used by a beneficiary who is nonambulatory; and, Has a soft interface June 2016 Noridian DME Outreach and Education 13 13

14 Not Separately Payable Time involved with: Evaluating the beneficiary Taking measurements, making a cast, making a model, use of CAD/CAM Making modifications to a prefabricated item to fit it to the individual beneficiary Follow-up visits Making adjustments at the time of, or within 90 days of the delivery Addition codes L4002 L4130, L4392 billed at time of initial issue of base orthosis June 2016 Noridian DME Outreach and Education 14 14

15 Coding & Billing Reminders 15

16 OTS vs. Custom Fitted Off-the-Shelf Prefabricated May or may not be supplied as a kit Requires minimal selfadjustment upon delivery Done by beneficiary, caretaker or supplier Does not require expert fitting Custom Fitted Prefabricated May or may not be supplied as a kit Requires substantial modification upon delivery Requires expert fitting Certified orthotist or someone with specialized training June 2016 Noridian DME Outreach and Education 16 16

17 OTS & Custom Fitted HCPCS Off the Shelf Custom Fitted L1902 L1910 L2116 L1906 L1930 L2132 L4350 L1932 L2134 L4361 L1951 L2136 L4370 L1971 L4360 L4387 L2035 L4386 L4397 L2112 L4396 L4398 L2114 June 2016 Noridian DME Outreach and Education 17 17

18 Mirror Image Codes Off the Shelf L4361 L4387 L4397 Custom Fitted L4360 L4386 L4396 June 2016 Noridian DME Outreach and Education 18 18

19 Modifiers LT Left side RT Right side June 2016 Noridian DME Outreach and Education 19 19

20 Modifiers (2) KX Coverage criteria met and supporting documentation is on file GA Coverage criteria not met and ABN obtained GZ Coverage criteria not met, valid ABN not obtained EY No physician or other licensed health care provider order for this item June 2016 Noridian DME Outreach and Education 20 20

21 Claim Submission Reminders L2999 Manufacturer s name; Product name, model name and number; Narrative description of the item (custom fabricated); Justification of beneficiary s medical necessity All codes for orthoses or repairs of orthoses billed with same DOS must be submitted on same claim Static AFO (L4396 and L4392) requires appropriate diagnosis code June 2016 Noridian DME Outreach and Education 21 21

22 Payment Included in Part A Covered Stay Payment for orthosis is included in payment to hospital or SNF if: Orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and Medical necessity for orthosis begins during hospital or SNF stay (e.g., after surgery) Orthosis is provided to beneficiary during an inpatient hospital or Part A covered SNF stay prior to day of discharge; and Beneficiary uses item for medically necessary inpatient treatment or rehabilitaion June 2016 Noridian DME Outreach and Education 22 22

23 Payment Eligible by DME MAC AFO/KAFO to beneficiary in hospital or Part A covered SNF stay is eligible for coverage if: Orthosis is medically necessary for beneficiary after discharge from hospital or Part A covered SNF stay; and Orthosis provided to beneficiary within two days prior to discharge to home; and Orthosis is not needed for inpatient treatment or rehabilitation, but left in room for beneficiary to take home Date of service on claim must be discharge date June 2016 Noridian DME Outreach and Education 23 23

24 Repairs and Replacements 24

25 Repairs A new order is not necessary Documentation of continued need by the physician is required Treating physician or supplier must document that the repair itself is reasonable and necessary Supplier must document need for and nature of the repairs June 2016 Noridian DME Outreach and Education 25 25

26 Repair Codes L4205 Repair of orthotic device, labor component, per 15 minutes Claim narrative explaining what was repaired Actual repair or medically necessary adjustments made more than 90 days after delivery Cannot use to bill for time involved in other professional services L4210 Repair of orthotic device, repair or replace minor parts Include narrative on claim describing each item billed June 2016 Noridian DME Outreach and Education 26 26

27 Replacements Replacement covered if due to: Lost, stolen, irreparable accidental damage Significant change in beneficiary s condition New order required for any replacement Supplier records must document reason for any replacement Replacement components provided on a routine basis are not covered The padding/lining of an AFO can be replaced if reasonable and necessary June 2016 Noridian DME Outreach and Education 27 27

28 Documentation 28

29 Intake and Assessment Assists in accurate claim submission Assures appropriate documentation collected Suggested intake form Customize your intake process Include PECOS verification for the referral Suggested Intake Form ( June 2016 Noridian DME Outreach and Education 29 29

30 Authorized to Order Treating Physician, MD, or DO Nurse Practitioner (NP) Clinical Nurse Specialist (CNS) Physician Assistant (PA) June 2016 Noridian DME Outreach and Education 30 30

31 Authorized to Order (cont.) NP or CNS Treating beneficiary for condition for which item is needed Practicing independently of physician Bill Medicare for other covered services using own National Provider Identifier (NPI) Permitted to do so 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 June 2016 Noridian DME Outreach and Education 31 31

32 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 Required elements Description of the item Beneficiary s name Prescribing physician s name Date of the order and start (if different) Signature Physician (written order) Supplier (verbal order) June 2016 Noridian DME Outreach and Education 32 32

33 Detailed Written Order (DWO) Claim may not be submitted without a detailed DWO If no DWO Submit claim with an EY modifier June 2016 Noridian DME Outreach and Education 33 33

34 Basic Elements Detailed Written Order Beneficiary s name Physician s name Date of the order Detailed description of the item(s) Physician signature and signature date Program Integrity Manual (PIM) ( Guidance/Guidance/Manuals/Downloads/pim83 c03.pdf) June 2016 Noridian DME Outreach and Education 34 34

35 DWO Additional Elements Item(s) to be dispensed Dosage or concentration, if applicable Route of administration Frequency of use Duration of infusion, if applicable Quantity to be dispensed Number of refills June 2016 Noridian DME Outreach and Education 35 35

36 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 June 2016 Noridian DME Outreach and Education 36 36

37 When is a New Order Required? Change in order When indicated in the medical policy State licensure or regulations Replacement Change in supplier June 2016 Noridian DME Outreach and Education 37 37

38 Continued Use Continued use describes ongoing utilization by a beneficiary Must be periodically documented to confirm item continues to be used Acceptable continued use documentation: Beneficiary s medical records or Supplier records Suppliers must discontinue billing if the item is no longer being used June 2016 Noridian DME Outreach and Education 38 38

39 Continued Need Continued medical need justifies the item remains reasonable and necessary Documentation justifying continued medical need includes: A recent order by the treating physician for refills A recent change in prescription A properly completed CMN or DIF with the LON specified Timely documentation in the medical record showing usage June 2016 Noridian DME Outreach and Education 39 39

40 Medical Records Physician s office records Hospital records Nursing home records Home health agency records Healthcare professional records Test reports Must be available upon request! June 2016 Noridian DME Outreach and Education 40 40

41 Prefabricated Documentation OTS vs. Custom Fitted When providing these items suppliers must: Provide the product that is specified by the ordering physician Medical record justifies the need for the type of product (i.e., prefabricated vs. custom fabricated) Only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting Detailed supplier documentation that justifies the code selected June 2016 Noridian DME Outreach and Education 41 41

42 Custom Fabricated Documentation Medical Records Detailed documentation to support medical necessity of custom rather than a prefabricated Why does the beneficiary need a custom orthosis? Why would a prefabricated orthosis not meet his/her needs? Documented by the treating physician June 2016 Noridian DME Outreach and Education 42 42

43 Proof of Delivery (POD) Supplier Standard 12 Signed POD required to verify beneficiary 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 June 2016 Noridian DME Outreach and Education 43 43

44 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 Date of service is the date of delivery June 2016 Noridian DME Outreach and Education 44 44

45 POD Signature POD can be signed by: Beneficiary Beneficiary s designee Relationship to beneficiary must be noted on delivery slip POD cannot be signed by: Suppliers Employees of suppliers Anyone with financial interest in delivery of item June 2016 Noridian DME Outreach and Education 45 45

46 Method 2 Deliver/Shipping Service Delivery to beneficiary via shipping service The POD record must include: Beneficiary's name Delivery address Package invoice and delivery confirmation Detailed description of the item(s) being delivered Quantity delivered Date delivered Evidence of delivery Date of service is the shipping date June 2016 Noridian DME Outreach and Education 46 46

47 POD Exception: Anticipation of Discharge Delivery to Facility Delivered for the purpose of fitting/training Two days prior to discharge from hospital or nursing facility DOS equals discharge date POS 12 (beneficiary s home) Delivery to Home Two days prior to discharge from hospital or nursing facility DOS equals discharge date POS 12 (beneficiary s home) June 2016 Noridian DME Outreach and Education 47 47

48 Refill Requirements Request for refill must include: Beneficiary s name Description of each item being requested Date of refill request Consumables (e.g., urological supplies) Quantity of each item the beneficiary still has remaining Non-consumables (e.g., CPAP supplies) Functional condition of the item being refilled to demonstrate the cause of the dysfunction that necessitates replacement June 2016 Noridian DME Outreach and Education 48 48

49 Beneficiary Authorization Beneficiary must authorize supplier to bill Medicare Sign and date Item 12 on CMS-1500 claim form Supplier-created Signature On File One-time authorization Statement from beneficiary authorizing Medicare benefits to be paid to themselves or supplier One-time Authorization Sample Language ( June 2016 Noridian DME Outreach and Education 49 49

50 Comprehensive Error Rate Testing (CERT) 50

51 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 June 2016 Noridian DME Outreach and Education 51 51

52 CERT Error Categories No documentation Insufficient documentation Medically unnecessary service Service incorrectly coded Other June 2016 Noridian DME Outreach and Education 52 52

53 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. CERT Inquiries June 2016 Noridian DME Outreach and Education 53 53

54 CERT Inquiries JD DME CERT 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 two business days June 2016 Noridian DME Outreach and Education 54 54

55 Resources and Reminders 55

56 Resources LCD/Policy Article ( olicies/lcd/active) Noridian Supplier Manual ( ducation/supplier-manual) Dear Physician Letters ( olicies/physician-resources) June 2016 Noridian DME Outreach and Education 56 56

57 Resources (cont.) Documentation Checklists ( olicies/documentation-checklists) Acronyms Noridian Acronym List ( cronyms-glossary) CMS Acronym List ( June 2016 Noridian DME Outreach and Education 57 57

58 2016 MSI Survey Evaluate Our Services in 10 Minutes! The MAC Satisfaction Indicator (MSI) is the best way to share your opinions of our service directly with the Centers for Medicare & Medicare Services (CMS). This survey should only take about 10 minutes of your time and helps us understand how we can better serve you. To take the survey, click on the URL. D DME Noridian &MAC_BRNC=4 June 2016 Noridian DME Outreach and Education 58 58

59 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) June 2016 Noridian DME Outreach and Education 59 59

60 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) June 2016 Noridian DME Outreach and Education 60 60

61 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) June 2016 Noridian DME Outreach and Education 61 61

62 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 ( June 2016 Noridian DME Outreach and Education 62 62

63 Tuesday and Friday Latest updates and announcements Customizable Sign-up in the lower right corner of our website Click subscribe Updates June 2016 Noridian DME Outreach and Education 63 63

64 Website Survey Your feedback is valuable Click Yes, I ll give feedback June 2016 Noridian DME Outreach and Education 64 64

65 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) June 2016 Noridian DME Outreach and Education 65 65

66 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) June 2016 Noridian DME Outreach and Education 66 66

67 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) June 2016 Noridian DME Outreach and Education 67 67

68 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) June 2016 Noridian DME Outreach and Education 68 68

69 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) Fall Seminar locations to be announced this summer! June 2016 Noridian DME Outreach and Education 69 69

70 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) June 2016 Noridian DME Outreach and Education 70 70

71 Single Toll Free Line Interactive Voice Response (IVR) Supplier Contact Center Telephone Reopenings Monday Friday 8 a.m. 6 p.m. CT June 2016 Noridian DME Outreach and Education 71 71

72 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 June 2016 Noridian DME Outreach and Education 72 72

73 Sync the Audio to Ask a Verbal Question Click on Event Info tab Verify Identity code Enter # you number # on your telephone keypad June 2016 Noridian DME Outreach and Education 73 73

74 Asking a Verbal Question To ask verbal question: Click on the Participant tab Click on the hand icon The telephone handset or computer headset must be present beside your name June 2016 Noridian DME Outreach and Education 74 74

75 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 June 2016 Noridian DME Outreach and Education 75 75

76 Questions? 76

77 Thank you for attending! 77