Össur R&R
A New Template for O&P
Posted by David McGill | May 21, 2013
The Centers for Medicare and Medicaid Services have posted a draft Lower Limb Prosthesis Electronic Clinical Template on its website. The four-page document "describes the data elements that CMS believes would be useful in supporting the documentation requirements for coverage of Lower Limb Prostheses."
The "Background" section of the template notes that the ordering physician's documentation must support the medical necessity of the device delivered to the beneficiary, and that prosthetists' records aren't sufficient by themselves for establishing medical necessity because the prosthetist has a "financial interest in the claim outcome."
- Chief complaint;
- History of present illness (with 5 sub-sections);
- Past medical and surgical history (with 2 sub-sections);
- Social History (with two sub-sections);
- Review of Systems (with 8 sub-sections that have 21 sub-sections of their own);
- Physical exam (with 8 sub-sections that have 13 subsections of their own);
- Beneficiary assessment; and
- Plan.
How Gifts Can End Your Career
Posted by David McGill | May 21, 2013
Why should you care that a Physician's Assistant spent 6 months in prison and another 6 in home confinement?
This particular PA accepted kickbacks from Orthofix in connection with that company's efforts to sell more bone stimulators. The government's investigation of the matter has resulted in 6 different people, including the PA, spending time in jail or wearing an ankle bracelet, financial penalties against each of the individuals, and $42M in criminal fines and civil penalties against Orthofix.
Coming on the heels of the US government suing Novartis for alleged kickbacks and false claims, including opulent dinners for doctors at fancy restaurants and repeated meals at the decidedly-less-opulent Hooters chain, we thought it might be a good time for a refresher course on the Federal Anti-Kickback Law.
What it is.
The AKL creates criminal and civil liability for anyone in the health care industry who knowingly and willfullly pays or receives something of value in order to induce the referral of items or services paid for by a Federal health care program (e.g., Medicare). While people associate the word "kickback" with suitcases full of cash, the AKL makes clear that a much wider range of activity also constitutes a bribe.
Fancy meals, tickets to sporting or concert events, issuing credits to a customer for no reason, providing free administrative/claims-related services - each of these gives the party receiving them something of value. If even one purpose of the transaction is to influence what product or service someone in the health care delivery system uses, then it violates the AKL.
What it means to you.
For anyone thinking that O&P operates outside of these rules, think again. AOPA has a Code of Interactions with Healthcare Professionals. This code follows most major industry guidelines, including prohibitions on exorbitant or frequent meals, sporting/concert tickets, and giving away free branded items (even if of minimal value). You should follow the principles laid out in the AOPA code not only in your interactions with physicians and other health care providers, but in your dealings with manufacturers as well.
There are exceptions to the AKL, so-called "safe harbors." Product discounts and properly structured rebate programs, though both clearly designed to induce someone to use a particular product or service, serve the public good by permitting access to medically necessary care at a lower cost. Both of these standard business practices fall within the safe harbor provisions of the AKL. But the program where a manufacturer offers to do your documentation for you to reduce your costs? Not so much.
As government scrutiny of health care generally, and O&P specifically, explodes, you need to carefully consider the "freebies" offered to you and the risks they pose. As the Orthofix case proves, taking gifts can put your business at risk today and you in jail tomorrow.
Keep on Learning
Posted by Linda Collins | May 14, 2013
Össur offers you numerous opportunities to participate in reimbursement workshops, webinars and presentations. We host regional “Ask the Reimbursement Expert” webinars, which give you an opportunity to submit your most pressing questions about reimbursement issues and receive practical answers from the experts. In conjunction with OPGA, we will offer three “Reimbursement Success” webinars offered throughout the summer. These webinars include loads of useful data and additionally give you 1.5 CEU credits.
We will also provide In-depth workshops on “Appeals Success” on a limited basis. These workshops give you and your billing staff tips and strategies for writing winning appeals. In addition, watch for us at several meetings throughout the year as we present on “Coding, Coverage and Reimbursement” success.
We have listed the details about each event on the “Events” page.
If you are interested in hosting an Össur Reimbursement Seminar in your area, please contact your local Össur Sales Representative.
Oh-Fer For O&P
Posted by David McGill | May 09, 2013
The Medicare HCPCS Coding Workgroup - the entity responsible for new reimbursement code creation - published its initial decisions for this year's crop of new code requests this week. The Workgroup declined to create new codes for any of the O&P submissions, listed below.
- Sure-Lok (upper-limb manually-controlled locking cable control system):
Finding - already described by L6675, L6676, or L6677 depending on level of amputation. - BiOM iWalk (bionic ankle-foot device):
Finding - already described by L5973. - PFS Med TAFO (tibial ankle-foot orthosis):
Finding - already described by L4398. - Noodle AFO (carbon fiber composite ankle-foot orthosis):
Finding - already described by L1930. - Kickstart Kinetic Orthosis (hip flexion/plantar flexion assist hip-knee-ankle-foot orthosis):
Finding - already described by L2000 plus L2200, L2250, L2780 and L2630, OR L2000 plus L2640 and L2385, OR L2000 plus L2600, depending on amputation level and whether patient is unilateral or bilateral. - Bledsoe PHX Elbow Orthosis:
Finding - already described by L3760.
What does this mean?
The next step in the code creation process is the HCPCS Coding Workgroup Public Meeting in June. At that time, the manufacturers who submitted these products for consideration will have the opportunity to contest these negative initial decisions. The HCPCS Coding Workgroup will then take the information presented under advisement and publish its final decisions in November.
In the meantime, when submitting claims to Medicare be aware that this information is a matter of public record. The DME MACs and other payers may choose to follow the Coding Workgroup's initial decisions between now and November. You should have thorough discussions internally about the potential risks and liability before billing in a manner inconsistent with these coding determinations.
L5930: Ancient History You Need to Know
Posted by Linda Collins | May 06, 2013
We continue to get regular questions about the appropriate use of L5930 (“high activity knee control frame”) from prosthetists around the United States. While Medicare’s guidance about this code qualifies as “old news,” we thought a quick and clear description of the applicable requirements would help.
In 2006, each of the 4 DME MACs adopted the following policy: prosthetists can only bill L5930 for K4 level patients. You can find this requirement in the Local Coverage Decision for your Medicare region.
Recently, the Recovery Auditors have cracked down on the use of this code. They are demanding that suppliers provide documentation substantiating the patient’s K level. If the documentation doesn’t exist or doesn’t demonstrate the patient’s K4 status, the Recovery Auditors are recouping the payments for L5930.
What do you need to do?
You and your staff should review the LCD for your region. You can access the Medicare database to search for these documents by clicking here.
AFO Prepayment Audits...continued
Posted by Linda Collins | May 02, 2013
As we stated in our March 19, 2013 post, New Audit Issue…Watch Your Step, Medicare continues to audit Ankle-Foot Orthoses. Last week Jurisdiction D announced the results of a widespread pre-payment review of HCPCS codes L4360, L1970 and L1960. A summary of the results of the prepayment reviews for the first quarter of 2013:
L4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
Common Errors:
- No proof of delivery submitted.
- No detailed written order or dispensing order received
L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED
L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED
- No detailed documentation to support medical necessity of custom rather than prefab orthosis
What does this mean for you?
- Review your product delivery process and assure you are providing detail, signatures and dates.
- Create a Detailed Written template for your practice that includes all required information.
- Establish a process for gathering corroborating documentation when supplying a custom-fabricated orthoses.
Practitioners in Jurisdiction D can continue to expect pre-payment reviews of AFO claims. The other three regions may also institute audits. The best way to minimize the impact of an audit is to follow the product definitions, codes and diagnoses outlined in the LCDs and Policy Articles. Other resources include:
- AFO Educational Presentation sponsored by Jurisdiction D, available for download
- https://www.noridianmedicare.com/dme/train/presentations/afo_kafo.pdf,
- Jurisdiction B is offering an upcoming seminar on Orders and Signature
- http://apps.ngsmedicare.com/ADC/EventList.aspx?fromdate=4/1/2013&todate=5/31/2013&display=Month&type=public&eventidn=1955&view=EventDetails&information_id=3420
The Reimbursement Resources will direct you to additional downloadable resources including an AFO Claims Checklist and an Orthoses Claims Documentation Guide.
Another Way to Get Your Medicare Claim Denied Part 2: Delayed!
Posted by David McGill | April 25, 2013
"Due to technical difficulties," Medicare will not implement the PECOS requirements discussed in our April 19 post. Medicare has not announced a new activation date for PECOS, which was scheduled to take effect May 1.
We will continue to monitor this situation and update you as soon as new information becomes available.
Competitive Bidding Round 2: Key Facts
Posted by David McGill | April 22, 2013
While your humble authors attended a meeting in Iceland last week, Medicare announced the contract suppliers for Round 2 of its Competitive Program. You can sum up Medicare's opinion about the program just by reading the title of its fact sheet: Contract Suppliers Announced for Expansion of Competitive Bidding Program That Will Increase Competition, Maintain Quality. Not included in the title but figuring prominently in Medicare's excitement about Competitive Bidding is another factor: cost savings.
Without further ado, here's everything you need to know about Round 2 of Competitive Bidding.
What Products Does It Apply To?
- Oxygen, oxygen equipment, and supplies.
- Standard (power and manual) wheelchairs, scooters, and related accessories.
- Enteral nutrients, equipment and supplies.
- Continuous Positive Airway Pressure devices and Respiratory Assist Devices and supplies and accessories.
- Hospital beds and related accessories.
- Walkers and related accessories.
- Negative Pressure Wound Therapy pumps and related supplies and accessories.
- Support surfaces (Group 2 mattresses and overlays.)
Where Does It Occur?
Competitive Bidding affects 91 major metropolitan areas. Medicare decided to split NY, LA and Chicago into multiple competitive bidding areas because of their size. So the total number of "MSAs" subject to Round 2 wound up at 100.
In short, if you operate in/near a reasonably-sized US city, you're more than likely in a Competitive Bidding area. For a complete list of MSAs, click here.
When Does Round 2 Go Into Effect?
July 1, 2013.
How Much Money Does Medicare Think It Will Save?
Medicare claims that Round 2 will save it 45% versus the current fee schedule.
How Many DMEPOS Suppliers Received Competitive Bid Awards?
799. In other words, an average of 8 suppliers per Competitive Bidding area secured contracts from Medicare.
Medicare classifies 63% of these suppliers as "small suppliers" (i.e., annual gross revenues of $3.5M or less).
What's The Impact on O&P?
As we write this, orthotics and prosthetics remain outside the scope of Competitive Bidding. However, future rounds may well include off-the-shelf orthotics.
In addition, by 2016 Medicare must either (a) expand competitive bidding across the entire country for identified products or (b) adjust its national fee schedule for those products based upon competitively bid amounts. Bottom line: competitive bidding will ultimately result in significant payment reductions for all DMEPOS suppliers. The only question is which products will fall within the scope of the program.
May 1: Another Way to Get Your Medicare Claim Denied
Posted by David McGill | April 19, 2013
"Provider Enrollment Chain & Ownership System."
Rolls right off the tongue, no?
The acronym "PECOS" has floated around O&P the last few years. But effective May 1, it directly affects your ability to receive Medicare payments.
Beginning then, Medicare will "flip the switch" that automatically denies DMEPOS claims resting on a prescription from a doctor who hasn't yet enrolled in PECOS. In other words, starting May 1st your prescribing physician must be in the PECOS system if you want to get paid.
What does this mean to me?
Adding one new step to your pre-claim process will protect you from a "PECOS denial." For all claims submitted on May 1 or later, confirm that your prescribing physician/practitioner has already enrolled in PECOS.
Medicare has a downloadable list of all PECOS-enrolled physicians/practitioners available here. The download is available as both a PDF and Excel file. (The PDF is 21,000+ pages long. I searched for my doctor's name using the "find" function and it located him in less than 10 seconds.)
If the prescribing doctor/practitioner appears in Medicare's PECOS database, you should be able to file your Medicare claim without fear of a PECOS denial.
Our Error
Posted by David McGill | April 18, 2013
On January 22, 2013, we authored a post stating that effective July 1, doctors would have to sign Detailed Written Orders before delivery of a prosthetic or orthotic device. We were wrong.
Buried on page 262 (of 483) of the comments to the Final Rule is the following statement by Medicare:
As noted previously, section 1834(h)(3) of the Act incorporates by cross reference prosthetic devices, orthotics, and prosthetics to the items encompassed by section 1834(a)(11)(B) of the Act. At this time, we are not implementing the proposed changes to § 410.36(b) to require documentation of a face-to-face encounter for prosthetic devices, orthotics, and prosthetics that, according to § 410.36(b), require a written order before delivery in this final rule. We intend to use future rulemaking to determine which prosthetic devices, orthotics, and prosthetics, require, as a condition of payment, a written order before delivery supported by documentation of a face- to-face encounter with the beneficiary consistent with section 1834(a)(11)(B) (ii) of the Act. [Emphasis added]
What does this mean for me?
If you're an O&P supplier, the Detailed Written Order requirements that you've always followed remain unchanged. If you have the doctor sign the DWO before billing the prosthetic or orthotic device, you are Medicare compliant.
However, the new "DWO-before-delivery" rule does apply to items other than prosthetics and orthotics, effective July 1, 2013.
Our Apology
We know you trust us to get it right the first time. We also know that trust is hard to earn and easy to lose. We've implemented new safeguards to prevent this kind of error in the future.
We apologize for the confusion we caused. And we thank you for subscribing to and reading Össur R&R.
A Follows B
Posted by David McGill | April 03, 2013
In our Feburary 21 post, we noted that MAC Region B had updated its requirements for claims using "not otherwise classified" codes (e.g., L5999 in prosthetics). MAC Region A has now followed suit.
On April 1, Region A announced revised guidelines for NOC codes. Suppliers must now include:
- Product name;
- Make/model of the item; and
- MSRP.
What does this mean for you?
As we've discussed several times in the recent past, we believe this these requirements demonstrate the MACs' intent to increasingly focus on the specific products delivered by suppliers to beneficiaries. If you intend to use an NOC code like L5999, you need to make sure that it's appropriate, as the MACs may be scrutinizing NOCs more closely to identify potential coding abuse.
The new requirements take effect May 1st. Failure to follow them will result in claim denials.
2% Less
Posted by Linda Collins | April 01, 2013
Effective Monday, April 1, 2013 there will be a 2% payment reduction for all Medicare claims. The payment reduction is required under sequestration and applies to all claims filed on or after April 1, 2013.
Back to Back
Posted by Linda Collins | March 25, 2013
As we predicted in our October 15, 2012 post, Cover Your Back, Medicare has turned its auditing eye towards Spinal Orthoses. Last Friday, MAC Region A announced a widespread pre-payment review of codes L0631 and L0637. MAC A has initiated this review due to a high volume of claim errors identified by the Comprehensive Error Rate Testing (CERT) contractor.
This announcement comes on the heels of the pre-payment review completed by MAC Region D, where they found a high percentage of claims errors due to lack of sufficient documentation, lack of medical necessity, missing proof of delivery, and erroneous claims billing for Part A (see, Severe Back Pain post, December 21, 2012)
What does this mean for you?
It appears the DME MACs will focus on physician records to justify the medical necessity for these devices. In other words, even if you receive a prescription from a physician, you will have to obtain documentation from the doctor to support the need for the orthoses. Just as we’ve seen over the past 18 months with prosthetic claims, the supporting documentation must be part of the doctor’s medical record. Documents created by you and dated/initialed by the doctor do not satisfy this requirement! Rather, the doctor’s own notes must contain the required information.
This means that after submission but before payment on the claim, an auditor may come to you and ask for copies of the supporting documentation. If you do not have this in your files the claim will be denied.
A summary of requirements outlined in the LCD is listed here:
- If you dispense an item based on a verbal order, you must have the following documentation:
- Description of the item
- Name of the beneficiary
- Name of the physician
- Start date of the order
- Do not submit claims before obtaining a valid written order that contains:
- Beneficiary's name
- Detailed description of the item(s) to be dispensed (The detailed description in the written order may be either a narrative description or a brand name/model number.)
- Treating physician's signature (Signature and date stamps are not allowed.)
- Date the treating physician signed the order
- Start date of the order - if the start date is different than the signature date
- Beneficiary authorization
- Proof of delivery
- Product information demonstrating that the TLSO provides control of motion in one or more planes or provides intracavitary pressure
- Documentation in the beneficiary’s medical records that supports that the TLSO was ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
Taking the time to organize documents before claims submission will help you respond to prepayment audits in a timely and efficient way.
New Audit Issue…Watch Your Step
Posted by Linda Collins | March 19, 2013
The Region A Recovery Auditor has posted a new issue for review. The identified issue is “Ankle-Foot Orthosis.” The specifics of the audit include a review of correct billing codes and supporting medical necessity documentation. This issue is not surprising considering the recent changes in the LCDs and the CERT pre-payment probe.
Currently the issue is only under review in Region A, but we believe it likely that the other three Medicare Regions will pick up the issue for review in the near future.
What can you do to minimize the impact of an audit on AFOs? Follow the product definitions, codes and diagnoses outlined in the LCDs and Policy Articles:
*Ankle-foot orthoses described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory beneficiaries:
- with weakness or deformity of the foot and ankle,
- who require stabilization for medical reasons,
- and have the potential to benefit functionally.
Ossur Products
|
L1902 |
GameDay Ankle Brace(PDAC) | ||
|
L1906* |
Rebound Ankle Brace (PDAC) | ||
|
L1930 |
AFO Light (PDAC) | ||
|
L1932 |
AFO Dynamic (PDAC) | ||
|
L4350 |
Air Form Inflatable Stirrup Ankle Brace | ||
|
L4350 |
Air Form Stirrup Ankle Brace |
| |
|
L4350 |
Air Form Universal Inflatable Stirrup Ankle Brace |
| |
|
L4350 |
Form Fit Foam Ankle Brace |
| |
|
L4350 |
Form Fit Honeycomb Ankle Brace |
| |
|
L4350 |
Gel Ankle Brace |
| |
|
L4360 |
Equalizer Air Walker (PDAC) |
| |
|
L4360 |
Equalizer Pre-Inflated Air Walker (PDAC) |
| |
|
L4360 |
Malleable Strut Air Walker |
| |
|
L4360 |
Rebound Walker (PDAC) |
| |
|
L4386 |
DH Offloading Walker |
| |
|
L4386 |
Equalizer Walker (inc. low top version)(PDAC) |
| |
|
L4386 |
Pediatric Walker |
| |
|
L4386 |
Range of Motion Walker |
| |
*Effective for claims with dates of service on or after April 1, 2012, the only products which may be billed to Medicare using code L1906 are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor.
Night Splints
*A static or dynamic positioning ankle-foot orthosis (L4396) is a prefabricated ankle-foot orthosis which has all of the following characteristics:
- Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°; and,
- Applies a dorsiflexion force to the ankle; and,
- Used by a beneficiary who is minimally ambulatory, or nonambulatory; and,
- Has a soft interface.
Ossur Products
|
L4396 |
Form Fit Night Splint (PDAC) |
*A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:
- Designed to maintain the foot at a fixed position of 0° 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.
Ossur Products
|
L4398 |
Air Form Night Splint (PDAC) |
|
L4398 |
Exoform Dorsal Night Splint (PDAC) |
Modifiers
The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts.
When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the RTLT modifiers and 2 units of service.
Add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.
Source:
Local Coverage Article for Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article - Effective January 2013 (A19800)
New Name, Same Game
Posted by Linda Collins | March 18, 2013
Medicare has given a new name to the Recovery Audit Contractors (RACS). Now known as Recovery Auditors, their mission is to identify and reduce Medicare improper payments made on claims of health care services provided to Medicare beneficiaries. There are four Recovery Auditors, aligned with the four DME MACs.
Click the link below to get contact information for each Recovery Auditor.
The Recovery Auditors research potential claims issues to audit. Once an RA identifies an issue and has approval from Medicare, the issue is posted on the website. Issues may cover inpatient hospital stays, diagnostic procedures, or outpatient surgeries. Each of the four RAs lists its own issues, but over time they tend to follow each other.
Currently, there are only a few RA issues posted that impact the O&P industry. Here is a brief review of the current posted issues for orthotics:
Knee Orthosis Bundling - Payments for knee orthoses additions, as specified in the LCD for Knee Orthoses, are bundled into the payment for specific base knee orthoses, and should be recouped if paid separately.
What does this mean to you? Add-on codes are not typically separately payable for knee braces. If the base code is medically necessary, certain add on codes may be considered for payment per the chart below:
Code Addition Codes - Eligible for Separate Payment
L1810 None
L1820 None
L1830 None
L1831 None
L1832 L2397, L2795, L2810
L1836 None
L1843 L2385, L2395, L2397
L1845 L2385, L2395, L2397, L2795
L1847 None
L1850 L2397
DMEPOS while inpatient -The Medicare DMEPOS benefit applies only to items that a beneficiary uses in his or her home. Medicare will not make separate payment for DMEPOS when a beneficiary receives treatment at an institutional provider (e.g., hospital). The institution is expected to provide all medically necessary DMEPOS during a beneficiary’s covered Part A stay.
What does this mean to you? You can bill Medicare for an item you provide on an outpatient basis or within 48 hours of discharge from an institution when the item is for exclusive home use. If the item is to be used inpatient, the facility is responsible for payment to you for the service and you may not separately bill Medicare for that. If you do, Medicare considers it unbundling.
Spinal Orthoses -Thoracic-Lumbar-Sacral Orthosis and Lumbar-Sacral Orthosis must meet basic coverage criteria, whether at initial purchase or at any point during a rental period as outlined in CMS Publications, the Local Coverage Determination (LCD) for Spinal Orthoses: TLSO and LSO. RA’s will review medical documentation to determine that services were reasonable and necessary.
What does this mean to you? The signed order must have a diagnosis that establishes medical necessity. According to guidelines:
A thoracic-lumbar-sacral orthosis (L0450-L0492), lumbar orthosis (L0625-L0627) or lumbar-sacral orthosis (L0628-L0640) is covered when it is ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
This information will be validated by medical record documentation, most likely from the orthotist and the ordering physician.
Learn to play the game and win by keeping yourself informed of changes in RA issues. For more assistance check the “Useful Resources” link on the left for a variety of checklists and guides.
Region A Says Prepay Prosthetic Reviews Here to Stay (For Now)
Posted by David McGill | March 11, 2013
Last Friday, MAC Region A published the latest results for its ongoing widespread prepayment complex review of lower limb prosthetic claims.
Key findings:
- The focus of this review, like previous ones, was on claims involving the K3 functional level;
- Prosthetists failed to respond to 13% of the claims reviewed when asked for additional information.
- For the remaining claims, the claim denial rate was 77% (i.e., MAC Region A determined that 77% of the claims failed to meet Medicare's payment standards).
- Of the denied claims, Region A rejected 32% for failing to adequately justify the K3 functional level, 30% for lacking physician corroboration of prosthetists' records, 12% for missing proof of delivery, and 4% for missing the prosthetist's assessment of the patient's functional level.
What does this mean for you?
First, MAC Region A concluded that based upon these results, it will continue its widespread review of lower limb prosthetic claims involving the K3 functional level moving forward. This means that prosthetic suppliers in Region A should expect ongoing scrutiny of these kinds of claims.
Second, we find it interesting that the MAC differentiated between the 4% of claims denied for "missing the evaluation/assessment documentation for the functional level of item(s) billed (prosthetist assessment) on the one hand, and the 32% of claims denied because the "clinical records [ ] did not justify the functional level of the billed item. While the distinction between these two categories isn't entirely clear, our current interpretation of the data is that 96% of prosthetists did include evaluation/assessment documentation regarding functional level, demonstrating that prosthetists are, the vast majority of the time, fulfilling their responsibilities. On the other hand, we believe the 32% failure rate for "clinical records" may be referring to physician documentation.
Third, you have to know Medicare's requirements backwards and forwards, and there are no shortcuts here. However, we have made key resources available to you right within the web pages of Össur R&R. Specifically, in the Reimbursement Resources link we have the following documents that will help you make sure you dot your i's and cross your t's when preparing claims for submission to Medicare: (1) Lower Limb Prosthesis Documentation Checklist 2013, and (2) Physician Worksheet for Prosthetic Documentation 2013. We encourage you to click through to those resources and integrate them into your standard operating procedure to help avoid the kinds of results discussed in the latest report from MAC Region A.
More Info Required
Posted by David McGill | February 21, 2013
MAC Region B issued new guidance yesterday about how to appropriately bill L5999, the code for "not otherwise classified" prosthetic components. The requirements, "effective immediately," provide that claims using an NOC code must include
a concise description of the code,
a concise description of the item billed,
the manufacturer's name,
the product name and number,
the model and serial number, and
the manufacturer's suggested retail price.
These new requirements further support a hypothesis that we first wrote about nearly a month ago.
In our posts of January 28, 2012 (Check Your Feet!) and February 5, 2013 (The Coding Revolution), we specifically posited that the MACs will increasingly focus on the specific product delivered to a patient. In less than a month, we have now received MAC guidance about 3 separate issues, all of which share the same key element: an explicit link between codes and specific products. Whether it's prepayment claim reviews for specific foot codes, product-specific directives for microprocessor knees, or yesterday's news from Region B, it's clear that the MACs want to more closely examine or control codes selected by suppliers.
What does this mean for you?
In Region B, it means that you need to be sure that your use of an L5999 code truly describes a unique product feature, as all of the supporting information you are now required to include links that L5999 to a specific manufacturer and product. More broadly, as we stated in January, it means that O&P's across the country "must take care to only bill those codes that clearly apply to the product being delivered."
The RAC Annual Report: Behind the Headlines
Posted by David McGill | February 07, 2013
Medicare has released its annual report regarding RAC audits for Fiscal Year 2011. Most articles you'll read about this will restate basic facts culled largely from the Executive Summary of this 18-page document. We'll assume that you can all read those headlines on your own, and instead will focus on the three most interesting points pulled from the data supporting the report.
Interesting Point #1: Northeast & Midwest, You Ain't Seen Nothin' Yet
The RACs for Region A & B collected $127.8M and $160.3M in overpayments, respectively. Regions C & D, on the other hand, collected $191.3M and $318.0M. Put simply, nearly 2/3rds (roughly 64%) of the total overpayments came from the South and West, suggesting that the Northeast and Midwest are in for stormier times ahead.
You might counter by asking whether looking at dollars is the best metric. What if Regions A and B had lower overpayment amounts because providers and suppliers in those regions submitted cleaner claims than their counterparts in Regions C and D? Good question, but the data doesn't really bear it out.
Regions A and B had roughly the same number of claims as each other resulting in the aforementioned overpayments: 97,929 and 86,215, respectively. But Regions C and D looked at significantly more claims: 259,124 and 383,462. So 78% of the claims reviewed by RACs occurred in Regions C and D.
Interesting Point #2: No One Appeals, But You Should
The Report breaks claims into 3 general buckets: Medicare Part A claims; Medicare Part B claims; and "DME" claims. The report isn't specific as to whether "DME" includes O&P, but there is a general reference in the report to the fact that Part B claims typically involve physicians and DME claims typically involve suppliers, so for the purposes of this section, we're going to assume that "DME" does include O&P in the context of this Report.
In 2011, the RAC's identified 295,425 DME claims that it classified as overpayments. Suppliers appealed 8,770 of those decisions, a mere 3%. Stated inversely, suppliers accepted the RACs' findings 97% of the time without even appealing!
More depressing, only 50 (!) claims were appealed to the ALJ level. For those of you who like dealing with really, really small numbers, that's a .02% appeal rate.
The real tragedy in this pathological decision not to appeal is that suppliers who do appeal often win. The national provider appeal win rate was 43.6% in 2011, though there was large variations by Region. (Region B had a 2% DME win rate while Region C had a 58.9% win rate.)
Interesting Point #3: Some RACs Focused on DME More Than Others
Looking again at the 3 buckets – Part A, Part B, and DME – there's pretty significant variation between what the RACs looked at regionally. In Regions A and B, DME claims constituted roughly 10% and 14%, respectively, of the total number of claims resulting in RAC clawbacks. But in Regions C and D, those numbers spiked to roughly 47% and 40%.
So what does this mean for you?
First, for those people in the Northeast and Midwest thinking that audits have reached a fever pitch and that it can't get worse, these numbers are sobering. Assuming that the RACs in Regions A and B ramp up to the same number of claims reviewed as in Regions C and D, you're staring down the barrel of an audit explosion in 2013. How much of that will focus on O&P versus other claim types remains to be seen.
Second, you have to appeal RAC decisions! If we told you that your chances of winning an appeal – particularly for higher cost items like prosthetics and custom orthotics – were greater than 40%, wouldn't you take those odds? Despite what the data shows, a stupefyingly low number of suppliers appeal RAC decisions.
In light of that fact, we shouldn't be shocked then, that all of Medicare's messaging regarding RAC audits trumpets how few claims get overturned. When suppliers decide not to appeal 97% of the time, Medicare concludes that they're implicitly acknowledging that the RACs are right!
Finally, depending on where you are in the United States, your RAC may have focused more or less intensely on DME, which, again, we're assuming – perhaps incorrectly, but based on the limited data that's available to us in this Report – includes O&P. If Regions A and B start scrutinizing DME claims in ratios more like Regions C and D, things could get even hairier in the Northeast and Midwest this year.
The best way to deal with all of these negative data points? Avail yourself of the resources available to you. Össur has a wide range of educational materials and events specifically designed to address the reality of running an O&P business in 2013. Use them. Attend them. Whatever you do, don't keep on doing the same thing you did 3 years ago – it won't be good enough now.
Note: All data in this post is based upon analysis of the Exhibits included in the RAC FY 2011 Report.
New and Improved
Posted by Linda Collins | February 07, 2013
We have recently upgraded the R&R Bulletin. It now includes helpful links to various industry-specific sites and reimbursement resources such as checklists for AFO’s, spinal orthoses, and lower limb prostheses, all of which are consistent with newly-released Medicare requirements.
Under the “Helpful Links” section of the menu you will have access to the DME MACs, PDAC, Recovery Auditors, Medicare Coverage database and more. Additional links will be added in the future so check back often.
The “Reimbursement Resources” tab will take you to a listing of custom documents provided by Össur. The AFO Checklist includes specifics about the new height requirements and which products meet the requirements. The Spinal Orthoses checklist includes each requirement for claims submission as outlined by CMS. The Lower Limb Prostheses documentation checklist will aid you in gathering necessary information prior to claims submission. These documents are available for download and use by practitioners and billing staff.
The Össur R&R site also includes recently developed Reimbursement Guides for the Össur Bionic products: RHEO KNEE, SYMBIONIC LEG, PROPRIO FOOT and POWER KNEE. These comprehensive guides contain information about the product, its clinical application, published research and claims requirements. The guides also offer product-specific exemplar letters of medical necessity and detailed written orders. The final section of each Reimbursement Guide offers important tips on preparing an appeal to both Medicare and private payers.
One of the newest resources in the “Reimbursement Resources” section is the Physician Worksheet for Prostheses. This novel tool helps Prosthetists communicate with treating physicians to gather the necessary corroborative documentation required by Medicare and, increasingly, by private payers as well. A Prosthetist can fill in the worksheet during the patient evaluation and send the worksheet to the treating physician along with a letter of medical necessity. The physician, in turn, can use the worksheet as a guide when writing/dictating clinical reports.
Össur also offers a variety of webinars, seminars, and symposia on reimbursement. Each of these events is listed on a calendar under the “Events” tab. The first reimbursement webinar offered by Össur will be a series of “Ask the Reimbursement Specialist” calls. Practitioners will have opportunity to submit pressing reimbursement and regulatory questions prior to the call. The Össur Reimbursement Specialists will thoroughly research the answers and present the information during the webinar. Watch the R&R calendar for information on dates.
In addition, Össur Reimbursement Specialists will be offering in-person presentations about reimbursement strategies. The presentation will focus on the A-Z details you can implement in your practice to assist in audit preparedness and decrease denials. Watch the calendar for a location near you or speak to your Össur Area Manager to schedule.
With the introduction of the Össur’s POWER KNEE, we will be offering a serius of symposia focused on clinical challenges facing transfemoral amputees, POWER KNEE function and rehabilitation potential, and reimbursement guides. CEU credits are available for each symposium. Watch the calendar on the R&R site for locations and dates.
Finally, in joint presentations with renowned lecturer and gait trainer Robert Gailey, PT, Össur’s Reimbursement Specialists will provide a detailed, interactive approach to constructing winning appeals for both Medicare audits and private payor claims. These events present a ground-breaking and holistic approach that integrates the worlds of claim processing, data collection, and patient care into a unified system necessary to operate in today’s reimbursement environment.
These are just some of the resources available to independent O&P’s from Össur, with even more new resources on the way soon. Watch the Össur Reimbursement & Regulatory Bulletin to stay up to date on these and other exciting announcements from Össur.
The Coding Revolution
Posted by David McGill | February 05, 2013
MAC Regions A & B issued new guidance last Friday about how to appropriately bill microprocessor knee codes. We expect Regions C & D to follow suit in the very near future (if they haven't already between the time I sent this post to the web-overlords who help us with Össur R&R and the time it takes them to upload it onto the magical interweb).
The highlights of the MACs' guidance:
- The following codes are the only ones that suppliers can use when billing Medicare for Össur's RHEO KNEE: L5856, L5828, L5845, L5848, L5930.
- The following codes are the only ones that suppliers can use when billing Medicare for (a) Otto Bock's C-Leg, Genium, or X2, (b) Freedom's plié, (c) Endolite's Orion, and (d) DAW's SLK: L5856, L5828, L5845, L5848.
- The following codes are the only ones that suppliers can use when billing Medicare for Endolite's Orion: L5857, L5848. [The MACs reference the Orion in two places with two different groups of codes (see first bullet, (c), above.]
- The following codes are the only ones that suppliers can use when billing Medicare for Otto Bock's C-Leg Compact: L5858, L5828, L5845.
- The MACs add that "the use of additional HCPCS codes other than those specified above, either specific codes or NOC [i.e., L5999) codes, for other add-ons, functions or features is considered unbundling and thus is incorrect coding. [Emphasis added]
What does this mean for you?
First, the MACs will now take the position that they have put all O&P suppliers on notice that correct billing for microprocessor-knees has to follow the above criteria. Failure to follow the MACs' guidance could put your business at risk not only for negative audit/pre-payment claims review results, but for more significant liability under the False Claims Act.
Second, this new guidance, together with the recent notice from Region D that it is conducting a widespread prepayment claims review of all claims using L5980, L5981, and L5987 (see our January 28 post), suggests that Medicare and its contracting entities are increasingly interested in getting down to the product level when reviewing claims. With this kind of scrutiny, suppliers must take care to only bill those codes that clearly apply to the product being delivered. Otherwise, they may become casualties of the coding revolution.
Clarification from MAC Region B: "Hold on a sec!"
Posted by David McGill | January 30, 2013
On December 17 we posted regarding MAC Region B's guidance regarding physician documentation. In a nutshell, we noted that based upon the transcript from November's "Ask the Contractor Teleconference," Region B had taken the position that the prescribing physician's annotation of both specialists' and prosthetists' patient notes would convert those notes into part of the prescribing physician's medical record.
Thanks to information provided by one of our Region B readers, we have learned that the MAC updated its summary of the teleconference just over a week ago. Included in that update was the following clarification regarding the annotation concept:
Suppliers are reminded per the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual … supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. [emphasis added]
Review of the relevant section of the Internet-Only Manual leads us here:
[A] supplier prepared statement … [does not] by itself provide[ ] sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. [emphasis added]
Chapter 5, Section 5.7
What does this mean for you?
- MAC Region B has effectively reversed course on the guidance provided by its representative during the November teleconference. Based upon this update, we no longer believe that it is appropriate to have a physician annotate a prosthetist's records. If you nevertheless continue, MAC Region B will take the position that the prosthetist's annotated note is not part of the physician's medical record!
- As a result, we believe the new "best practice" is the same as the old one (i.e., the one that applied before publication of the original MAC transcript): the physician's notes must contain appropriate documentation separate and apart from the prosthetist's records. We do not recommend delivering a prosthetic item to a Medicare beneficiary until you have confirmed that the physician's records include this information.
- The updated guidance does not affect the ability of the prescribing physician to annotate another specialist's medical records. In other words, if the prescribing physician annotates a PM&R doctor's report/records, that would continue to be appropriate and would make the PM&R doctor's notes part of the prescribing physician's medical record. The limitation on annotation applies only to DMEPOS suppliers.
Check Your Feet!
Posted by David McGill | January 28, 2013
MAC Region D has announced a widespread prepayment probe of 3 L codes: L5980, L5981, and L5987, all of which describe different prosthetic feet. The MAC states that the results of Comprehensive Error Rate Testing have led to this decision.
All Region D suppliers are subject to these reviews, and will receive an Additional Documentation Request letter asking for the following information, including but not limited to:
- Treating MD's dispensing and written order;
- Documentation of dispensing order (if the foot is dispensed based on the dispensing order);
- Medical records supporting medical necessity (including MD records, PT records, etc.);
- Functional level justification documentation;
- Proof of delivery; and
- Any Advanced Beneficiary Notice (if applicable).
What does this mean for you?
If you are a supplier in Region D, you have 45 days from receiving an Additional Documentation Request letter. If you fail to respond within that time frame, Medicare will deny your claim.
Therefore, your medical records must include the above information (to the extent it's in your file), and you should verify that supporting documentation exists in the files of other relevant medical professionals treating the patient (to the extent it's in theirs).
Also recognize that this will lead to longer stretches between delivery of the prosthetic foot to Medicare beneficiaries on the one hand, and payment by Medicare on the other. To the extent you have not already, you should be managing your cash flow accordingly.
Now more than ever, it's critical that you check your feet!
Details about Detailed Written Orders (DWO)
Posted by Linda Collins | January 22, 2013
The Centers for Medicare & Medicaid Services’ (CMS) requirements for a Detailed Written Order will change this July. Historically, a supplier must have a DWO prior to billing. DWO’s confirm what the treating physician ordered .Effective July 1, 2013, suppliers must obtain the detailed written order from the treating physician before delivering and billing for a covered DMEPOS item.
What does this mean for you? Unless you integrate the receipt of a DWO from the prescribing physician into your pre-delivery process, Medicare and its various auditing agencies will have a basis for recouping non-compliant claims beginning on July 1!
The Program Integrity Manual, Chapter 5, outlines the specifics of the DWO:
*Medicare requires an order for every item (except repairs) of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Detailed written orders must not be used to add unrelated items, whether requested by the beneficiary or not, in the absence of a dispensing order from the physician for that item.
Example: The physician has given a dispensing order for lower limb prosthesis. The supplier may not add an AFO/KAFO for the residual limb to the order. The brace is not related to the item requested in the original order.
*A DWO must include the patient’s name, item ordered, the prescriber’s national provider identifier and signature along with the date of the order. An order without these minimum elements will be considered incomplete and will not support claim payment
Example: After receiving the dispensing order, and thoroughly evaluating the patient, the Prosthetist can create a DWO that includes all the necessary points and send back to physician for signature and date.
*Someone other than the physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement
Example: Practitioners may use templates for their detailed written orders that include a listing of the specific items being provided for the individual beneficiary. In this case, the final document that is signed and dated by the physician must clearly identify the specific items that are being ordered for that particular patient.
*Medical necessity information (e.g., an ICD-9-CM diagnosis code, narrative description of the patient's condition, abilities, and limitations) is NOT in itself considered to be part of the order although it may be put on the same document as the order. The DWO is not considered part of the patient’s medical record so it will NOT meet the requirements of corroborating documentation.
Example: The Prosthetist creates a DWO which includes a narrative on the patient’s past prosthetic use, expected functional level and desire to ambulate. The Prosthetist is required to gather other physician notes/reports that support this assessment.
Refer to the Supplier Manual and the LCDs for additional information about order requirements.
To be continued
Posted by Linda Collins | January 10, 2013
The Jurisdiction A DME MAC Medical Review Department announced the results of a Widespread Prepayment Probe Review for Lower Limb Prostheses claims billed with a K3 modifier. The probe revealed a high percentage of claims errors due to lack of sufficient documentation, lack of functional level documentation, and missing proof of delivery.
The probe indicated the overall error rate continues to decline each quarter. However, the overall error rate for LLP remains high (66%+) so the prepayment reviews will continue for Jurisdiction A.
What can you do to prevent your claims from failing a MAC prepayment review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Then remember the ABCs:
Assess the patient
- Document the patient’s condition thoroughly
- Use an objective functional level/mobility test to justify K level
Be in contact with the prescribing physician
- Provide the physician with a letter of medical necessity
- Provide the physician with a Detailed Written Order
Corroborate your records with the physician’s
- Educate the prescribing physician about Medicare’s documentation requirements if the patient is a Medicare beneficiary
- If necessary, provide the patient and/or physician with a copy of the “Dear Physician” letter from Medicare
Don’t forget to get proof of delivery
- Have patient or patient’s representative sign and date form indicating exact products received
The full report, along with specific examples of claim documentation, is available at: http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_pca/122812_llp.pdf
Updates to Spinal Orthoses LCDs effective January 1, 2013
Posted by Linda Collins | January 07, 2013
The four DME MACs recently announced an update to the Spinal Orthoses Local Coverage Decisions. The changes include more detailed information about Detailed Written Orders (DWO) and documentation requirements. It appears the DME MACs will be focusing on physician records to justify the medical necessity for the device. In other words, even if a prescription from a physician is received there will need to be documentation in the doctor’s records to support the need for the orthoses.
Based upon these changes, it is likely the MACs and/or RACs will begin auditing this issue. Which means that after payment on the claim, the auditor may come to you and ask for copies of the supporting documentation? If you do not have this in your files the claim will be denied retrospectively and the money will be recouped by Medicare.
Going forward the best practice will be to have a signed and dated DWO and a physician’s report or copies of medical records prior to dispensing the TLSO. The documentation in the beneficiary’s medical records must show the TLSO was ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
A summary of requirements for a TLSO claim are provided for your reference:
Important Medicare Billing Info for 2013
Posted by David McGill | January 02, 2013
Welcome to 2013 and the first day of Medicare paying claims according to its new fee schedule. Here are the 2 things you need to know about Medicare payments as of today.
1. If one is the loneliest number …
...then what is .8? It's the percentage increase in what Medicare pays for L codes in 2013 v. last year.
2. Ossur's POWER KNEE has a new code!
Starting today, Medicare will process claims using L5859 to describe the unique features offered by POWER KNEE. There are two things you need to understand when billing for POWER KNEE.
First, when creating L5859 for POWER KNEE, Medicare expressly stated that this new code should be used in conjunction with four other already-existing L codes: L5856; L5828; L5845; and L5848. In other words, Medicare has approved the use of all 5 of these codes when billing POWER KNEE.
Second, if you download the 2013 DMEPOS Fee Schedule and look up L5859, you will see a fee of $0.00. But this does not mean that Medicare refuses to reimburse L5859! All it means is that until Medicare decides on a fee, the supplier must select an appropriate amount for L5859. Medicare will review all claims submitted to it between now and April and then set a final fee schedule amount for this new code. Medicare has explicitly stated that L5859 will be updated with a fee effective July 1, 2013.
If you have any questions about appropriately billing L5859, please contact an Össur sales representative or customer service.
Severe Back Pain
Posted by Linda Collins | December 21, 2012
Jurisdiction D DME MAC Medical Review Department announced the results of a Widespread Prepayment Probe Review of Spinal Orthoses (HCPCS L0631 and L0637) claims. It revealed a high percentage of claims errors due to lack of sufficient documentation, lack of medical necessity, missing proof of delivery, and erroneous claims billing for Part A. As a result of the high error rate, the DME MAC will continue to closely review TLSO claims.
So what can you do to prevent your claims from failing a MAC review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Here is a summary of key requirements:
Reasonable and Medically Necessary
A lumbar-sacral orthosis is covered when ordered for one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak spinal muscles and/or a deformed spine.
For Medicare to cover any item, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.
The diagnosis code must justify the need for the TLSO. Additional clinical notes in the medical record outlining the need for the TLSO can support this diagnosis.
Medical Coverage Documentation
Medicare expects that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.
In the case of a spinal orthosis, the beneficiary’s medical record must have sufficient objective documentation to validate beneficiary use of a LSO as reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member.
Proof of Delivery
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.
Billing for Spinal Orthosis while patient in hospital or SNF
A spinal orthosis delivered to a beneficiary while inpatient at a hospital or SNF will not be paid separately and is included in the facility payment.
According to DME MAC, a spinal orthosis claim may considered for separate payment when a spinal orthosis is delivered to patient in hospital or Part A covered SNF if:
- The orthosis is medically necessary for a patient after discharge from a hospital or Part A covered SNF stay; and
- The orthosis is provided to the patient within two days prior to discharge home; and
- The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the patient to take home.
The full report is available at:
https://www.noridianmedicare.com/dme/news/docs/2012/12_dec/results_of_widespread_probe_review_of_spinal_orthoses_hcpcs_l0631_and_l0637.html%3f
Following a few clearly defined requirements will mean that your claims are more likely to pass reviews and audits, which means quicker payment for you.
A Few Steps to Assist in AFO Claims Submission
Posted by Linda Collins | December 19, 2012
Last week the Jurisdiction D DME MAC Medical Review Department announced the results of a Widespread Prepayment Probe Review of Ankle-Foot/Knee-Ankle-Foot Orthoses (HCPCS L4360, L1970 and L1960) claims. It revealed a high percentage of claims errors due to lack of sufficient documentation, no written or verbal order, and/or no proof of delivery. As a result of the high error rate, the DME MAC will continue to review AFO claims.
So, what can you do to prevent your claims from failing a MAC review? First and foremost, follow the guidelines outlined in the MACs’ LCD and Policy Article. Here is a summary of the three key requirements:
Detailed Written Order
CMS requires you to obtain a detailed written order on all items before dispensing them to patients. The treating physician must sign and date an order for each new or full replacement item billed, the supplier must keep it on file, and it must be made available upon request. For items provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim. A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:
- Beneficiary's name
- Physician's name
- Date of the order and start date, if start date different than date of order
- Detailed description of the item(s)
- Physician signature and signature date
Medical Coverage Criteria Documentation
Medicare expects that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.
In the case of L1970 and L1960, which are custom fabricated AFOs, additional documentation is required. The LCD states that for a custom-fabricated orthosis to be eligible for coverage the patient must meet one of the following criteria, and this criterion must be detailed in the medical record:
- The beneficiary could not be fit with a prefabricated AFO; or
- The condition necessitating the orthotic is expected to be permanent or of longstanding duration (more than 6 months); or,
- There is a need to control the knee, ankle or foot in more than one plane; or
- The beneficiary has a documented neurological, circulatory or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
- The beneficiary has a healing fracture which lacks normal anatomic integrity or anthropometric proportions.
Proof of Delivery
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement. Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.
The full report on the review is available here
Following a few clearly defined requirements will mean that your claims are more likely to pass reviews and audits, which means quicker payment for you. Put your best foot forward and implement these procedures in your practice today.
Physician Documentation: One Region’s Guidance
Posted by David McGill | December 17, 2012
DME MAC Region B has made the transcript for last month’s “Ask the Contractor Teleconference” available. Based on our review of that transcript, we want to emphasize two aspects of what the MAC said about physician documentation.
First, Region B confirmed that a letter from a specialist physician can become part of the prescribing physician’s medical record. The requirements are as follows:
a. The prescribing physician needs to sign the specialist’s letter;
b. The prescribing physician needs to date the specialist’s letter; and
c. The prescribing physician needs to annotate if they agree or disagree with what’s in the letter.
If prescribing physicians complete each of these three steps, then the specialist’s letter becomes part of their medical records as far as the MAC is concerned.
Second, Region B also responded to a question about documenting K levels appropriately. The implications are significant, and we quote the MAC representative’s comments in their entirety:
When it’s coming to the functioning level, we are needing exact documentation that’s pointing directly to the functional level that you’re billing for.
What we see happening a lot is that, based off the functioning level of the beneficiary, they’re a K2, but they’re being supplied for services for a K3, and that’s not sufficient information.
What we also hear a lot is that physician records don’t have the information, but the [ ] prosthetist’s records have that information. So what the prosthetist should be doing is contacting the physician, by sending their records over to the physician, so the physician can review that documentation that has been made by the prosthetist, and then that way, the physician (go) [sic] ahead and sign and date that report, along with annotating if they agree or disagree, so that information does become a part of the record. [Emphasis added]
* * *
[W]e can’t take [ ] your word in regards to your medical record only, because you have the financial relationship in order to get payment from Medicare. If that [ ] information comes from the physician, they’re going to be able to put what they want or what they don’t want, or what they’re not liking about your record.
Together, what do these two things mean for you?
1. Sometimes, key findings relevant to support your claim for reimbursement may exist in a letter from a specialist, not in the prescribing physician’s notes. When you’re confirming the prescribing physician’s documentation before delivering an item to a Medicare beneficiary, make sure (1) to ask if there are any notes/letters from a specialist about your patient, and (2) that the prescribing physician has signed, dated, and noted their agreement/disagreement with the specialist’s finding.
2. Based on the response to the K-level question from MAC Region B, the same requirements that apply to specialty physicians’ notes becoming part of the prescribing doctor’s medical record also apply to prosthetist’s notes. In other words, if a doctor signs, dates, and annotates the patient notes forwarded by the prosthetist, those notes would now be considered part of the doctor’s medical record, not “ancillary” to it.
We know that many prosthetists have implemented measures that are substantially more involved than what’s described in the preceding paragraph in an effort to ensure appropriate physician documentation. But, if MAC Region B is taken at its word, prosthetists can simply send their notes to the prescribing physician, include their K-level findings, and so long as the prescribing MD signs, dates, and annotates the prosthetist’s notes, that will serve as sufficient documentation.
NOTE #1: A prosthetist’s K-level documentation must include information about (1) the beneficiary’s medical and prior functional status if it’s the beneficiary’s first-ever prosthetic claim, (2) whether the beneficiary will reach or maintain a defined functional state within a reasonable period of time, and (3) whether the beneficiary is motivated to ambulate.
NOTE #2: We would recommend that suppliers in other Medicare Regions confirm this information with their specific MAC before choosing to follow Region B’s publicly-stated guidance.
Up. Down. Left. Right.
Posted by David McGill | December 11, 2012
While suppliers today may question some of the documentation requirements that RAC auditors focus on, few would argue that Medicare’s insistence on “left” or “right” modifiers for orthotic/prosthetic devices is unreasonable. However, Medicare’s guidance about the use of these directional modifiers when a supplier delivers them bilaterally on the same day of service has caused confusion in the past.
Last Friday, MAC Region B posted a “Billing Reminder” to its website, which includes the following guidance:
When bilateral items are provided on the same date of service, the supplier must append both the modifiers LT and RT on the same claim line and indicate two units of service. [emphasis added] Failure to append the required modifier(s) will result in a CO-16 denial due to lack of information required to completely adjudicate the claim.
This sounds basic. It is basic. Just don’t overlook the basics.
Note: this requirement applies to the following items: ankle foot orthoses; knee-ankle-foot orthoses; knee orthoses; lower limb prostheses; orthopedic footwear; and external breast prostheses, among others.
Time is Money…
Posted by Linda Collins | December 10, 2012
There has been much discussion about the RAC audits and how to provide the documentation needed to beat the audit. If you practice does receive an Overpayment Demand Letter there are specific steps and timeframes to follow to protect your practice and your money.
First-Level Appeal: You have 120 days to file the first appeal which is known as a "redetermination." Redeterminations are conducted by Medicare Administrative Contractors (MAC). Here’s where it gets tricky. While you have 2 months to file that first appeal, you can only avoid a Medicare recoupment action if you do so within 30 days. The request for redetermination must be date stamped and in the MAC's mailroom no more than 30 days from the date of the demand letter.
Second-Level Appeal: If you lose your first-level appeal and decide to appeal that adverse decision, you must file your second-level appeal within 60 days of receipt of the first level determination to extend the prohibition on recoupment. Second-level appeals are called "reconsiderations." Reconsiderations are conducted by Qualified Independent Contractors (QICs). (If you lose your second-level appeal, recoupment will commence 30 days after the second-level appeal decision is issued. Medicare will recoup the full amount of the audit determination plus interest. This money will not be returned to you unless you prevail in one of the next levels of appeal)
Third-Level Appeal: You have 60 days from receipt of the second level reconsideration to appeal to the third level, at which an Administrative Law Judge (ALJ) will review your case. If the ALJ level process reverses the Medicare overpayment determination, Medicare will refund both principal and interest collected, and pay interest on any recouped funds that Medicare took from ongoing Medicare payments. We are hearing that in some sections of the country, waits for ALJ hearings are 12 months or more.
Fourth-Level Appeal: You have 60 days to appeal to the fourth level. At the fourth level of appeal, an HHS Department Appeals Board (Medicare Appeals Council) will review your case. The MAC will generally issue its decision within 90 days from receipt of your request for review.
Fifth-Level Appeal: Again, you have 60 days to appeal to the fifth level. Here, a Federal District Court will review your case. At least $1,220 must be in controversy following the MAC review, and the government increases this “minimum amount in controversy” annually.
Having all the documentation in the patient’s file prior to delivery of service makes it easy to meet the deadlines for appeals. This means you can keep control of your money during the sometimes lengthy appeal process. And since the majority of appeals are in the provider’s favor at the ALJ level, this means you may never have to pay back money or wait for your money to be returned. Take the time to manage your documentation up front because, in this case, time is money.
Cleaning up documentation
Posted by Linda Collins | December 04, 2012
According to FY 2011 CERT report, 66% of improperly paid claims were due to insufficient documentation.
A standardized format for clinical notes is one way to prepare your practice for claims reviews or audits. The most common form of clinical notes is the SOAP note. "SOAP" stands for Subjective, Objective, Assessment and Plan. The SOAP note is a written notation of a patient's condition, progress and immediate plan for diagnosis and treatment. A well-written SOAP note is important for maintaining quality of medical care and for supporting the claim of medical necessity.
S= subjective state of the patient
You have to document the patient's chief complaint and the reason they are seeking medical care. If you haven’t done it before, obtain and record a history of the patient's illness including their medical history, past surgery, family history, current medications, allergies and activities of daily living. Document this information specifically – notes that say “performs all normal ADL’s” are of virtually no value when you’re being audited. Similarly, talk in detail about any pain or loss of function that the patient is experiencing.
Example: The Wrong Way
Mr. Jones has right knee pain. Unable to perform ADL’s.
Example: The Right Way
Mr Jones states he is experiencing pain in his right knee. He reports the pain started one month ago after he fell while hiking. Mr Jones is taking OTC pain medication twice a day with no relief. He has been off work the last two days due to increased pain and has had to dramatically curtail even basic activities of daily living (e.g., walking to/from his house/car, taking garbage to the curb, shopping for food, etc.)
O= objective state of the patient
The objective state includes precisely measured patient vital signs, as appropriate – age, height, weight – findings of physical exams and the results of functional tests.
Example: The patient is a 52 year old male who is 5’9” and 193 lbs. He entered the office with the assistance of crutches. Upon examination, the patient’s right knee is swollen and tender to the touch. The patient is not able to bend the knee.
A= assessment of the patient, a one- or two-line summary of the patient's treatment
Example: Right knee pain due to OA. Patient measured and fitted with an Unloader Knee brace.
P= plan for the patient
This includes plans for imaging, surgical or non-surgical procedures and medication. Note any referrals to other doctors or specialists and any discussion with the patient. Set times for follow-up and specific goals.
Example: Patient instructed to continue OTC pain medication and to wear the brace during all activities. Follow up with orthopedic physician in two weeks.
All clinical notes are to be dated and signed by the practitioner.
The SOAP note is a well-recognized method of documentation employed by health care providers to write out notes in a patient's chart. Clean up your charts and prepare yourself for audits with SOAP.
The Medicare Policy Manual: What You Have to Know (Part 1)
Posted by David McGill | November 30, 2012
As a DMEPOS Supplier, you are responsible for knowing, understanding and complying with Medicare’s requirements. In a world of RAC and ZPIC audits, CERT reports, heightened MAC scrutiny, and PDAC directives, you can lose sight of the broader Medicare forest, focusing instead on the individual acronym trees. As year-end approaches and we start to think about New Year’s resolutions, we thought that a series on the requirements of the Medicare Policy Manual would be instructive. That way, when you resolve to do a better job of operating your business in 2013, you’ll have an easily reviewable primer on Medicare’s requirements.
In the abstract, this seems like it should be simple. (A large undertaking, but at least simple.) After all, surely each DME MAC organizes its Medicare Policy Manual so that it follows the same basic outline and covers the same topics in the same order as the other MACs, right? Of course, the answer to these questions is a resounding, "No." But fear not, we have attempted to bring some order to this chaos by cross-referencing the substantive topics within each MACs manual so that you can find what you need no matter which Region you’re in. So with that, let’s dip our toe in the pool of Medicare knowledge.
Contact Information
(Region A: Chapter 1)
(Region B: Chapter 24)
(Region C: Chapter 15)
(Region D: Appendix)
While the information provided by each MAC varies from Region to Region, there’s lots of useful data in the Contact Information chapter/appendix. For example, in Region A, it lists (1) where you send Redetermination documentation; (2) where you send Reconsideration documentation; (3) ALJ hearings contact information; (4) where you can send comments regarding draft Local Coverage Determinations; and (5) where you can send comments regarding draft LCD Reconsiderations. And this is in no way an exhaustive.
Not every MAC offers this same range of information, but as a starting point for where to go to deal with different Medicare issues, this is it.
Supplier Enrollment
(All Regions: Chapter 2)
We won’t spend lots of time reviewing this chapter because we’re going to operate under the assumption that our readers, by and large, are already enrolled in the Medicare program. But there are two things we want to highlight.
First, for every Region, this is where you get information on the DMEPOS Supplier Standards. (The Supplier Standards are clearly listed in every Manual except Region D’s. In Region D, the Supplier Standards appear under the heading, “NSC Process for Becoming a DME Supplier.”) We recommend that you review the Supplier Standards on a quarterly basis to make sure that you are in line with each and every one.
Second, in each Region this chapter contains a reminder about reporting changes to Medicare. You must report changes to information provided in your original CMS-855S form to Medicare within 30 days of the change occurring. Examples include the addition or cessation of a specialty, product, or service you provide, moving to a new location, and ownership changes. If you fail to comply with these reporting requirements, Medicare can deny your claims, recoup amounts paid, or even revoke your billing number.
Stay tuned next week for Part 2 of The Medicare Policy Manual: What You Have to Know.
The Economics of Insurance Companies
Posted by Linda Collins | November 29, 2012
Insurance companies measure their profitability as a Medical Loss Ratio (MLR). A Medical Loss Ratio is determined by calculating money spent by the insurance company spends on healthcare for patients and how much is spent on administrative costs. If an insurer uses 80 cents out of every premium dollar to pay its customers' medical claims and activities that improve the quality of care, the company has a medical loss ratio of 80%. A medical loss ratio of 80% indicates that the insurer is using the remaining 20 cents of each premium dollar to pay overhead expenses, such as marketing, profits, salaries, administrative costs, and agent commissions.
The Affordable Care Act sets minimum medical loss ratios for different markets, as do some state laws. MLR requires insurance companies to spend at least 80% or 85% of premium dollars on medical care, with the review provisions imposing tighter limits on health insurance rate increases. If they fail to meet these standards, the insurance companies will be required to provide a rebate to their customers starting in 2012.
If an insurance company has a low MLR (below 80%) this means they are spending more on administrative costs and likely denying medical services to patients. Conversely, if the insurance company has a high MLR (greater than 85%) they are spending more money on medical services than they budgeted. Basic economics says that when there is more money going out than coming in it is time to tighten the budget. In the case of a high MLR, the insurance company will scrutinize services and issue more denials.
What does this mean for you? If you are working with an insurance company who has denied a service for your patient, ask them about their Medical Loss Ratio. This identifies you as a savvy provider and puts the insurance company on alert that you will not take the denial without a fight. Another tool for you to use when appealing claims and services.
Relief and Call to Action
Posted by Linda Collins | November 12, 2012
The Medicare Audit Improvement Act for 2012, H.R. 6575, was introduced in the House on October 16. Addressing some of the audit issues facing providers, the bill has been referred to the Committee on Ways and Means and to the Committee on Energy and Commerce for consideration.
http://www.govtrack.us/congress/bills/112/hr6575
Key provisions in the bill include:
- Limiting the number of Medical record requests from contractors
- Requiring improvements in auditors’ operations, including financial penalties to the auditor for failing to meet stated timelines
- Penalizing auditors in the case of claims denials overturned on appeal
- Publicizing information on audit rates, denials, and appeals outcomes by auditor.
What does this mean for you?
These proposed changes, if passed into law, would provide needed relief to O&P providers. To support this proposed bill, you should contact your local representative.
If your representative is a member of the Ways and Means committee it is especially important to make contact.
When communicating with your representative, follow these guidelines:
Express your concerns and the difficulties you face in continuing to provide optimal patient care in today’s audit climate.
- Provide specific examples of denied claims. For example: “A 67 year-old man who has been a below-knee amputee for 35 years needed a new prosthetic. He is a barber, avid golfer, and enjoys traveling. A K3 prosthesis was provided to him, consistent with previous devices he has received for more than three decades. The denial from the auditor stated there was no history of his prosthetic use.”
- Provide specific patient examples of delay in patient care due to documentation requirements. For example: “69 year-old female with above-knee amputation has seen three doctors and one physical therapist in past 2 months but is still unable to get a medically-necessary prosthesis because her doctor has been unable to assemble the voluminous and complex data required by Medicare.”
- Explain the undue emphasis placed on physician documentation. For example: “Physicians will generally acknowledge that they are not subject matter experts when it comes to prosthetics. But requiring their records to nevertheless be the determining factor when auditing a claim does less to deter fraud, and more to deter medically necessary care and treatment to amputees than Medicare intended.”
Encourage your patients to contact their representatives as well. Together we can make our voices heard and influence change in the process.
“Somebody has to do something; it’s just incredibly pathetic it has to be us.” -Jerry Garcia
NOTE: While some of the provisions of HR 6575 apply specifically to Medicare Part A (Hospital) care and treatment, others apply more broadly to Part B, which includes the world of DMEPOS. The central issue is this: for the first time, there is legislation acknowledging issues created by RAC auditors and trying to solve them. HR 6575 provides you a unique opportunity to reach out to your local representative and educate him or her about how RAC audits impact the care you provide. If you do nothing, the effect of this bill on the O&P community could be extremely limited. But if you get involved, the final version could read more broadly and solve key issues facing your business today. The choice is yours.
The 2013 L-Codes: A Summary
Posted by David McGill | November 06, 2012
Monday, Medicare officially announced the L code update for 2013. With respect to lower extremity prosthetic codes, it is mercifully simple.
- Medicare did not delete any already-existing L codes.
- Medicare modified the language of L5972 to eliminate references to manufacturers’ specific products, but otherwise left the descriptor the same.
But in what is the biggest news for 2013, Medicare announced its final decision to create a new L code describing a powered knee joint: L5859. The new code reads as follows:
Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)
The significance of this decision is that it marks the first time that a motor-powered and programmable lower extremity joint has been recognized by Medicare as deserving of an L code. And we are proud to report that the application giving rise to this new code was submitted by Össur’s for its POWER KNEE, the first motor-powered knee joint available to above-knee amputees in the United States.
The new code will become effective on January 1, 2013. Pricing for the code remains unknown at this time, as Medicare has not yet unveiled the 2013 HCPCS Fee Schedule. That decision could come as early as the next month or so, but Medicare could choose to wait until sometime in 2013 to announce the fee for L5859.
So what does this mean for you?
1. Billing Medicare for POWER KNEE Between Now and January 1, 2013
Based upon the guidance from the HCPCS Coding Workgroup and its final decision regarding the POWER KNEE, Össur suggests the following codes for POWER KNEE claims submitted between now and January 1, 2013:
| L-Code | Description |
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type |
| L5999 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
| L5828 | ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL |
| L5845 | ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE, STANCE FLEXION FEATURE, ADJUSTABLE |
| L5848 | ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY |
2. Billing Medicare for POWER KNEE Effective January 1, 2013
Based upon the HCPCS Coding Workgroup’s final decision, you should use the following codes when billing Medicare for POWER KNEE effective January 1, 2013:
| L-Code | Description |
| L5856 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type |
| L5859 | Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s) |
| L5828 | ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL |
| L5845 | ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE, STANCE FLEXION FEATURE, ADJUSTABLE |
| L5848 | ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY |
Össur would like to thank Medicare’s HCPCS Coding Workgroup for its consideration of our application.
‘Tis the Season….for enrollment in Medicare Advantage plans
Posted by Linda Collins | October 31, 2012
Every year the open enrollment period for Medicare C, known as Medicare Advantage, is October 15 – December 7th. During this time beneficiaries are inundated with mailings, calls and TV ads about the various Medicare Advantage plans available in their area. In order to help you and your patients understand the choices presented, here are a few facts about Medicare Advantage programs:
- Medicare Advantage (MA) is a health insurance program that provides an eligible person with the United States' Medicare benefits. In other words, the Medicare Advantage plan must offer the same standard benefit package and cover everything covered by Original Medicare.
- Most Medicare Advantage plans are either health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which allow you to use specific doctors or facilities within a certain network. This means the patient may be restricted to certain providers within a geographic area.
- Medicare Advantage members generally pay a fixed amount (a copayment of $20, for example) every time they see a doctor as opposed to meeting a deductible and paying a coinsurance (typically 20%) under Original Medicare. This means the patient may have lower out of pocket costs for high dollar items, but the provider must agree to accept the fee schedule offered by the Medicare Advantage plan.
- A member of a Medicare Advantage plan cannot also use a Medicare Supplement Insurance (Medigap plan) to pay for out of pocket expenses. Medigap policies can only be used with Original Medicare programs.
- Many Medicare Advantage plans offer additional benefits such as gym membership, as a way to induce healthy members to join their plan.
- Medicare Advantage plans may require a provider to sign a participation contract outlining utilization responsibilities and fee schedules that are below the standard Medicare payment.
- Typically, Medicare Advantage plans have timely filing requirements of 60-90 days versus the 365 days allowed by Original Medicare.
- The availability of Medicare Advantage plans vary by geographic region. Not all plans are equal and not all plans are available in every location.
What does this mean to you?
Make sure that you inform any patients who are considering enrolling in a Medicare Advantage plan to research all options before making a decision. They should compare the cost of the plan to the cost of Original Medicare and check the provider directory for provider preference. Providers who are considering participating in a Medicare Advantage network need to be aware of pre-authorization/utilization reviews, fee schedules and claims filing timelines.
The difference in both a patient’s out-of-pocket costs and the amount a supplier gets reimbursed by a Medicare Advantage plan versus Original Medicare can be significant! So take the time to educate your patients and yourself before making a decision that could have a big impact on that relationship.
The Error of Your Ways
Posted by David McGill | October 26, 2012
MAC Region A posted a CERT Error Rate publication to its website last Friday. Like all such publications, this one is designed to “assist suppliers in understanding the CERT review process, and to become familiar with the type of medical records requested.”
The key findings for 2 prosthetic claims discussed in the CERT Review:
Claim #1
- The prosthetist’s evaluation “identifies the functional level at K3, but the evaluation does not document how K3 was arrived at.”
- “There is a strength assessment but lacks documentation [sic] of ambulation capability and or potential ambulation capability.”
- “[D]ocuments only general statements of the fit and function with no assessment of ambulation, balance, etc. that would support the K3 functional level and no documentation of how the beneficiary ambulates with the new prosthesis[.]”
- Missing documentation in the treating physician’s clinical records regarding the patient’s K3 status.
Claim #2
- Prosthetist’s final fitting and deliver note states, “socket fit very well” however no documentation of gait with new prosthesis.
- “No notation of intent or need to replace prosthesis.
- Missing “[t]reating physician’s clinical documentation supporting the medical necessity of replacing the Prosthesis [sic] prior to ordering the replacement[.]”
- Missing “CPO’s evaluation of gait w/ new prosthesis at delivery supporting functional ability.”
What Does This Mean For You?
Taken together, the claims discussed in the CERT publication highlight three key things you need to address.
First, you need to be sensitive to K level documentation, a point we have discussed this in the past. (See our “Running the Functional Level Gauntlet” post, August 24, 2012). The MACs no longer blindly accept a prosthetist’s notes claiming K3 or K4 status. It’s clear they want something more. Your records must include a detailed description of why your patient is K#. “Because I said so” doesn’t cut it.
One way to buttress your K-level claim – and likely the most effective should you ever have to appeal a denial – is video of your patient. Given the ease with which you can now take high-quality video – iPhone with hi-def video recording, anyone? – why wouldn’t you take 5 minutes to shoot your patients walking every time they visit your facility?
Second, general statements of fit and function – “Patient donned prosthesis and it fit well”; “patient walked with no complaints and satisfied with fit” – will not withstand MAC scrutiny. A note based on non-specific statements should instead be broken down into a detailed description. For example:
“Patient donned new socket; no issues donning and no complaints of discomfort when static in prosthesis; patient walked for 25 minutes in facility without complaint; instructed patient to walk at extremely slow, self-selected, and faster than self-selected walking speeds; patient walked at all speeds without difficulty (video taken); evaluated gait and alignment; externally rotated prosthetic foot slightly after observing internal orientation unrelated to how socket donned by patient; following 25 minutes of walking, patient doffed socket and residual limb examined; no signs of breakdown, irritation, redness, or other indicia of compromised fit. (video taken)”
Third, ensuring that physician documentation corroborates your records remains a central challenge and necessity. We strongly recommend not delivering any prosthesis or a part thereof to a Medicare beneficiary until you confirm that the physician’s record adequately supports yours. You do this by establishing a relationship with the physician so that she understands your patient’s documentation needs. In addition, ask your patient to help. The Amputee Coalition has even developed a letter to assist you in that effort.
Conclusion
The MACs are clearly signaling to the O&P community what it is that they are looking at and for. The facilities best able to bring their processes in line with these requirements will have a huge competitive advantage over those that throw their hands up in despair and ask, “Why can’t it be like it was in the good old days?” The good old days are gone. You have to adapt to survive.
Cover Your Back
Posted by Linda Collins | October 15, 2012
Last week the OIG released their proposed Work Plan for 2013, which included several items related to the DMPOS industry (https://oig.hhs.gov/reports-and-publications/workplan/index.asp#current ). One issue relates to the cost of Medicare payments for back orthoses compared to supplier acquisition costs. The OIG announced they will compare the actual reimbursement amounts for products billed using L0631 to supplier invoice amounts. The OIG states that it believes the actual purchase price may be well below the reimbursement amount.
What does this mean?
First, it is likely that you will receive requests for copies of invoices for spinal orthoses. The OIG will expect you to have these in your files and make them available as needed.
Second, even though nothing has been announced, this action by the OIG may cause other auditing agencies, such as RACs, to pursue spinal orthoses claims as an issue.
What can you do?
Make sure you are purchasing your products from a reputable source and that you keep all invoices on file. Educate your staff about the process for obtaining and filing supplier invoices. Also make sure you staff is aware of possible requests from the OIG for copies of the invoices. Any requests should be responded to within the time frame indicated.
Since 2010 it has been a requirement that any spinal orthoses billed have a PDAC letter. Make sure the spinal orthoses you dispense have a manufacturers’ PDAC letter and that you are billing the code listed in that letter by the PDAC. It is a good idea to check the PDAC website to make sure the product is listed and the model numbers you are using are assigned to the code you are billing. (www.dmepdac.com).
Take this opportunity to review the Local Coverage Decision (LCD) and Policy Article for Spinal Orthoses. The Policy Article defines a spinal orthoses as a device with the following characteristics:
- Used to immobilize the specified areas of the spine.
- Intimate fit and generally designed to be worn under clothing.
- Not specifically designed for patients in wheelchairs.
The LCD states that a spinal orthoses is covered when there is documentation to support the orthosis was ordered one of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue; or
- To otherwise support weak SPINAL muscles and/or a deformed spine.
Finally, there are guidelines about spinal orthoses used at an inpatient or SNF facility. Payment for a spinal orthosis delivered to a patient in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:
- The orthosis is medically necessary for a patient after discharge from a hospital or Part A covered SNF stay; and
- The orthosis is provided to the patient within two days prior to discharge to home; and
- The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the patient to take home.
So, take a load off your BACK and familiarize yourself with the utilization and billing requirements now so you do not find your BACK against the wall in the future.
OIG Report Examines Medicare Payments for Prosthetics and Custom Orthotics
Posted by David McGill | October 12, 2012
Today, the OIG published a new report.The key findings:
- BIPA: Medicare has failed to create regulations implementing the “qualified provider” requirement of the Benefits Improvement and Protection Act (BIPA) of 2000. BIPA prohibits Medicare from paying for prosthetics or custom orthotics unless those items are furnished by a “qualified practitioner” and fabricated by a “qualified practitioner” or “qualified supplier”. Medicare was supposed to implement regulations enforcing this requirement by December 21, 2002. It hasn’t. So the OIG’s conclusion in this regard isn’t a surprise – it’s a statement of the obvious.
- Qualified Suppliers: More important, OIG concluded that despite the fact that Medicare has failed to implement the BIPA qualified supplier requirements, the vast majority of claims paid by Medicare – 97% - were in fact still paid to qualified suppliers. Stated another way, based upon the sampling conducted by OIG, unqualified suppliers do not make up a statistically-significant percentage of approved Medicare claims.
- Delivery Documentation: Finally, OIG noted that 11.6% (weighted average) of the sampled claims failed to have adequate documentation regarding delivery of the supplied item. 8.3% of those claims lacked the patient’s signature, and 3.3% lacked any documentation to support delivery. The lack of adequate documentation was much more pronounced in custom orthotics (17.2% of sampled claims) than prosthetics (4%). When OIG looked more closely at these numbers, focusing particularly on custom orthotics, it noted that 40.1% of those claims without adequate documentation were submitted by doctors, PT’s, OT’s, DPM’s, and orthopedic surgeons. In contrast, individual orthotists accounted for only .2% of those clams.
What Does This Mean?
First, the data suggest that certified/licensed orthotists do an excellent job of complying with Medicare’s requirements regarding the required documentation for delivery.
Second, OIG’s sampling – it looked at over 1100 claims – reveals that almost all of them involved “qualified practitioners”. This is significant because we expect that OIG will now conclude that any fraud/abuse data – both in the past and going forward – involves qualified practitioners, which includes ABC and BOC-certified practitioners and those licensed in those states with licensure laws. In other words, OIG may not be receptive to the argument that most fraud and abuse is the result of unqualified practitioners.
Third, OIG recommended that Medicare implement the “qualified practitioner” requirement in BIPA 2000. Medicare has agreed with that recommendation. If that happens, Medicare should be in a position to prevent payment of the estimated 3% of prosthetic/custom orthotics claims currently being made to unqualified practitioners.
Important Miscellaneous Information
Posted by David McGill | October 03, 2012
Medicare recently updated its Coding Procedures guidance, available on its website. While every supplier should take the time to become familiar with this revised document, we want to focus specifically on its guidance regarding miscellaneous (or “not otherwise classified”) codes.
What are NOC Codes?
Medicare states that “[t]hese codes are used when a supplier is submitting a bill for an item or service and there is no existing national code that adequately describes the item or service being billed.” (Emphasis added) Example: when Össur began selling PROPRIO FOOT in 2006, no other microprocessor-controlled ankle foot system existed. As a result, no then-current code described the unique characteristics of that device and Össur suggested the use of the prosthetic NOC code (L5999) while Medicare reviewed Össur’s application for a new L code.
Why do NOC Codes Exist?
Medicare created NOC codes for two main reasons.
First, “[t]he importance of miscellaneous codes is that they allow suppliers to begin immediately billing for a service or item as soon as it is allowed to be marketed by the Food and Drug Administration (FDA) even though there is no distinct code that describes the service or item.” In other words, Medicare sees the NOCs as a way to provide beneficiaries access to new services or devices before Medicare has the chance to formally consider and rule on a new code for them.
Second, “the use of miscellaneous codes also helps us to avoid the inefficiency and administrative burden of assigning distinct codes for items or services that are rarely furnished or for which we expect to receive few claims.” Stated another way, when Medicare determines that the administrative costs of creating a new code are greater than the cost of reviewing a small number of claims with a NOC, it will recommend the NOC for a particular service or device.
How Do You Use Them in Practice?
Medicare states that before using a NOC code
a supplier should check with the entity that will receive the payment claim to determine whether there is a specific code that should be used rather than a miscellaneous code. In the case of claims that are to be submitted [to Medicare], suppliers that have coding questions should check with the pricing, data analysis, and coding (PDAC), contractor to [Medicare].
If the PDAC confirms that use of a miscellaneous code is appropriate, Medicare will manually review the claim, will request a clear description of the item or service being billed, and will additionally seek detailed pricing information. Because of these requirements, NOC codes do trigger a high level or payer scrutiny, both with Medicare and with private payers. It is therefore critical that you have exhaustive documentation explaining the need for the service or device giving rise to the NOC code.
Future Trends re. NOC Code Use
A new development in the use of NOC codes is the strategic use of them in place of seeking a new code to describe a particular service or technology. Example: Manufacturer develops a new knee brace that isn’t described by the current code set. Instead of submitting an application for a new code to Medicare, it decides to suggest to customers that they use an NOC code to describe it on a permanent basis.
The appropriateness of using a NOC code as a replacement for seeking a new code is questionable. The primary goals of NOC codes, as outlined above, are (1) giving beneficiaries early access to new products, and (2) administrative efficiency for rarely-used items. But the widespread and indefinite use of NOC codes for a new prosthetic or orthotic device serves neither of those aims. In fact, using NOC codes in this context actually increases the administrative burden on payers.
We believe that if this practice becomes more widespread, Medicare will respond strongly. And the nature of that response may not be one that suppliers find attractive.
What Should You Do?
First, be aware of the updated Coding Procedures published by Medicare.
Second, before using NOC codes for Medicare claims, follow Medicare’s guidance, set forth above.
Third, if you get confirmation that use of a NOC code is appropriate, prepare yourself for a rigorous examination of the claim.
Beyond those three things, consider the future trend: is it a good thing to try and use NOC codes in place of new codes that specifically describe the service or item? And when asking that question, think about how Medicare and other payers will view the practice. Will they consider it a legitimate use of NOC codes given what they were originally designed for? Or will they view it as an inappropriate attempt to end-run the coding application process?
Blue Card Changes
Posted by David McGill | September 28, 2012
“The only constant is change”– Heraclitus a 500BC, Greek philosopher
The Blue Cross Blue Shield Association has notified the 39 independent Blue Plans of a change to the BlueCard® program that requires ancillary claims to be filed to their local plans. This ruling impacts independent clinical labs, DME/HME and specialty pharmacy providers. Many of the Blue Plans have already implemented this new procedure and Anthem has notified their contracted providers this process will become effective October 14, 2012. Anthem is the Blue Cross Blue Shield plan is 14 states, including California.
What Does This Mean?
First, this new ruling will impact billing of DME delivered to patients at home.
Second, the BlueCard® program historically defined the “local plan” as the service area where the provider was located. The revised ruling now defines the “local plan” as the service area where the equipment is delivered. An example illustrates the impact of this change:
a provider with a distribution center in Arizona provides a TENS unit to a patient residing in Iowa. The provider is contracted with the Blue Plan in Arizona. Under the new ruling, the provider must submit the claim to the Blue Plan in Iowa, regardless of whether it has a contract or not. Importantly, this means the claim may be processed at the out-of-network benefit level and financially impact both the patient and provider.
Third, and complicating matters is the fact that many of the Blue plans are not contracting with new, out-of-state providers, making it impossible for those individuals to get reimbursed at the in-network benefit level.
And one final twist: many Blue Plans pay out-of-network benefits directly to the patient. So, looking at the above example, if the provider is not contracted with the Blue plan in Iowa, the reimbursement will go to the patient, and the provider will be forced to pursue the patient directly for the entire payment. The effects of this ruling are not yet entirely clear. There are questions about what is included in the DME category. Does this include only the “E” HCPCS codes or does it also include orthotics billed under the “L” HCPCS codes? The various Blue plans have not yet been able to answer this question consistently.
Also, in order to determine location, the Blue Plans are now requiring the Place of Service field (Field 24B on the CMS 1500 Health Insurance Claim Form or - Loop 2300, CLM05-1 on the 837 Professional Electronic Submissions) on the claim to be completed with the patient’s address. Yet, there is no clarity as to how the claim will be processed if this field is left blank.
What Should You Do?
Until the BCBS Association provides further clarification, bill any DME services to the place of service Blue Plan. If you are not contracted with that plan, have a financial responsibility discussion with the patient before delivering anything. You may also wish to educate patients about how this restricts their care and how it affects them financially so that they can make an informed decision about whether to file a complaint with their plan. Finally, review your current payer contracts and service areas. If needed, contact additional Blue Plans for possible contracting opportunities.
“We're Not Gonna Take It Anymore”
Posted by Linda Collins | September 21, 2012
In the crazy world of reimbursement, linking Twisted Sister to an insurance lawsuit shouldn’t strike anyone as unusual.
Last week a group representing Los Angeles doctors and two patients partnered to sue Health Net Inc. for denying claims based on the insurer's definition of "medical necessity." The lawsuit, filed in Los Angeles Superior Court, accuses Health Net of unfair and unlawful business practices. While Health Net has not responded to the specific allegations in the lawsuit, it issued a press release noting that medical care is complex and there are differing medical opinions as to what constitutes medically necessary care
Does this mean that providers and patients have had enough and are fighting back? Should treating physicians define “medical necessity”? While a single lawsuit doesn’t constitute a trend, this one puts the medical necessity issue squarely in front of the California court system. Notably, the attorneys representing plaintiffs previously sued Health Net for rescinding insurance policies after insureds contracted expensive medical conditions, a suit that resulted in expensive fines against Health Net and new insurance rules.
Importantly, patients facing an insurance denial do have avenues of appeal, first internally with their health plan and then often with government regulators.
You can provide valuable clinical resources to support the appeal. Be familiar with the plan’s appeal process and follow the guidelines and time frames. Do not stop at the first level of appeal as that is what the managed care company wants from you. Instead, fight all the way to the external review. (If it’s a self-insured plan, your final level of review will be with the employer, not an external review agency.) If your state has a Consumer Assistance Program (CAP) utilize this source for assistance. For a listing of states with CAPs follow this link : http://www.healthcare.gov/using-insurance/managing/consumer-help/index.html).
As the song says:
“oh We're Not Gonna Take It
no, We Ain't Gonna Take It
oh We're Not Gonna Take It Anymore
no Way!”
source: http://www.lyricsondemand.com/
The Power of the Appeal
Posted by David McGill | September 20, 2012
Figuring out how to deal with a claim denial on the ground that the provided device/service was either (a) medically unnecessary or (b) experimental and investigational is a critical component of your business’s long-term success. Search the internet and you can find hundreds of articles detailing the elements of a successful appeal in a few hundred words. Attend a seminar and you can spend a day getting blow-by-blow instructions on the elements of a successful claims and appeal process. But both of these solutions assume an important truth: that appealing a denied claim actually works.
Though the data on this isn’t new, so few people know about it that spending a moment on the topic may prove an eye-opening exercise.
Why You Should Appeal: the Data Shows That it Works!
In 2011 the OIG published a report titled “Data on Application and Coverage Denials”. Key findings included:
- In the first quarter of 2010, only one-half of one percent of denied claims in Ohio were appealed. Stated another way, 99.5% of denied claims in that state ended with the insurer’s denial
- Successful internal appeals of claim denials ranged from a low of 39% for NY HMO’s to a high of 59% for Connecticut HMO’s. Overall, across the four states examined – CT, MD, NY, and OH – internal appeals resulted in successful outcomes nearly 50% of the time.
- Successful external appeals of claim denials ranged from a low of 23% in OH to a high of 54% in MD and CA. Most of the other states analyzed – CT, FL, NY clustered between 40% and 50% external appeal win rates.
What Does This Mean?
First, it’s important to recognize that most denials result in … nothing. Most suppliers/insureds never appeal the initial denial of their claims, letting payers walk away from any financial responsibility for the treatment scot free.
Second, those that do choose to appeal win. A lot. According to the data, your worst-case scenario involves a nearly 1 in 4 chance of defeating the insurer. While that may not sound fantastic, on a prosthetic claim worth $15, $25, or $50 thousand, why wouldn’t you take the time to file an appeal for a 25% chance to prevail?
And as noted, that’s the worst-case scenario; the data show that more often than not, your chances of successfully appealing a denied claim range from 40 to 50+ percent.
Finally, remember that this data only reflects averages. If you develop a sophisticated claims and appeal process, those numbers can trend higher. We know anecdotally that customers who take the time to develop an appropriate documentation trail win 75%+ of their claims. In my past life as a co-owner of a DMEPOS supplier, we had an appeal win rate in excess of 90%.
I will leave you with one final story: a customer who attended a reimbursement seminar I delivered came up to me two weeks ago at a conference. He shook my hand and told me that his company had implemented our recommendations. Since doing that last August, in one of the most claim-unfriendly environments in recent memory, his company has had 12 claims for high-end prosthetics denied. The company has appealed every one. They are 12-0.
Take the time to appeal. If you already do that, then take the time to learn how to do it better. The results are worth the investment.
ABNs Again
Posted by Linda Collins | September 12, 2012
CMS put into effect revisions to the Advanced Beneficiary Notification (ABN) manual this week. These changes bring the ABN into compliance with requirements arising out of the health care reform law (the Affordable Care Act). The changes clarify the use of the ABN in (1) new preventative services, (2) the DMEPOS competitive bidding program and (3) when upgraded components are added to a device.
ABNs are issued by providers and suppliers to inform Medicare beneficiaries about possible charges for items or services that are not covered by Medicare. The ABN serves as a notice to the beneficiary of impending financial obligation. The use of an ABN is mandatory when:
- A non-contracted supplier provides a beneficiary with an item or service listed in the Competitive Bidding Program.
Example: A patient has been referred to your practice for numerous DME items, including a standard walker. You are not a contracted supplier for walkers under the Competitive Bidding Program. You must provide the patient with an ABN and the option to obtain the item from a contracted supplier. - Prior to providing a service that is usually covered by Medicare but will not be covered because frequency limitations have been exceeded.
Example: A patient received a prefabricated, elastic knee brace (L1810) six months ago and now wants a new brace since the first one has been worn a lot. The reasonable useful lifetime for this brace is defined as one year. You are required to provide the patient with an ABN. - When a beneficiary receives a Medicare covered item containing upgrade components that are not medically reasonable and necessary and not paid for by the supplier.
Example: The patient has received a pre-fabricated, rigid knee brace (L1832) and is requesting an extra, removable soft interface (K0672) to wear with the brace. The patient will need to sign an ABN with explanation that the interface will be his/her financial responsibility.
A supplier does not have to use an ABN when the service provided is statutorily excluded from coverage by Medicare. However, in this situation, you may wish to issue the ABN voluntarily.
It is your responsibility to make sure your staff is aware of the requirements for the use of an ABN. More information can be obtained at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf
Code Cracking
Posted by David McGill | September 07, 2012
CMS. PDAC. HCPCS. Enough acronyms exist in the world of Medicare to confuse even experienced O&P professionals. The purpose of this post is to clarify two closely related but separate processes: (1) how codes get created; and (2) how that’s different from what the Pricing, Data Analysis & Coding (PDAC) group does.
How Codes Get Created
Based upon a variety of factors, Medicare can choose to create a code for a new prosthetic or orthotic device when the already-existing code set doesn’t adequately describe it. Medicare does not initiate this process. Rather, a product manufacturer submits an application setting forth what the new product is and why it believes a new code is warranted. A specific workgroup within Medicare – the HCPCS Coding Workgroup – reviews these applications. Every spring, the HCPCS Coding Workgroup publishes its initial decisions regarding the submissions made the previous year. Those decisions are finalized in November, and any new codes that are deemed payable by Medicare are added to the fee schedule effective January 1 of the following year.
So, for example, Össur submitted a request for a new code describing its POWER KNEE in December, 2011. This past spring, the HCPCS Coding Workgroup published a favorable initial decision indicating that it had decided to create a new code to describe this product. In November, the Workgroup will issue its final decision.
The Difference Between Code Creation and What PDAC Does
Unlike the HCPCS Coding Workgroup, the PDAC isn’t involved in new code creation. Rather, the PDAC assigns already-existing codes to devices. This can happen in two ways.
First, the PDAC can require that entire classes of devices come to it for review. For example, in 2011, the PDAC notified manufacturers that all products claiming L0174 had to be submitted to it. In order for a supplier to continue billing Medicare for a L0174 device, it had to be formally reviewed and listed on the PDAC website as qualifying for that code.
Second, a manufacturer can voluntarily go to the PDAC and request a coding verification. For example, Össur chose to do this for its Re-Flex Shock and Re-Flex Rotate feet, requesting L5987 for the former and L5987+L5984 for the latter. The PDAC issued coding verifications that confirmed the correct code for Re-Flex Shock was L5987 and the correct codes for Re-Flex Rotate were L5987+L5984.
One other thing about the PDAC: whenever the HCPCS Coding Workgroup creates a new code, the PDAC lists the product giving rise to that code on its website (e.g., PROPRIO FOOT and L5973). The PDAC does this because the creation of a code by the HCPCS Coding Workgroup acts as Medicare’s confirmation that the new code applies to that new product. The PDAC doesn’t have to review that product separately, because the creation of a new code for it by the HCPCS Coding Workgroup serves as verification of the code’s correctness.
Summary: What You Need to Know
The HCPCS Coding Workgroup creates new codes. The PDAC assigns already-existing codes to products. It’s that simple.
Consolidation is a Side Effect of Health Care Reform
Posted by Linda Collins | September 01, 2012
Last week Aetna announced the acquisition of Coventry Health Care, a provider of Medicare Advantage and Medicare Part D programs, as well as Medicaid managed care plans, group and individual health insurance. The deal will add more than 5 million customers to Aetna’s 36.7 million members, including 250,000 people on Medicare health plans and 930,000 on Medicaid. The investment means 30 percent of Aetna’s revenue will come from federal-backed plans for elderly Medicare enrollees and low-income Medicaid patients, compared with the current 23 percent. Aetna joins competitors WellPoint Inc. and Cigna Corp. in making acquisitions over the past year as the U.S. government expands medical coverage.
Why are the big health plans expanding their presence in managed Medicaid and Medicare Advantage? The current health-care law will add as many as 17 million patients to Medicaid programs across the US. Medicare managed-care plans are among the fastest-growing products for health insurers as Americans age Health care reform will likely decrease insurers’ profits margins because they will no longer be able to deny individuals with pre-existing conditions, and because the law limits how much they can raise their rates. On the other hand, more members means the health plan can more easily spread out costs over a larger population.
So, what does this mean for our industry? More patients will be covered by a managed Medicare or Medicaid plan. This might mean patients have less financial responsibility in copays and deductibles. The Medicare programs will be required to follow the coverage guidelines outlined by CMS, which are openly published. However, it also means that the managed care plans might be able to limit which providers are in a given network available to patients. Also, managed plans typically have reimbursement rates significantly below standard Medicare rates.
Managed care plans will continue to diversify their business and branch out into Medicare, Medicaid and workers compensation programs. As a provider, you will have to decide for yourself if you want to participate as an in-network provider with managed care plans. If so, now is the time to start cultivating those contractual relationships and reviewing the fee schedules. Being proactive and having a strategy of diversification will help you remain competitive in the field of health care.
Ten things to remember about TENS Device
Posted by Linda Collins | August 28, 2012
DME MAC Jurisdiction D recently completed a widespread pre-payment review of transcutaneous electrical nerve stimulators (“TENS”) devices, 2 lead (HCPCS code E0720). The results showed an overall error rate of 95%. In other words, 95% of the claims submitted lacked necessary elements for payment.
The key reasons for denial included missing medical documentation that indicated need for a TENS/other modalities tried and an invalid CMN.
What do you need to know in order to avoid TENS claims errors?
- The physician ordering the TENS unit must be the attending physician or a consulting physician for the disease or condition resulting in the need for the TENS unit.
- If a TENS with 4 leads is used, the medical record must document why 2 leads are insufficient to meet the patient's needs.
- A TENS is covered for the treatment of patients with chronic, intractable pain or acute post-operative pain.
- For chronic pain, the medical record must document the location of the pain, the duration of time the patient has had the pain, and the presumed etiology of the pain. The pain must have been present for at least three months. Other appropriate treatment modalities must have been tried and failed, and the medical record must document what treatment modalities have been used.
- When used for the treatment of chronic, intractable pain, the TENS unit must be used by the patient on a trial basis for a minimum of one month (30 days), but not to exceed two months. The trial period will be paid as a rental.
- The physician's records must document a reevaluation of the patient at the end of the trial period, must indicate how often the patient used the TENS unit, the typical duration of use each time, and the results.
- The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.
- An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.
- For a purchased TENS unit, a Certificate of Medical Necessity (CMN), which has been completed, signed and dated by the treating physician, must be kept on file by the supplier and made available upon request. The initial claim must include an electronic copy of the CMN. A CMN is not needed for a TENS rental.
- A TENS supply allowance (A4595) includes electrodes (any type), conductive paste or gel (if needed, depending on the type of electrode), tape or other adhesive (if needed, depending on the type of electrode), adhesive remover, skin preparation materials, batteries (9 volt or AA, single use or rechargeable), and a battery charger (if rechargeable batteries are used). Codes A4556 (Electrodes, [e.g., apnea monitor], per pair), A4558 (Conductive paste or gel), and A4630 (Replacement batteries, medically necessary TENS owned by patient) are not valid for claim submission to the DMERC. A4595 should be used instead.
For more information consult Transcutaneous Electrical Nerve Stimulators (TENS) Local Coverage Determination (LCD) and Policy Article at medicare-coverage-database.
Running the Functional Level Gauntlet
Posted by David McGill | August 24, 2012
The Medicare Administrative Contractor for Region A has announced the results of a complex prepayment medical review of prosthetic claims using the K3 functional level. The key findings were:
- after medical review, Medicare denied nearly 3/4ths of the claims (74.2%);
- 57% of the denied claims lacked clinical documentation to corroborate the prosthetist’s records and support medical necessity;
- 7% of the claims lacked functional level documentation from the prosthetist;
- 22% of the claims involved clinical records that didn’t justify the billed functional level.
Based on these results, the Region A MAC has stated that it will continue to review K3 claims. Notably, 1/3rd of the total denials center on the failure to adequately document or corroborate (through physicians’ notes) the patient’s functional level appropriately.
So what can you do?
First, make sure that your records adequately document the patient’s functional level in detail. Given the explicit guidance around K levels from the MACs and RACs over the last 12 months, a 7% prosthetist functional level “fail rate” is too high.
Second, and perhaps more important, you must take the time to make sure that the prescribing physician’s records corroborate yours. The majority of functional level denials referenced by MAC Region A have occurred because the doctor’s records either contradict or, more likely, remain completely silent about the patient’s functional level.
Medicare has made its position crystal clear: what’s in the doctor’s records should support the prosthetist’s findings and vice versa. Whether you like it or not, a key element of running a successful prosthetic practice in 2012 depends on a strong, collaborative relationship with the prescribing physician. The days of sending off a requested prescription, having the physician rubber stamp it, and getting paid by Medicare without any questions are over.
This no doubt presents enormous challenges to suppliers who have difficulty addressing these requirements. But it’s also an area of enormous opportunity for those who figure out a way to effectively manage them. The companies that adapt quickly (or that have already adapted) will have a significant competitive advantage over those that don’t. Which camp do (will) you fall into?
The Quest for Legible Signatures
Posted by Linda Collins | August 17, 2012
Medicare administrative contractors (“MACs”) are cracking down on signatures and certifications. Recent examples from the Comprehensive Error Rate Testing Program (“CERT”) indicates that claims are being denied for illegible practitioner signatures, illegible physician signatures, notes with no identifying practitioner, and signatures without dates or credentials.
According to CMS, in order for a signature to be valid, the following criteria must be met:
- Services that are provided or ordered must be authenticated by the ordering practitioner;
- Signatures are handwritten or electronic (stamped signatures are not acceptable); and
- Signatures are legible.
Reference: CMS “Medicare Program Integrity Manual” (Publication [Pub.]100-08), Chapter 3, Section 3.4.1.1.D
So in addition to assuring all clinical documentation is received, a practitioner must make sure all progress notes and reports are dated and signed with credentials. For more information go to Medicare Learning Network’s® MLN Matters® Article MM6698, “Signature Guidelines for Medical Review Purposes”
How does this relate to RAC audits and prepayment claim reviews? Based upon these CERT results, it appears that the MACs and RACs are getting ever more particular about strict technical compliance with things such as legibility requirements. The RACs, in particular, may look especially closely at these kinds of issues given the fact that they get paid a percentage of the money they recover.
So what can you do? Make sure you have standard charting procedures in place and always verify the legibility of all signatures before submitting your claim. Being able to read someone’s handwriting is an increasingly essential element in responding successfully to a RAC audit or a prepayment claim review. And, like it or not, it’s a clear Medicare requirement.
Region D Initiates Prepayment Review for Prosthetic L Codes
Posted by David McGill | August 13, 2012
MAC Region D (AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY) announced on Friday that it will be initiating a “widespread” prepayment review of claims utilizing codes L5673 (addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism) and L5301 (below knee, molded socket, shin, sach foot, endoskeletal system). In other words, nearly any claim for a below-knee prosthesis and/or a locking liner will fall within the scope of this prepayment review.
What can you do?
In the current environment, the question isn’t “what do I do to avoid prepayment review?”, but rather, “what do I do to successfully navigate it?” The key to a successful outcome on a prepayment review – especially one as far reaching as this one – is having a robust, repeatable claims process that captures all necessary documentation both from the prosthetist and the physician before you proceed to file your claim. The MAC Supplier Manuals (e.g., see Region D’s documentation requirements from Chapter 3 of its Supplier Manual here) and “Dear Physician” letters from last September outline these requirements clearly and comprehensively.
In addition, Össur Academy offers detailed seminars on exactly this topic. For more information about how to attend an upcoming seminar, please do not hesitate to contact your local Össur Area Manager for details.
PDAC Requirement Reversed: Is it Really a “Win”?
Posted by Linda Collins | August 09, 2012
On July 6, 2012 the four Durable Medical Equipment Medicare Administrative Contractors (MACs) posted a revised Local Coverage Determination (LCD) for Ankle-Foot/Knee-Ankle-Foot Orthoses (Effective Date July 1, 2012). The updated LCD has two items of note:
- It removed the requirement for PDAC coding verification for all L1930, L1932, L1940, L1960, L1970 and L1971 products.
- It re-stated that coding verification is still required for L1906.
While you could conclude that the removal of the PDAC coding verification requirement constitutes a “win” for the O&P industry, the recent action of MAC Region D suggests otherwise. Specifically, that MAC announced a widespread pre-payment review of claims involving codes L1960 and L1970. (It also included L4360 in the list of codes that would trigger pre-payment reviews.) So at least in that Region, even though manufacturers will not have to submit products claiming those codes for verification, suppliers will end up getting audited on them.
The new LCD language suggests the audits will be looking at the applicable diagnosis code to justify medical necessity of the orthotic, as well as appropriate medical documentation to support the diagnosis and prognosis. According to the CMS Supplier Manual, medical records include physician and prosthetist/orthotist assessment of the patient.
We will continue to monitor what the other MAC Regions do and will keep you apprised accordingly.
PROPRIO FOOT Coding Explained
Posted by David McGill | August 08, 2012
A frequent question we get asked is why we do not suggest add-on codes for PROPRIO FOOT.
The short answer is simple: when Medicare created code L5973 in 2010 to describe PROPRIO FOOT, its letter approving the code explicitly prohibited it:
[Our goal] is to establish language that is consistent with CMS’ intent to create a code that describes the entire system, and that is not intended to be used together with other codes. [Emphasis added]
Letter from CMS Coding Workgroup to Össur, Nov. 02, 2009
Based on this guidance, we believe that use of any add-on codes in conjunction with L5973 isn’t appropriate for Medicare claims. Please be sensitive to this when using L5973 for a microprocessor-controlled ankle-foot system.
If you would like to see a copy of the Medicare letter cited above, please do not hesitate to contact your Össur Area Manager.
Public-Private Cooperation Spells Higher Risk for Providers
Posted by David McGill | August 02, 2012
On July 26, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder announced a new partnership between the federal government, State officials, and key private insurers to identify and prevent health care fraud. In announcing the new initiative, Holder stated that “[b]ringing additional health care industry leaders and experts into this work will allow us to act more quickly and effectively in identifying and stopping fraud schemes, seeking justice for victims, and safeguarding our health care system.”
Among the organizations participating in this effort are:
- America’s Health Insurance Plans
- Amerigroup Corporation
- Blue Cross and Blue Shield Association
- Blue Cross and Blue Shield of Louisiana
- Centers for Medicare & Medicaid Services
- Coalition Against Insurance Fraud
- Federal Bureau of Investigations
- Health and Human Services Office of Inspector General
- Humana Inc
- Independence Blue Cross
- National Association of Insurance Commissioners
- National Association of Medicaid Fraud Control Units
- National Health Care Anti-Fraud Association
- National Insurance Crime Bureau
- New York Office of Medicaid Inspector General
- Travelers
- Tufts Health Plan
- UnitedHealth Group
- U.S. Department of Health and Human Services
- U.S. Department of Justice
- WellPoint, Inc.
What is the significance of this announcement? While the impact of this new partnership probably won’t be felt until 2013 at the earliest, it suggests that the environment of increased audits, prepayment reviews, and overall enhanced scrutiny of claims that we’ve seen in the Medicare program over the last 12 months is not only unlikely to slow down, but will instead expand into the private payer marketplace as well.
If that is the case, having detailed and complete medical records, coordinating and collaborating with physicians, and being able to demonstrate that your care and treatment leads to objectively verifiable positive outcomes will be the key ingredients to running a successful O&P business in the long term. We therefore recommend that you take time before the end of this year to perform a comprehensive, objective review of your record-keeping and billing practices. Identify your areas of weakness and fix them now. The time and money you spend today on those efforts may be the difference between you succeeding and failing tomorrow.
Össur R&R – An Introduction
Posted by David McGill | August 01, 2012
Welcome to Össur R&R, Össur’s Reimbursement & Regulatory blog providing updates and analysis of key payer, regulatory, and coding news. Our experts for both prosthetics and bracing will post weekly articles regarding items of interest to the O&P community. And if time-sensitive news from Medicare, the MACs, RACs, or the PDAC breaks, Össur Answers will be there not only to report on it in real time, but to interpret and analyze its potential significance to you, the supplier.
We hope you enjoy (and subscribe to) Össur R&R, yet another Össur resource designed to put you in a better situation to help your patients Live Life Without Limitations.