5/31/2016. Oxygen and Oxygen Equipment

Transcription

1 Oxygen and Oxygen Equipment Presented by Noridian Provider Outreach and Education Jurisdiction D DME MAC 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 Please Sign into Audio Using Either Method Call Me Option Enter your contact phone number You will receive a call that connects you Call Using Computer Option Ensure you have mute off on your Computer and Headphones June 2016 Noridian Jurisdiction D DME MAC 3 3

4 Sync Your Phone with Your Name Click on Event Info Tab Verify Identity code Enter # your number # June 2016 Noridian Jurisdiction D DME MAC 4 4

5 Workshop protocol Entering Workshop Attendee lines are muted upon entry Throughout Workshop Written questions in Q & A section Conclusion of Workshop: Q & A Session Use Raise Hand feature to ask questions aloud When question finished, select Lower Hand button 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 and can also be found at: June 2016 Noridian Jurisdiction D DME MAC 5 5

6 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 6 6

7 Acronyms ABG: Arterial Blood Gas ABN: Advance Beneficiary Notice of Noncoverage ACA: Affordable Care Act ADR: Additional Documentation Request CBA: Competitive Bidding Area CEDI: Common Electronic Data Interchange CERT: Comprehensive Error Rate Testing CMN: Certificate of Medical Necessity CMS: Center for Medicare & Medicaid Services CO: Contractual Obligation DMECS: Durable Medical Equipment Coding System DME MAC: Durable Medical Equipment Medicare Administrative Contractor DMEPOS: Durable Medical Equipment Prosthetics Orthotics and Supplies FAQ: Frequently Asked Question FFS: Fee for Service HCPCS: Healthcare Common Procedure Coding System HHA: Home Health Agency HICN: Heath Insurance Claim Number June 2016 Noridian Jurisdiction D DME MAC 7 7

8 HMO: Health Maintenance Organization IDTF: Independent Diagnostic Testing Facility IOM: Internet Only Manual IVR: Interactive Voice Response (system) LCD: Local Coverage Determination LPM: Liters per minute mm Hg: Millimeters of Mercury M&S: Maintenance and Service MLN: Medicare Learning Network NCD: National Coverage Determination NSC: National Supplier Clearinghouse Acronyms PA: Policy Article PHI: Protected Heath Information PIM: Program Integrity Manual POD: Proof of delivery PTAN: Provider Transaction Access Number RA: Remittance Advice RAC: Recovery Audit Contractor RUL: Reasonable Useful Lifetime SAT: Oxygen Saturation SNF: Skilled Nursing Facility WOPD: Written Order Prior to Delivery ZPIC: Zone Program Integrity Contractor June 2016 Noridian Jurisdiction D DME MAC 8 8

9 Noridian Widespread Review Non-complex E1390 June 2016 Noridian Jurisdiction D DME MAC 9 9

10 Noridian Widespread Review Complex E1390 June 2016 Noridian Jurisdiction D DME MAC 10 10

11 Noridian Widespread Review Complex E0439 and E0434 June 2016 Noridian Jurisdiction D DME MAC 11 11

12 New Noridian Widespread Review June 2016 Noridian Jurisdiction D DME MAC 12 12

13 Frequent documentation errors No alternative treatments documented No chronic underlying Lung disease documented Non-Response to ADR letter Missing documentation WOPD not valid June 2016 Noridian Jurisdiction D DME MAC 13 13

14 Agenda Oxygen and the ACA Coverage Criteria Testing Requirements Coverage Groups Certificate of Medical Necessity Coding and Billing Guidelines Documentation CERT Resources and Reminders June 2016 Noridian Jurisdiction D DME MAC 14 14

15 Oxygen and the ACA (Section 6407) MM

16 MM8304 Face-to-Face evaluation Documentation Authorized to order Timeliness Detailed Written Order WOPD Required Elements Physician NPI Affected HCPCS/Policies June 2016 Noridian Jurisdiction D DME MAC 16 16

17 Implementation vs. Enforcement Implementation Date For all requirements July 1, 2013 Enforcement Date For WOPD requirements Date of Service (DOS) January 1, 2014 For F2F requirements To be announced by CMS in 2015 June 2016 Noridian Jurisdiction D DME MAC 17 17

18 Oxygen Specific Items & ACA Requirements for Order Do Require WOPD E0431 E0434 E0439 E0424 E0441 E0442 E0443 E0444 Do Not Require WOPD E1390 E1392 K0738 June 2016 Noridian Jurisdiction D DME MAC 18 18

19 Written Order Prior to Delivery (WOPD) Basic elements Beneficiary s name Note Physician s name change Date of the order Detailed description of the item(s) Physician signature and signature date Physician NPI Date stamp (or equivalent) upon receipt June 2016 Noridian Jurisdiction D DME MAC 19 19

20 DWO: Additional Elements Items Provided on a Periodic Basis 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 Jurisdiction D DME MAC 20 20

21 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 CMN can serve as the WOPD if sufficiently detailed June 2016 Noridian Jurisdiction D DME MAC 21 21

22 ACA Common documentation errors on a WOPD No Date stamp/similar No NPI # on WOPD Date stamp is completed after the date of delivery Fax line used for date stamp or similar No supplier identifier included No date included Illegible In these instances the fax line has been covered up partially by several follow-up fax lines NPI # added to WOPD after Physician date/signature without proper amendment/correction procedures followed by the Physician June 2016 Noridian Jurisdiction D DME MAC 22 22

23 Corrections & Amendments to Face-to-Face and WOPD 23

24 Prior to Delivery Have treating physician properly amend the face-to-face visit or WOPD A new face-to-face or a new WOPD June 2016 Noridian Jurisdiction D DME MAC 24 24

25 After Delivery Prior to Claim Submission Supplier may recover the delivered items Obtain a compliant faceto-face or WOPD Re-deliver items After Claim Submission Supplier may recover the delivered items A new supplier must complete the transaction June 2016 Noridian Jurisdiction D DME MAC 25 25

26 Coverage Criteria National Coverage Determination (240.2) Local Coverage Determination (L33797) Policy Article (A52514) 26

27 Covered Home Oxygen Therapy 1. Severe lung disease or hypoxia related symptoms; and 2. Beneficiary s blood gas study meets specific criteria; and 3. Blood gas study performed by physician or a qualified provider or supplier of laboratory services; and 4. Blood gas study performed under specific conditions; and 5. Alternative treatments ineffective June 2016 Noridian Jurisdiction D DME MAC 27 27

28 FAQ Q: What is considered to be alternative treatment measures before the oxygen is ordered? A: Many disease conditions have standard treatment regimens associated with them. This criterion, together with the requirement that testing be done while the patient is in their chronic, stable state means that the usual treatment modalities need to be optimized before oxygen becomes eligible for reimbursement. June 2016 Noridian Jurisdiction D DME MAC 28 28

29 Home Oxygen Not Reasonable and Necessary Angina pectoris in the absence of hypoxemia Dyspnea without cor pumonale or evidence of hypoxemia Severe peripheral vascular disease in absence of systemic hypoxemia Terminal illnesses that do not affect respiratory system June 2016 Noridian Jurisdiction D DME MAC 29 29

30 NCD Conditions for Which Oxygen Therapy May Be Covered A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, whether of known or unknown etiology; cystic fibrosis, bronchiectasis; widespread pulmonary neoplasm; or Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. Examples of these symptoms and findings are pulmonary hypertension, recurring congestive heart failure due to chronic cor pulmonale, erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache. While there is no substitute for oxygen therapy, each patient must receive optimum therapy before long-term home oxygen therapy is ordered. June 2016 Noridian Jurisdiction D DME MAC 30 30

31 FAQ Q: Are pneumonia or post-surgical hypoxia covered conditions for home oxygen upon discharge from the hospital? A: Short-term support strictly due to an acute hypoxia need related to Pneumonia or postoperative recovery would not meet the requirement of a chronic underlying lung condition requiring long-term Oxygen therapy. June 2016 Noridian Jurisdiction D DME MAC 31 31

32 Testing Requirements 32

33 Blood gas study Testing Definitions Refers to both arterial blood gas (ABG) studies and pulse oximetry Oximetry Refers to routine or spot pulse oximetry Overnight oximetry refers to stand-alone pulse oximetry continuously recorded overnight. It does not include oximetry results done as part of other overnight testing such as polysomnography or home sleep testing June 2016 Noridian Jurisdiction D DME MAC 33 33

34 Blood Gas Study Qualifying test covered under Medicare Part A or B Test must be performed by provider qualified to bill Medicare: Part A Provider Laboratory Independent Diagnostic Testing Facility (IDTF) Physician June 2016 Noridian Jurisdiction D DME MAC 34 34

35 FAQ Q: Can the testing be performed by a home health or hospice nurse at the beneficiary's home or by a Nurse in a SNF? A: Yes. If the beneficiary s home health episode was bundled and billed under a Part A episode at the time the home health nurse measured the oxygen saturation, then it would meet the qualified provider standard. During a Part A covered stay payment is bundled such that services rendered are covered under a lump sum payment by Medicare. In this case, oxygen qualification testing performed in a hospital, nursing facility, home health or hospice or other covered Part A episode meets the "qualified provider" standard. June 2016 Noridian Jurisdiction D DME MAC 35 35

36 Testing Types of qualifying tests: Arterial blood gas (ABG) below 60 mm Hg Blood oxygen saturation (SAT) below 90% Group I 88% or below Group II 89% Most recent study prior to CMN initial date (w/in 30 days) June 2016 Noridian Jurisdiction D DME MAC 36 36

37 Testing Study can be performed: At rest During sleep During exercise Can be formal exercise or exertion while performing daily activities Three separate readings must be taken Record reading taken during exercise breathing room air on CMN June 2016 Noridian Jurisdiction D DME MAC 37 37

38 Testing Conditions Inpatient Hospital Stay Outpatient Closest to, but no earlier than 2 days prior to the hospital discharge date Last test prior to discharge Must be performed while the beneficiary is in a chronic stable state Not during acute illness or exacerbation of underlying disease June 2016 Noridian Jurisdiction D DME MAC 38 38

39 FAQ Q: Would a blood gas obtained during an Observational status from the Emergency room qualify for inpatient testing? A: No, nor would it meet chronic stable state requirements. If using two days prior to hospital discharge for testing conditions the beneficiary must have been in a true inpatient hospital stay. The patient must have had an order for Hospital inpatient services as stated under Medicare Part A. June 2016 Noridian Jurisdiction D DME MAC 39 39

40 Sleep Oximetry Studies Oximeter must be: Stand-alone overnight pulse oximetry Tamper proof Capable of downloading data that allows documentation of duration of O2 desaturation below specified value June 2016 Noridian Jurisdiction D DME MAC 40 40

41 Sleep Oximetry Studies Home based overnight 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 5-min qualifying period June 2016 Noridian Jurisdiction D DME MAC 41 41

42 Concurrent Use Oxygen and PAP 42

43 Overnight Oximetry, OSA AND PSG Testing must be done in Chronic Stable State Both oxygen LCD and PAP LCD must be followed OSA sufficiently treated and lung disease unmasked June 2016 Noridian Jurisdiction D DME MAC 43 43

44 Overnight Oximetry, OSA AND PSG (2) Overnight oximetry during home sleep test not eligible to be used for oxygen qualification. Testing may only occur during a Titration Study and 1. Minimum 2 hours 2. During titration specific reduction in AHI/RDI criteria met 3. Only performed after optimal PAP settings determined 4. Nocturnal oximetry conducted during PSG shows <88% for 5 minutes. June 2016 Noridian Jurisdiction D DME MAC 44 44

45 Titration Example PAP Cm H2O 0 Baseline Total Sleep Time (min) TIB (min) Sleep Eff % # Hypopneas # Central Apneas # Obstructive Apneas AHI Mean SPO Time O2 88% or under (min) Total minutes June 2016 Noridian Jurisdiction D DME MAC 45 45

46 FAQ Q: The Sleep Physician sends an order for overnight oxygen, the medical records state the beneficiary is scheduled for a Polysomnogram (PSG) to test for Obstructive Sleep Apnea (OSA). Is Oxygen covered until the PSG is completed? A: No, if OSA is suspected it must either have been ruled out or treated to confirm that the oximetry is done while the beneficiary is in their chronic stable state during a titration study. June 2016 Noridian Jurisdiction D DME MAC 46 46

47 FAQ Q: If the patient is on PAP and then is tested for continuous Oxygen with a daytime at rest/exercise saturation test and qualifies for 24hr a day Oxygen do they also need a titration study to use the Oxygen with PAP at night? A: No, Obstructive Sleep Apnea (OSA) is not present in the daytime so if the qualification is for continuous oxygen use that would qualify the beneficiary and an additional titration would not be necessary. June 2016 Noridian Jurisdiction D DME MAC 47 47

48 Coverage Groups 48

49 Coverage Groups Group I ABG at or below 55 mm Hg or SAT at or below 88% 1. At rest, or 2. During exercise (3 tests) 3. During sleep (at least 5 minutes) 4. During sleep (signs of hypoxemia) 1. 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 limited to 12 months June 2016 Noridian Jurisdiction D DME MAC 49 49

50 Coverage Groups Group II ABG between mm Hg or SAT at 89% Same testing requirements as Group I AND beneficiary has one of following conditions: Dependent edema, suggesting congestive heart failure; or Pulmonary hypertension or cor pulmonale; or Erythrocythemia with a hematocrit greater than 56% Initial coverage limited to 3 months June 2016 Noridian Jurisdiction D DME MAC 50 50

51 Portable Oxygen Beneficiary must be mobile within the home Qualifying study performed at rest or during exercise Study performed during sleep not reasonable and necessary Separately payable if coverage criteria met Reimbursement is the same regardless of quantity dispensed June 2016 Noridian Jurisdiction D DME MAC 51 51

52 High Liter Flow High liter flow (greater than 4 LPM) Must meet Group I or II criteria when tested at 4 or more LPM If not, payment limited to standard allowance Higher allowable for stationary but portable not separately payable June 2016 Noridian Jurisdiction D DME MAC 52 52

53 Certificate of Medical Necessity 53

54 Initial CMN 1. First claim to DME MAC Testing and physician evaluation within 30 days of initial date 2. Break in need during 36 month rental period Testing and physician evaluation within 30 days of initial date June 2016 Noridian Jurisdiction D DME MAC 54 54

55 Initial CMN (2) 3. Replacement due to RUL No new testing or new physician visit required per LCD ACA section 6407 items require new F2F 4. Replacement due to irreparable damage, theft, or loss of the originally dispensed equipment No new testing or new physician visit required June 2016 Noridian Jurisdiction D DME MAC 55 55

56 Recertification 5. Group I patients 12 months after initial Most recent qualifying test prior to 13th month 6. Group II patients 3 months after initial Most recent qualifying test between 61st 90th day Other requirements for 5 and 6: Re-evaluation within 90 days prior to recertification Above criteria not met, but use continues, coverage resumes when requirements are met June 2016 Noridian Jurisdiction D DME MAC 56 56

57 Recertification Recertification for replacement equipment: Same timeframes apply Repeat testing and re-evaluation not required Use most recent qualifying value and test date June 2016 Noridian Jurisdiction D DME MAC 57 57

58 Revised CMN 7. Change in flow rate category Less than 1 liter per minute (LPM) 1-4 LPM Greater than 4 LPM 8. Length of need expired Revised CMN does not change recertification schedule June 2016 Noridian Jurisdiction D DME MAC 58 58

59 Revised CMN 9. Portable added to stationary 10. Stationary added to portable 11. New treating physician - oxygen order is the same 12. New supplier does not have the prior CMN Revised CMN does not change recertification schedule June 2016 Noridian Jurisdiction D DME MAC 59 59

60 Other CMN Notes CMN Sections B and D completed by physician Signature and date stamps are not acceptable for use on CMNs and DIFs Form CMS-484 (11/11): Forms/Downloads/CMS484.pdf Misc. changes not requiring new CMN or testing Flow rate changes but remains in same category Change of modality New written order is required though June 2016 Noridian Jurisdiction D DME MAC 60 60

61 Other CMN Notes 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 new CMN Whiteout not acceptable June 2016 Noridian Jurisdiction D DME MAC 61 61

62 Coding and Billing Guidelines 62

63 FAQ Q: Can I bill code E0439 in the same month with code E1390? A: No. Both the E0439 and E1390 are stationary oxygen items and are considered similar equipment. 63

64 Modifiers RR Monthly rental Q0 Investigational, approved clinical research study (replaced QR) QE Flow rate less than 1 LPM QF Flow rate is greater than 4 LPM and portable oxygen is prescribed June 2016 Noridian Jurisdiction D DME MAC 64 64

65 Modifiers QG Flow rate is greater than 4 LPM and portable oxygen is not prescribed QH Oxygen conserving device is being used with an oxygen delivery system RA Replacement of DME item, first month rental only June 2016 Noridian Jurisdiction D DME MAC 65 65

66 Months 1-36 Supplier who furnishes equipment in 1st month must continue for entire 36-mo rental period unless: Beneficiary relocates or elects a new supplier Individual case exceptions made by CMS or the DME MAC Item becomes subject to competitive bidding June 2016 Noridian Jurisdiction D DME MAC 66 66

67 Months 1-36 Contents, maintenance, supplies and accessories all included in rental allowance Exception: contents separately allowed if beneficiary only uses portable liquid or gas June 2016 Noridian Jurisdiction D DME MAC 67 67

68 Relocation Months 1-36 Supplier responsible for providing equipment for remainder of current rental month For subsequent rentals months, home supplier encouraged to continue to provide equipment or assist the beneficiary in finding another supplier to take over June 2016 Noridian Jurisdiction D DME MAC 68 68

69 Months No further payment for remainder of the 5 year RUL Continue providing equipment, supplies, accessories, maintenance during remainder of 5 year RUL New 36-mo rental can only begin if equipment lost, stolen or irreparably damaged No new 36-mo cap for normal wear and tear, changes of modality, breaks in need or billing or change of suppliers June 2016 Noridian Jurisdiction D DME MAC 69 69

70 Relocation Months Home supplier required to provide or make arrangements for another supplier to provide equipment and all related items/services June 2016 Noridian Jurisdiction D DME MAC 70 70

71 Travel Beneficiary responsible for airline oxygen services Beneficiary responsible for services provided outside the United States June 2016 Noridian Jurisdiction D DME MAC 71 71

72 Break in Service Break less than 60 days = break in billing Does not start a new 36-mo cap Continue existing rental where left off until 36 rental payments made Break greater than 60 days New 36-month cap begins Requires new testing, order and initial CMN Include narrative on claim for new rental explaining why medical necessity ended June 2016 Noridian Jurisdiction D DME MAC 72 72

73 Contents Billing Chart Equipment Furnished in Month 36 Oxygen Concentrator (E1390, E1391, or E1392) Portable Gaseous Transfilling Equipment (K0738) Portable Liquid Transfilling Equipment (E1399) Stationary Gaseous Oxygen System (E0424) Stationary Liquid Oxygen System (E0439) Portable Gaseous Oxygen System (E0431) Portable Liquid Oxygen System (E0434) None None None Monthly Contents Payment after Stationary Cap Stationary Gaseous Contents (E0441) Stationary Liquid Contents (E0442) Portable Gaseous Contents (E0443) Portable Liquid Contents (E0444) June 2016 Noridian Jurisdiction D DME MAC 73 73

74 Contents Payment included in fee schedule allowance for stationary equipment during 36-month cap Can begin billing contents for liquid/gas systems after end of 36-month stationary cap June 2016 Noridian Jurisdiction D DME MAC 74 74

75 FAQ Q: Since the contents code E0443 requires a WOPD/F2F if this code is not listed on our initial/recertification CMN does the patient require a new order/f2f before we can start billing for contents after the equipment has capped? A: Yes. You can't bill contents initially, but you can include them on the recertification CMN in preparation for when they will be needed. If they are not on the recertification CMN, you need a new WOPD and F2F before billing. June 2016 Noridian Jurisdiction D DME MAC 75 75

76 Maintenance and Service Applies to concentrators and transfilling equipment No M&S payment for gaseous or liquid equipment No separate payment for M&S during 36-month cap June 2016 Noridian Jurisdiction D DME MAC 76 76

77 Maintenance and Service M&S billable every 6 months starting 6 months after end of 36-month cap or end of warranty, whichever is later Supplier must actually make a visit to bill the service Only one M&S payment made regardless of number of visits made during 6-month period See MLN Matters 6792 and 6990 for more information June 2016 Noridian Jurisdiction D DME MAC 77 77

78 FAQ Q: When can Maintenance and Service be billed for oxygen? A: If a beneficiary was using a stationary concentrator, portable concentrator, or trans-filling equipment during the 36th rental month, Medicare will pay for a maintenance and service visit no more often than every 6 months, beginning no sooner than 6 months following the end of the rental period. A supplier must actually make a visit to bill the service. There is no maintenance and service payment for gaseous or liquid equipment. June 2016 Noridian Jurisdiction D DME MAC 78 78

79 Reasonable Useful Lifetime RUL = 5 years Supplier responsible for furnishing all accessories, contents, repairs during RUL Options once RUL reached Make arrangements to pick up equipment and discontinue servicing beneficiary Replace equipment and begin new 36-month cap and RUL Continue servicing beneficiary, billing only for contents and M&S Stationary equipment governs RUL-based rules MLN Matters MM7213 June 2016 Noridian Jurisdiction D DME MAC 79 79

80 Reasonable Useful Lifetime Payment allowed when original equipment is: Lost (includes replacement due to bankruptcy) Stolen Irreparably damaged (due to a specific incident) RUL reached Replacement rules: New 36 month cap and RUL begins Must include RA modifier on 1st rental of replacement equipment and narrative explaining why replacement is being provided Need new detailed written order and initial CMN A new reasonable useful lifetime or 36 month rental period does not start when: Equipment modalities are changed Equipment needs to be replaced due to not functioning properly Beneficiary switches to new supplier and/or new equipment June 2016 Noridian Jurisdiction D DME MAC 80 80

81 FAQ Q: Which modifier is used on the first months claim for replacement of oxygen equipment with dates of service on or after January 01, 2009? A: The RA modifier must be appended to the first months claim for replacement of oxygen equipment. June 2016 Noridian Jurisdiction D DME MAC 81 81

82 Documentation 82

83 Standard Documentation Requirements Dispensing Order If item was delivered based on dispensing order or for suppliercreated DWO/WOPD Detailed Written Order (DWO) Written Order Prior to Delivery (WOPD) Based on policy/aca requirements Beneficiary Authorization Proof of Delivery Continued Use Continued Need Refill Requirements Items dispensed on a periodic basis Medical Records June 2016 Noridian Jurisdiction D DME MAC 83 83

84 Proof of Delivery (POD) Supplier Standard 12 Signed POD required to verify beneficiary received DMEPOS 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 Jurisdiction D DME MAC 84 84

85 Comprehensive Error Rate Testing (CERT) 85

86 CERT Letter June 2016 Noridian Jurisdiction D DME MAC 86 86

87 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 Jurisdiction D DME MAC 87 87

88 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 88 88

89 CERT Error Categories Insufficient documentation No documentation Service incorrectly coded Medically unnecessary service Other June 2016 Noridian Jurisdiction D DME MAC 89 89

90 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 Jurisdiction D DME MAC 90 90

91 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 Health Information (PHI) Response within 2 business days June 2016 Noridian Jurisdiction D DME MAC 91 91

92 Common CERT Oxygen Errors Missing the treating physician s clinical records to support beneficiary s condition that requires oxygen use and that the beneficiary continues to need and use supplemental home oxygen proximal to billed date of service (DOS). Missing the signed and dated order from the physician that reflects the change in oxygen liter flow rate. Missing a copy of the qualifying oxygen saturation study that applies to the conditions stated on the CMN. Missing the treating physician's re-evaluation within 90 days of the recertification CMN supporting the beneficiary's lung disease or hypoxia-related symptoms that improve with oxygen therapy. June 2016 Noridian Jurisdiction D DME MAC 92 92

93 Resources and Reminders 93

94 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 94 94

95 Resources (cont.) Documentation Checklists ( olicies/documentation-checklists) Acronyms Noridian Acronym List ( cronyms-glossary) CMS Acronym List ( June 2016 Noridian DME Outreach and Education 95 95

96 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 96 96

97 Browse By DMEPOS Category Oxygen June 2016 Noridian Jurisdiction D DME MAC 97 97

98 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 98 98

99 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 99 99

100 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

101 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

102 What is an ABN? Written notice of non-coverage Informs beneficiary that Medicare may not pay for item Allows beneficiary to make informed decision Protects supplier from liability Can only be used for beneficiaries enrolled in the Medicare Fee-For-Service program Can be used for PAP month 4 and beyond if beneficiary not compliant or face-to-face after the 31 st day has not occurred June 2016 Noridian Jurisdiction D DME MAC

103 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

104 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

105 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

106 Noridian Medicare Portal Replaced Endeavor Same functionality as Endeavor Endeavor was 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

107 DME on Demand NEW - Noridian Medicare Portal specific Additional Documentation Requests Appeal Status Appeal Submission Automatic Password Reset Claim-Specific Remit Claim Status Eligibility Financials Overpayments PMD PAR Registration Same or Similar June 2016 Noridian Jurisdiction D DME MAC

108 ALJ Appeal Status Info System (AASIS) Check the status of an ALJ appeal June 2016 Noridian Jurisdiction D DME MAC

109 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

110 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

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

112 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! ms June 2016 Noridian Jurisdiction D DME MAC

113 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

114 Education Opportunities Web-Based Workshops DME On Demand Oxygen Maintenance and Service Dear Physician Prescribing Home Oxygen Concurrent use of Oxygen and PAP Oxygen: Testing Requirements Oxygen: Coverage Guidelines Oxygen: Coding and Billing Guidelines Oxygen: CMN Requirements Continued Use/Continued Need DWO and Face to Face Requirements Break in Service/Break in Billing Medicare Midterms Oxygen Medical Review Program June 2016 Noridian Jurisdiction D DME MAC

115 Live Online Q&A Online question and answer sessions with members of the Education staff via written/verbal communication One hour sessions 2nd Monday of every month 3:00pm CT Next session June 13 th June 2016 Noridian Jurisdiction D DME MAC

116 Upcoming Web-Based Workshops June 8 Patient Lifts 3PM CST June 9 AFO and KFO 1PM CST June 23 Manual Wheelchair Bases 11AM CST DME Modifiers 1PM CST June 28 Hospital Beds 3PM CST June 29 General Documentation 11AM CST June 2016 Noridian Jurisdiction D DME MAC

117 Ask the Contractor Teleconference Upcoming ACT: June 9 th 3 p.m. CT [email protected] Call Information Phone Number: (800) After placing the call for the ACT, suppliers need to provide the following: Conference Name: Noridian Ask the Contractor Teleconference Name Name of the company represented State June 2016 Noridian Jurisdiction D DME MAC

118 Fee Schedule Lookup June 2016 Noridian Jurisdiction D DME MAC

119 One-on-One Medical Review Education June 2016 Noridian Jurisdiction D DME MAC

120 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

121 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 June 2016 Noridian Jurisdiction D DME MAC

122 Questions 122

123 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

124 To ask verbal question: Asking a 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

125 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

126 Thank you for attending! 126