DME Basics Part 1: Background Knowledge Presented by Noridian DME Outreach and Education May 2016 1
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 (https://med.noridianmedicare.com/web/jddme) CMS Website (https://www.cms.gov) May 2016 Noridian DME Outreach and Education 2 2
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 CEUs are NOT offered for this course 1 AAPC CEU is offered for this course Certificate of Completion emailed to all attendees with 2-3 business days following the workshop May 2016 Noridian DME Outreach and Education 3 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 May 2016 Noridian DME Outreach and Education 4 4
Sync Your Phone with Your Name Click on Event Info Tab Verify Identity code Enter # your number # May 2016 Noridian DME Outreach and Education 5 5
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 May 2016 Noridian DME Outreach and Education 6 6
Acronyms CMS: Centers for Medicare & Medicaid Services IOM: Internet Only Manual IRP: Inexpensive or Routinely Purchased LCD: Local Coverage Determination LPM: Liters Per Minute NCD: National Coverage Determination PA: Policy Article SNF: Skilled Nursing Facility May 2016 Noridian DME Outreach and Education 7 7
Agenda Comprehensive Error Rate Testing PECOS Contractors General Coverage Benefit Categories Fee Schedule Categories Medical Policies Resources and Reminders May 2016 Noridian DME Outreach and Education 8 8
Comprehensive Error Rate Testing (CERT) 9
CERT 2015 Improper Payment Rates CERT Improper Payment Rate webpage (https://www.cms.gov/research-statistics-data- 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 May 2016 Noridian DME Outreach and Education 10 10
CERT Address Customize the location for possible CERT letters Call CERT Documentation Contractor (Livanta) at 888-779-7477 or, Update this information at: https://www.certprovider.com/changecontactinf o.aspx?contractorid=&providerid *This only changes the address for CERT inquires *Changes to a suppliers physical address should go to the National Supplier Clearinghouse (NSC) May 2016 Noridian DME Outreach and Education 11 11
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 May 2016 Noridian DME Outreach and Education 12 12
CERT Error Categories Insufficient documentation No documentation Service incorrectly coded Medically unnecessary service Other May 2016 Noridian DME Outreach and Education 13 13
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. Send CERT Inquiries May 2016 Noridian DME Outreach and Education 14 14
CERT Inquiries jddmecert@noridian.com Email 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 May 2016 Noridian DME Outreach and Education 15 15
Provider Enrollment Chain and Ownership System (PECOS) 16
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 (https://med.noridianmedicare.com/web/jddme/cl aims-appeals/claim-submission/pecos-edits) View the PECOS DME on Demand (http://www.brainshark.com/noridian/vu?pi=zhlz qykbpz87umz0) May 2016 Noridian DME Outreach and Education 17 17
PECOS Educational Tools https://med.noridianmedicare.com/web/jddme/ed ucation/event-materials Web-Based Workshop Presentation Self-Paced Tutorial (DME on Demand) Q&A Session Consolidated Resources May 2016 Noridian DME Outreach and Education 18 18
Contractors 19
Primary DME Contractors Durable Medical Equipment Medicare Administrative Contractor (DME MAC) National Supplier Clearinghouse (NSC) Pricing, Data Analysis and Coding (PDAC) Common Electronic Data Interchange (CEDI) Competitive Bid Implementation Contractor (CBIC) Review Contractors (RA, CERT, SMRC, ZPIC) May 2016 Noridian DME Outreach and Education 20 20
DME MAC Process claims according to where beneficiary resides Based on Social Security Administration address on file (where social security benefits are received) Types of claims processed by DME MACs Durable Medical Equipment Prosthetics Orthotics Supplies May 2016 Noridian DME Outreach and Education 21 21
Noridian s DME MAC Role Noridian s role: Process Medicare claims Communicate Medicare guideline changes Noridian does not: Establish Medicare rules and regulations CMS determines rules and regulations Legislation Determine beneficiary eligibility Social Security Administration May 2016 Noridian DME Outreach and Education 22 22
NSC National Supplier Clearinghouse Supplier enrollment CMS 855-S application Changes to enrollment must go through NSC Medicare DMEPOS Supplier Standards Can also be found in chapter 2 of our supplier manual Verifies Accreditation requirement Verifies Surety Bond requirement Contact information 1-866-238-9652 or www.palmettogba.com/nsc May 2016 Noridian DME Outreach and Education 23 23
PDAC Pricing, Data Analysis and Coding Proper use of HCPCS Assist CMS with DMEPOS fee schedules DMECS HCPCS information Modifiers Fee schedules DMEPOS product classifications Contact information 1-877-735-1326 or www.dmepdac.com May 2016 Noridian DME Outreach and Education 24 24
Common Electronic Data Interchange Single front end electronic solution Free Software Front end error report manual CEDI CEDI works closely with: DME MAC software venders Billing services Clearinghouses Trading partners Contact Info: Website: www.ngscedi.com Phone: 1-866-311-9184 Email: ngs.cedihelpdesk@wellpoint.com May 2016 Noridian DME Outreach and Education 25 25
CBIC Competitive Bid Implementation Contractor Application assistance Contracting process, contract changes and terminations Questions/complaints concerning policy and/or program regulations Report concerns about a supplier/referral agent, quality of service, suspected fraud Obtain assistance locating a supplier Clarify guidelines on a particular policy Educational material or programs May 2016 Noridian DME Outreach and Education 26 26
CBIC Contact Information Contact information www.dmecompetitivebid.com/palmetto/cbic.nsf/docs Cat/Home www.cms.gov/medicare/medicare-fee-for-service- Payment/DMEPOSCompetitiveBid/index.html 1-877-577-5331 9 a.m. and 5:30 p.m. prevailing Eastern Time, M-F May 2016 Noridian DME Outreach and Education 27 27
Review Contractors Improper payment identified by: Recovery Auditor (formerly known as RAC) https://med.noridianmedicare.com/web/jddme/certreviews/rac Comprehensive Error Rate Testing (CERT) https://med.noridianmedicare.com/web/jddme/certreviews/cert Medical Review Special Study (SMRC) www.strategichs.com Suspected fraud identified by: Zone Program Integrity Contractors (ZPICs) www.cms.gov/mlnmattersarticles/downloads/se1204.pdf May 2016 Noridian DME Outreach and Education 28 28
General Coverage 29
General Coverage Criteria All DMEPOS must be: Eligible for a defined Medicare benefit category Reasonable and Necessary Diagnosis or treatment of illness or injury; or Improve the functioning of a malformed body member Meet Medicare guidelines Statutory and regulatory requirements Prescribed by physician or other qualified medical professional prior to claim submission May 2016 Noridian DME Outreach and Education 30 30
Noncovered Items Wigs Hot water bottles Disposable underpads Toilet rails Tub stool or bench Bed board Noncovered items listing: https://med.noridianmedicare.com/web/jddme/topics/n oncovered-items May 2016 Noridian DME Outreach and Education 31 31
DME MAC Covered Drugs Oral anticancer Oral antiemetic Nebulizer Immunosuppressive External infusion pump drugs Insulin infusion through pump May 2016 Noridian DME Outreach and Education 32 32
Mandatory Assignment on Medicare Covered Drugs Assigned claim only Unassigned drug or biological claim processed as assigned May 2016 Noridian DME Outreach and Education 33 33
Benefit Categories 34
Benefit Categories Durable Medical Equipment Withstand repeated use Used to serve medical purpose Not useful in absence of illness or injury Appropriate for use in home Prosthetic Devices Replace all or part of function of permanently inoperative or malfunctioning body part May 2016 Noridian DME Outreach and Education 35 35
Braces (Orthotics) Benefit Categories (2) Rigid or semi-rigid device Supports weak or malformed body member Restrict or eliminate motion in diseased or injured part of body Surgical Dressings Therapeutic and protective coverings applied to surgical or debrided wounds Includes primary and secondary dressings Therapeutic Shoes for Persons with Diabetes Custom molded or extra-depth shoes and inserts May 2016 Noridian DME Outreach and Education 36 36
Benefit Categories (3) Immunosuppressive Drugs For transplant purposes only Oral Anticancer Drugs Must have same chemical composition and indications as parenteral form of drug Oral Antiemetic Drugs When used as full replacement for IV form during chemotherapy treatment May 2016 Noridian DME Outreach and Education 37 37
Fee Schedule Categories 38
Fee Schedule Payment Categories Most DMEPOS fall into one of the following categories: Inexpensive or Other Routinely Purchased DME (IRP) Items Requiring Frequent and Substantial Servicing Customized Items Prosthetic and Orthotic Devices Capped Rental Items Oxygen and Oxygen Equipment May 2016 Noridian DME Outreach and Education 39 39
Inexpensive or Other Routinely Purchased DME (IRP) Inexpensive DME Purchase price does not exceed $150.00 Routinely Purchased DME Purchased at least 75% of time Rental or lump sum purchase Total rental payment can not exceed actual purchase price Pricing Modifiers: NU, UE, RR Must advise beneficiary of rent or purchase option, per supplier standard #5 May 2016 Noridian DME Outreach and Education 40 40
Frequent and Substantial Servicing Rental only Modifier: RR Payment based on monthly fee schedule amount until medical necessity ends Supplies and accessories included May 2016 Noridian DME Outreach and Education 41 41
Customized Items Individual consideration based on medical need Physician must prescribe customized equipment and provide information regarding physical and medical status Items needed for coverage to be considered Detailed description Feature description making item unique Acquisition or production cost Lump sum payment Date of service = date of delivery May 2016 Noridian DME Outreach and Education 42 42
Prosthetics and Orthotics All prosthetic and orthotic devices excluding: Items requiring frequent and substantial servicing Certain customized items Transcutaneous electrical nerve stimulators (TENS) Parenteral/enteral nutritional supplies and equipment Intraocular lenses Lump sum payment Date of service = date of delivery May 2016 Noridian DME Outreach and Education 43 43
Capped Rental Items Paid on monthly rental basis 13 month period Item is beneficiary owned after 13 months Modifiers: RR: Rental KH: Month 1 KI: Months 2-3 KJ: Months 4-13 May 2016 Noridian DME Outreach and Education 44 44
Capped Rental Purchase Option Complex rehab power wheelchairs only K0835 -K0864 Must give beneficiary option to purchase in first month First month claim must include one of the following modifiers: BR Beneficiary has elected to rent BP Beneficiary has elected to purchase May 2016 Noridian DME Outreach and Education 45 45
Complex Rehabilitative Power Wheelchair Accessories April 1, 2014 Complex rehabilitative power wheelchair base codes and options/accessories Payable under the lump sum purchase method Suppliers give beneficiary's option of purchasing accessories at the time they are furnished Beneficiary declines purchase option Items paid under Capped Rental rules May 2016 Noridian DME Outreach and Education 46 46
Oxygen and Oxygen Equipment Rental only 36 month cap Modifiers RR: Rental QE: prescribed oxygen < 1 LPM QF: prescribed oxygen > 4 LPM & portable prescribed QG: prescribed oxygen > 4 LPM QH: Conserving device used with delivery system May 2016 Noridian DME Outreach and Education 47 47
Determining the Fee Schedule Payment Category www.dmepdac.com May 2016 Noridian DME Outreach and Education 48 48
PDAC Website Search May 2016 Noridian DME Outreach and Education 49 49
PDAC Website Search Results May 2016 Noridian DME Outreach and Education 50 50
Medical Policies 51
National Coverage Determination (NCD) Medicare coverage database: www.cms.gov/site-search/searchresults.html?q=coverage%20database Internet-Only Manual Publication 100-03: www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS014961.html NCD Major sections Indications & Limitations of Coverage and/or Medical Necessity Nationally Covered and Non-covered Indications General and other May 2016 Noridian DME Outreach and Education 52 52
LCD and Policy Article Both documents together constitute a medical policy Policy Article can be accessed at bottom of LCD Available on the Noridian DME website at: https://med.noridianmedicare.com May 2016 Noridian DME Outreach and Education 53 53
LCDs & Policy Articles Combined documents To view: Click the title of the medical policy May 2016 Noridian DME Outreach and Education 54 54
Local Coverage Determination (LCD) Major sections Indications and Limitations of Coverage and/or Medical Necessity Defines coverage criteria based on determination of whether item is reasonable and necessary Includes information on NCDs when applicable Item does not meet criteria, denies not medically necessary HCPCS modifiers and codes Diagnosis that support medical necessity Documentation requirements Standard Documentation Language Revision history May 2016 Noridian DME Outreach and Education 55 55
Major sections Policy Article (PA) Nonmedical necessity coverage and payment rules Items that do not meet statutory definition of benefit category Items not separately payable Items not in DME MACs jurisdiction Coding Guidelines Proper use of modifiers Further definitions codes May 2016 Noridian DME Outreach and Education 56 56
CMS IOM Internet-Only Manuals (IOM) Program issuances Operating instructions Policies Procedures Statutes Regulations Guidelines Models Directives May 2016 Noridian DME Outreach and Education 57 57
Internet-Only Manuals (2) www.cms.gov/regulations-and-guidance/guidance/manuals/internet- Only-Manuals-IOMs.html May 2016 Noridian DME Outreach and Education 58 58
Resources and Reminders 59
Resources LCD/Policy Article (https://med.noridianmedicare.com/web/jddme/p olicies/lcd/active) Noridian Supplier Manual (https://med.noridianmedicare.com/web/jddme/e ducation/supplier-manual) Dear Physician Letters (https://med.noridianmedicare.com/web/jddme/p olicies/physician-resources) May 2016 Noridian DME Outreach and Education 60 60
Resources (cont.) Documentation Checklists (https://med.noridianmedicare.com/web/jddme/p olicies/documentation-checklists) Acronyms Noridian Acronym List (https://med.noridianmedicare.com/web/jddme/help/a cronyms-glossary) CMS Acronym List (https://www.cms.gov/apps/glossary/) May 2016 Noridian DME Outreach and Education 61 61
2016 MSI Survey Your feedback matters! Coming in May the 2016 MSI The MAC Satisfaction Indicator (MSI) is coming May 2016. You will have opportunity to take this 10 minute survey administered by the Centers for Medicare & Medicaid Services (CMS). Watch for the survey on our website to participate. We re looking forward to hearing your experiences about the services we provide to you. May 2016 Noridian DME Outreach and Education 62 62
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 (https://med.noridian medicare.com/web/jd dme/topics/welcome) May 2016 Noridian DME Outreach and Education 63 63
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 (https://med.noridianmedicare.com/web/jddme/t opics/ra/denial-guidance) May 2016 Noridian DME Outreach and Education 64 64
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 (https://med.noridianmedicare.com/web/jddme/cl aims-appeals/claim-submission/pecos-edits) View the PECOS DME on Demand (http://www.brainshark.com/noridian/vu?pi=zhlz qykbpz87umz0) May 2016 Noridian DME Outreach and Education 65 65
ICD-10 Questions? ICD-10 Implementation took place 10/1/15 ICD-10 Resources Noridian Medicare ICD-10 Webpage (https://med.noridianmedicare.com/web/jddme/topics/i cd-10) CMS ICD-10 Webpage (https://www.cms.gov/medicare/coding/icd10/index.ht ml) Road to 10 Website (www.roadto10.org) May 2016 Noridian DME Outreach and Education 66 66
Tuesday and Friday Latest updates and announcements Customizable Sign-up in the lower right corner of our website Click subscribe Email Updates May 2016 Noridian DME Outreach and Education 67 67
Website Survey Your feedback is valuable Click Yes, I ll give feedback May 2016 Noridian DME Outreach and Education 68 68
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 (www.cms.gov/research- Statistics-Data-and-Systems/Computer-Dataand-Systems/ESMD/index.html?redirect=/esmd) May 2016 Noridian DME Outreach and Education 69 69
MREP Medicare Remit Easy Print Free software! View, search and print remits Print and export reports CMS Brochure (www.cms.gov/mlnproducts/downloads/medica reremit_0408.pdf) MREP Software (www.cms.gov/accesstodataapplication/02_me dicareremiteasyprint.asp) May 2016 Noridian DME Outreach and Education 70 70
Medicare Learning Network (MLN) Guides Articles Educational Tools Booklets Brochures Fact Sheets Training Presentations Web-Based Training And more! MLN Webpage (www.cms.gov/outrea ch-and- Education/Medicare- Learning-Network- MLN/MLNGenInfo/ind ex.html) May 2016 Noridian DME Outreach and Education 71 71
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 (https://med.noridian medicare.com/web/jd dme/topics/nmp) May 2016 Noridian DME Outreach and Education 72 72
We Are Coming To You! Catch the JD Express to Medicare Success Half day Sessions Register online In-Person Seminars (https://med.noridian medicare.com/web/jd dme/education/inperson-seminars) Locations and Dates: To Be Determined Fall Seminar locations to be announced this summer! May 2016 Noridian DME Outreach and Education 73 73
Education Opportunities Web-Based Workshops Q & A Sessions 2nd Monday of each month @ 3 p.m. CT DME On Demand Education Request Ask the Contractor Teleconference (ACT) Education and Outreach Webpage (https://med.noridianmedicare.com/web/jddme/e ducation) May 2016 Noridian DME Outreach and Education 74 74
877-320-0390 Single Toll Free Line Interactive Voice Response (IVR) Supplier Contact Center Telephone Reopenings Monday Friday 8 a.m. 6 p.m. CT May 2016 Noridian DME Outreach and Education 75 75
Beneficiary Contact Information Beneficiaries who need assistance can be directed to: 1-800-Medicare (800-633-4227) Question on claims and coverage of equipment Social Security Administration (800-722-1213) Update name/address, questions on premiums, Medicare entitlement Benefits Coordination Recovery Center (800-999- 1118) Primary insurance information update May 2016 Noridian DME Outreach and Education 76 76
Have a Verbal Question? Audio Conference Steps: Dial the phone number provided Enter the access number provided Enter your attendee ID provided Failure to follow these steps may disable some audio features May 2016 Noridian DME Outreach and Education 77 77
Asking a Verbal Question To ask verbal question: Click on the Participant tab at the top Click on the hand image at the bottom The telephone handset or computer headset must be present beside your name May 2016 Noridian DME Outreach and Education 78 78
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 May 2016 Noridian DME Outreach and Education 79 79
Questions? 80
Thank you for attending! 81