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CANES AND CRUTCHES
CANES AND CRUTCHES Presented by Noridian Jurisdiction D DME MAC Provider Outreach & Education October 2015 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 models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the information contained in this release can be found on the Noridian website at https://med.noridianmedicare.com/web/jddme and the CMS website at www.cms.gov. g or p product in this information does not The identification of an organization imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply. October 2015 Noridian Jurisdiction D DME MAC 2 2 Workshop Protocol • Entering g Workshop p – 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, finished select “Lower Lower Hand” 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 email, is available at • https://med.noridianmedicare.com/web/jddme/education/eventmaterials October 2015 Noridian Jurisdiction D DME MAC 3 3 How to Ask a Written Question Click on Q&A Tab Address “All Address All Panelists Panelists” Type your question into box October 2015 Noridian Jurisdiction D DME MAC 4 4 Acronyms • CERT: Comprehensive Error Rate Testing • DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics and Supplies • DWO: Detailed Written Order • IRP: Inexpensive or Routinely Purchased • LCD: Local Coverage Determination • MLN: Medicare Learning Network • MRADL: Mobility Related Activities of D il Li Daily Living i • POD: Proof of Delivery https://med.noridianmedicare.com/web/jddme/help/acronymsglossary www.cms.gov/apps/acronyms October 2015 Noridian Jurisdiction D DME MAC 5 5 Agenda Comprehensive Error Rate Testing Coverage Criteria Documentation Billing Reminders Resources and Reminders October 2015 Noridian Jurisdiction D DME MAC 6 6 Comprehensive Error Rate Testing (CERT) 7 CERT 2014 Improper Payment Rates Published 12/15/2014 www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/CERT/index.html October 2015 Noridian Jurisdiction D DME MAC 8 8 CERT Letter October 2015 Noridian Jurisdiction D DME MAC 9 9 CERT Address • Customize the location for possible CERT letters – Call CERT Documentation Contractor (Livanta) at 888-779-7477 or, – Update this information at: htt // https://www.certprovider.com/ChangeContactInfo.aspx?contractorID=&providerID t id /Ch C t tI f ? t t ID & id ID *This only changes the address for CERT inquires *Changes to a suppliers physical address should go to the National pp Clearinghouse g ((NSC)) Supplier October 2015 Noridian Jurisdiction D DME MAC 10 10 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 October 2015 Noridian Jurisdiction D DME MAC 11 11 CERT Error Categories • • • • • Insufficient documentation No documentation Service incorrectly coded Medically unnecessary service Other October 2015 Noridian Jurisdiction D DME MAC 12 12 Decrease CERT Errors • Educate staff • Train coders/billers • Submit correct information – Beneficiary name, name social security number number, Medicare number, date of service • Submit legible and complete records – Dates, required signatures, etc. • Send CERT Inquiries October 2015 Noridian Jurisdiction D DME MAC 13 13 CERT Inquiries • [email protected] • Email should include: – – – – CERT Claim Identification (CID) – In Subject Line Supplier pp name and address Telephone number Explanation of the issues, concern or question • DO NOT send Protected Health Information (PHI) • Response within 2 business days October 2015 Noridian Jurisdiction D DME MAC 14 14 Quick Look CERT Documentation Chart https://med.noridianmedicare.com/web/jddme/cert-reviews/cert/documentationchart October 2015 Noridian Jurisdiction D DME MAC 15 15 COVERAGE LOCAL COVERAGE DETERMINATION – L33733 (ICD-9 L11485) POLICY ARTICLE – A52459 (ICD-9 (ICD 9 A23897) 16 Coverage • Eligible for defined Medicare benefit category • Reasonable and necessary • Meet Medicare statutory and regulatory requirements • Written order prior to claim submission October 2015 Noridian Jurisdiction D DME MAC 17 17 Mobility-Related Activities of Daily Living (MRADL) Limitation • • • • Prevents MRADL entirely, or Risk of morbidity or mortality, or Prevents MRADL within reasonable timeframe MRADL examples: – – – – – Toileting Feeding Dressing g Grooming Bathing October 2015 Noridian Jurisdiction D DME MAC 18 18 Canes and Crutches • Canes: E0100, E0105 • Crutches: E0110 - E0116 • Covered if all criteria met: 1) Mobility limitation impairs MRADL in home 2) Safely use cane or crutch 3) Mobility limitation resolved with cane or crutch Noridian Jurisdiction D DME MAC E0100 October 2015 E0105 E0116 19 19 Underarm, Articulating, Spring Assisted Crutch • E0117 • Medical necessity not established • Denies as not reasonable and necessary keenhealthcare.com October 2015 Noridian Jurisdiction D DME MAC 20 20 Crutch Substitute • E0118 • AKA roll-a-bout, knee scooter or knee walker • Denies not reasonable and necessary – Supplier liable unless valid ABN obtained October 2015 Noridian Jurisdiction D DME MAC 21 21 DOCUMENTATION 22 Intake Process • • • • • • Askk the A th right i ht questions ti Be thorough Eligibility Same and similar Coverage criteria Medical records You are building your foundation! October 2015 Noridian Jurisdiction D DME MAC 23 23 Specialize Your Intake Process • Ask questions based on item dispensed – Have you had a wheelchair before? – Did you receive diabetic supplies last month from someone else? – Medicare HMO/Private Insurance? • Suggested Intake Form – https://med.noridianmedicare.com/documents /2230715/2240771/Suggested+Intake/2aa1d4 bc-b116-47dc-8fbc-1398fda9ca45 October 2015 Noridian Jurisdiction D DME MAC 24 24 Required Documentation • Dispensing Order – If item was delivered based on dispensing order • Detailed Written Order (DWO) • Beneficiary Authorization • Proof of Delivery (POD) – Method 1: DOS = Date of Delivery – Method 2: DOS = Shipping Date • Continued Use • Continued Medical Need • Medical Records October 2015 Noridian Jurisdiction D DME MAC 25 25 Medical Records Program Integrity Manual (100-08, Chapter 5) *Must be available upon request October 2015 Noridian Jurisdiction D DME MAC 26 26 Medical Records (2) • Medical records should include: – – – – – Beneficiary’s diagnosis and prognosis Duration of beneficiary’s medical condition Clinical course (worsening or improvement) Nature and extent of functional limitations Other therapeutic interventions, results, past experience with related items. October 2015 Noridian Jurisdiction D DME MAC 27 27 Advance Beneficiary Notice of g (ABN) ( ) Noncoverage • 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 https://med.noridianmedicare.com/web/jddme/topics/abn October 2015 Noridian Jurisdiction D DME MAC 28 28 Equipment Retained From a Prior Payer • Must obtain a new POD or, • Must obtain a statement, signed and dated by the beneficiary (or beneficiary's designee) – Supplier must examined the DMEPOS item – Equipment is in good working order – Equipment meets Medicare requirements October 2015 Noridian Jurisdiction D DME MAC 29 29 BILLING REMINDERS 30 Inexpensive or Routinely Purchased • Purchased or rented – RR: Rented item – NU: New purchased item – UE: Used purchased item • Must give beneficiary option and keep in records – Supplier Standard 5 – “Medicare Capped Rental and Inexpensive or Routinelyy Purchased Items Notification for Services on or after January 1, 2006” • Notification on website: https://med.noridianmedicare.com/web/jddme/forms October 2015 Noridian Jurisdiction D DME MAC 31 31 Capped Rental and IRP Notification October 2015 Noridian Jurisdiction D DME MAC 32 32 Modifiers • Policy Modifier – EY: No order for the item • ABN Modifiers – GA: Waiver of liability y on file (ABN) ( ) – GZ: Item expected to deny as not reasonable and necessary October 2015 Noridian Jurisdiction D DME MAC 33 33 Miscellaneous Codes • A9270 – Use for white cane for blind person • Considered “self help” item – Denied as noncovered • E1399 – Do not use regardless of special feature or weight capacity October 2015 Noridian Jurisdiction D DME MAC 34 34 Coding Guidance • Pricing, Data Analysis and Coding (PDAC) – Provides guidance on correct coding • Contact Information – PDAC PO Box 6757 Fargo ND 58108-6757 – 877.735.1326 Toll Free – www.dmepdac.com/contact/index.html (Email) • www.dmepdac.com October 2015 Noridian Jurisdiction D DME MAC 35 35 Resources and Reminders Noridian Jurisdiction D DME MAC 36 Resources • LCD/Policy Article – https://med https://med.noridianmedicare.com/web/jddme/policies/lcd noridianmedicare com/web/jddme/policies/lcd /active • Supplier Manual – https://med.noridianmedicare.com/web/jddme/education/ supplier-manual • “Dear Physician” letters – https://med.noridianmedicare.com/web/jddme/policies/ph ysician-resources • Documentation D t ti Checklist Ch kli t – https://med.noridianmedicare.com/web/jddme/policies/do cumentation-checklists October 2015 Noridian Jurisdiction D DME MAC 37 37 New Supplier Curriculum • General and policy specific • Short presentations grouped by g y relevance • Quiz at conclusion with certificate • Great for new and existing suppliers • Suppliers encouraged to view both general and policy specific curriculum https://med.noridianmedicare.com/web/jddme/topics/welcome October 2015 Noridian Jurisdiction D DME MAC 38 38 Denial Code Guidance Why did my claim l i deny? • 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 Why was my – Applicable resources claim processed • More pages to come! this way? https://med.noridianmedicare.com/web/jddme/topics/ra/denialguidance October 2015 Noridian Jurisdiction D DME MAC 39 39 PECOS Requirement • Claims mayy be denied if: – The ordering/referring physician is NOT in PECOS and eligible to order and refer – The ordering/referring physician is not of the specialty to order/refer – If the physician's name submitted on the claim does not match their name in PECOS • https://med.noridianmedicare.com/web/jddme/claimsappeals/claim-submission/pecos-edits • See how to avoid these claim denials by properly submitting the ordering physician name from the CMS PECOS Report • Implemented January 6, 6 2014 • View the PECOS DME on Demand on our website! – http://www.brainshark.com/noridian/vu?pi=zHlzqyKBpz87uMz0 October 2015 Noridian Jurisdiction D DME MAC 40 40 ICD-10 Questions? • ICD ICD-10 10 Implementation I l t ti took t k place l 10/1/15 • ICD-10 Resources – Noridian Medicare website • https://med.noridianmedicare.com/web/jddme/topics/icd10 – CMS website • https://www.cms.gov/medicare/coding/icd10/index.html – “Road to 10” website • www.roadto10.org www roadto10 org Month Year Noridian Jurisdiction D DME MAC 41 41 ALJ Appeal Status Info System (AASIS) • Check the status of an ALJ appeal www.hhs.gov/omha/Appeal_Status_Lookup/index.html October 2015 Noridian Jurisdiction D DME MAC 42 42 What’s New With Endeavor? Noridian Claim Status Reviews Same & Same • In process, paid, denied “ALV” Submission Supplies, O & P, Vision HCPCS Check beneficiary history for these codes October 2015 Noridian Jurisdiction D DME MAC • Respond to requests with documentation Claim comments • View nurse’s notes 43 43 Email Updates • • • • Tuesday and Friday Latest updates and announcements Customizable Sign-up in the lower right corner of our new website! October 2015 Noridian Jurisdiction D DME MAC 44 44 Website Survey October 2015 Noridian Jurisdiction D DME MAC 45 45 esMD (Electronic Submission of Medical Documentation) • esMD is the ability y to transmit documentation electronically for review • Who accepts documentation via esMD? – – – – DME MAC (Noridian) CERT Recovery Auditor ZPIC • What types of requests can be sent via esMD? – Complex C l M Medical di l R Review i & PMD PAR • Find out more: www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-andSystems/ESMD/index.html?redirect=/esmd October 2015 Noridian Jurisdiction D DME MAC 46 46 MREP • Medicare M di R Remit it E Easy P Print i t – Free software! – View, search and print remits – Print and export reports • CMS Brochure – www.cms.gov/MLNProducts/downloads/MedicareRe mit_0408.pdf • MREP Software – www.cms.gov/AccesstoDataApplication/02_Medicare RemitEasyPrint.asp October 2015 Noridian Jurisdiction D DME MAC 47 47 Medicare Learning Network (MLN) • • • • • Guides Articles Educational Tools Booklets Brochures Fact Sheets • Training Presentations • Web-Based Training • Special Initiatives • Web Resources www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNGenInfo/index.html October 2015 Noridian Jurisdiction D DME MAC 48 48 Endeavor Functions • • • • • • • • • Availability Eligibility Claim Status Same or Similar ALV Cl i S Claim-Specific ifi R Remittance itt Advices Overpayments Reopening/Redetermination PMD Prior Auth Request Status ADR • Eligibility – 24 hours/day, 7 days/week • All other functions – 6 a.m. – 8 p.m. CT, Mon.– Fri. – 7a a.m. m –3p p.m. m CT CT, Sat Sat. https://med.noridianmedicare.com/web/jddme/topics/portal October 2015 Noridian Jurisdiction D DME MAC 49 49 Education Opportunities • Web-Based Workshops • Q & A Sessions – 2nd Monday of each month @ 3 p.m. CT • DME On Demand • Education Request • ACT – 12/10/15 @ 3 p.m. CT – General Session • https://med.noridianmedicare.com/web/jddme/ education October 2015 Noridian Jurisdiction D DME MAC 50 50 Single Toll Free Line 877‐320‐0390 Supplier Contact Center/IVR Monday‐Friday October 2015 Telephone Reopenings 8 a.m. – 6 p.m. Central Time Noridian Jurisdiction D DME MAC Effective March 1, 2015 51 51 Beneficiary Contact Information • Suppliers please use Noridian Contact Center number for supplier inquiries only • Beneficiaries who need assistance can be directed to: – 1-800-Medicare 1 800 Medicare (800 (800-633-4227) 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 (800-999-1118) 999 1118) • Primary insurance information update October 2015 Noridian Jurisdiction D DME MAC 52 52 Have a Verbal Question? Be sure that you have entered the Attendee ID # on this screen to ensure you are correctly connected to the phone lines, which will allow you to ask verbal b l questions October 2015 Noridian Jurisdiction D DME MAC 53 53 Asking a Verbal Question Click on Participants tab at top right Must have a phone as shown Click on Hand on bottom right October 2015 Noridian Jurisdiction D DME MAC 54 54 How to Ask a Written Question Click on Q&A Tab Address “All Address All Panelists Panelists” Type your question into box October 2015 Noridian Jurisdiction D DME MAC 55 55 Questions 56 THANK YOU FOR ATTENDING! 57
