CERT Oxygen Errors - CGS Medicare · Common Errors - Detailed Written Orders No detailed written...

DME CERT Outreach and Education Task Force

National Oxygen Webinar, July 22, 2014

CERT Oxygen Errors: The DME CERT Outreach and Education

Task Force Responds

Revised July 16, 2014 © 2014 Copyright. 1

Today’s Presenters

Michael Hanna, CERT Task Force Coordinator

Jurisdiction A: Denise Winsock

Provider Outreach & Education Consultant

Jurisdiction B: Stacie McMichel


Jurisdiction C: Angie Cooper


Jurisdiction D: Jody Whitten



CERT Errors –

Medical Records


Oxygen Common Errors -

Medical Documentation

No medical records submitted indicating a qualifying arterial blood gas or

saturation test conducted within 30 days of the date on the initial CMN

No medical records submitted indicating re-evaluation conducted within 90

days of the date on the recertification CMN

No signature (handwritten or electronic) on the medical records

Missing or illegible signature and no attestation statement provided

No medical records submitted

No notation of clinical disease management in the medical record

Missing one of three required oximetry tests performed

during exercise


Oxygen Policy

Requirements –

Medical Documentation


Oxygen Coverage

1. Oxygen is considered for coverage if the following are met:

2. Severe lung disease or hypoxia-related symptoms that will improve with

oxygen therapy

3. Beneficiary’s blood gas study meets certain criteria

4. Qualifying blood gas study performed by physician or qualified provider of

laboratory services

5. Qualifying blood gas performed in one of the following:

1. Within two days of discharge from an inpatient stay

2. Beneficiary in a chronic, stable state

6. Alternative treatment measures considered and deemed

clinically ineffective


Oxygen Coverage – Group I

Group I includes any of the following:

1. ABG at or below 55 mm Hg or SAT at or below 88% taken at rest

2. ABG at or below 55 mm Hg or SAT at or below 88% for at least five

minutes during sleep (for beneficiaries with ABG at or above 56 mm Hg

or SAT at or above 89% while awake)

3. Decrease in ABG more than 10 mm Hg or decrease in SAT more than 5%

taken during sleep associated with symptoms or signs reasonably

attributed to hypoxemia


Oxygen Coverage – Group I

4. ABG at or below 55 mm Hg or SAT at or below 88% taken during

exercise for beneficiaries who exhibit ABG at or above 56 mm Hg

or SAT at or above 89% taken at rest.

Three blood gas tests required to complete this “exercise test” and

show improvement in hypoxemia during exercise:

i. Test taken on room air while at rest

ii. Test taken on room air while exercising

iii. Test taken on oxygen while exercising


Oxygen Coverage – Group II

A. ABG of 56-59 mm Hg or SAT at 89% taken during while at rest, during

sleep for at least five minutes or during exercise (as noted in the

preceding slide), and

B. Any of the following:

• Dependent edema suggesting congestive heart failure, or

• Pulmonary hypertension or cor pulmonale, or

• Erythrocythemia with hematocrit greater than 56%


Oxygen Coverage – Time Frame

Initial coverage for Group I beneficiaries is limited to 12 months

(or physician-specified length of need, whichever is shorter)

Initial coverage for Group II beneficiaries is limited to 3 months

(or physician-specified length of need, whichever is shorter)

Beneficiaries with ABG at or above 60 ml Hg or SAT at or above 90%

are considered Group III and there is no Medicare coverage


Oxygen Coverage –

Recertification

Recertification for Group I patients occurs twelve (12) months after initial

certification (i.e., with the thirteenth month’s claim)

Recertification for Group II patient occurs three (3) months after initial

certification (i.e., with the fourth month’s claim)

Beneficiary must be seen and evaluated within 90 days of the recertification

for either Group I or Group II beneficiaries and the most recent qualifying

test should be reported on the CMN

For Group II beneficiaries, a new qualifying test is required between the 61st

and 90th day following initial certification


Oxygen Coverage - Documents

If requested by a Medicare auditing entity, the supplier should provide

medical records (primary care physician, hospital inpatient records, IDTF

test results, home health chart notes, etc.) that show the beneficiary has

Qualifying test results within 30 days of initial date

Presence of lung condition or other medical condition that causes hypoxia

Notes indicating other treatments that were tried and not effective


Oxygen Coverage - Documents

The following are some guidelines to remember:

Supplier-generated forms are not considered part of the beneficiary’s

medical record (PIM 5.7 – 5.9)

Templates and forms (i.e., CMNs) are subject to corroboration with

information in the medical record (PIM 5.7 – 5.9)

All medical records must be signed by the author (PIM 5.3)

If the qualifying test result is on the physician’s orders, that same test result

must be in the beneficiary’s medical record (PIM 5.7 – 5.9)


CERT Errors –

Physician’s Orders


Common Errors -

Detailed Written Orders

No detailed written order submitted or the order is illegible.

Orders written or signed and dated after submission of the Medicare claim.

Detailed written order did not include all items ordered or did not match

item delivered/billed to the Medicare program

The length of need or number of refills on the order has expired

Orders missing elements such as frequency, dosage, or description of item

Detailed written order was not dated by the treating physician or a date

stamp was used


Oxygen Policy

Requirements –

Physician’s Orders


Oxygen Coverage –

Dispensing Orders

Equipment may be delivered to the beneficiary based on dispensing

orders if those orders include:

The beneficiary’s name

Prescribing physician’s name

Date of the order and the start date of the order (if the start date is

different than the order date)

Physician signature (for written orders) or supplier signature

(for verbal orders)

The supplier must obtain a detailed written order prior

to submitting a claim

Note: Exceptions for some HCPCS codes per MM8304.


Oxygen Coverage –

Detailed Written Orders

Detailed written orders must include:

Beneficiary’s name

Physician’s name

Detailed description of the items being ordered

Physician signature

Physician date

Physician NPI (for HCPCS codes affected by ACA 6407)

Signature stamps and date stamps are not accepted by Medicare


Oxygen Coverage –

Oxygen HCPCS in ACA 6407

Some oxygen HCPCS codes are found in ACA 6407 and require valid

detailed written orders prior to delivery

HCPCS Code Description

E0424 Stationary gaseous oxygen system

E0431 Portable gaseous oxygen system

E0433 Portable liquid oxygen system, home liquefier

E0434 Portable liquid oxygen system

E0439 Stationary liquid oxygen system

E0441 Stationary gaseous oxygen contents

E0442 Stationary liquid oxygen contents

E0443 Portable gaseous oxygen contents

E0444 Portable liquid oxygen contents


Oxygen Coverage –

Oxygen HCPCS in ACA 6407

The codes on the preceding slide require a face-to-face examination

within six months prior to delivery

The codes on the preceding slide require a detailed written order prior

to delivery that includes the physician’s NPI

Refer to Medicare Learning Matters article MM8304

for additional information


Oxygen Coverage:

Contents

If…. Your next step

F2F and WOPD for oxygen equipment Claims may be submitted for oxygen

includes oxygen contents for the initial contents once the stationary equipment

set up of home oxygen therapy…. meets the 36 month cap.

F2F and WOPD for oxygen equipment A new F2F and WOPD is required prior

does not include oxygen contents prior to delivery of the contents after the 36

to the initial set up for home oxygen month cap.

therapy…


CERT Errors –

CMNs


Common Errors -

Detailed Written Orders/CMNs

CMN used as a detailed written order and Section C was not sufficiently

detailed

Invalid CMN for date of service under review

Missing signed recertification CMN

Initial CMN invalid/incomplete/not submitted

Revised CMN not submitted when the LPM per medical records differ from

initial CMN


Oxygen Policy

Requirements –

CMNs


Oxygen Coverage – CMNs

CMNs are required per the Oxygen LCD. CMNs must be on form

CMS-484 – no other type or version of the Oxygen CMN will be

accepted. There are three types of CMNs in the Oxygen LCD

Initial – required when oxygen therapy begins

• Valid for twelve (12) months for Group I beneficiaries

• Valid for three (3) months for Group II beneficiaries

Revised – used to reflect change in supplier, physician, modality,

length of need, etc.

Recertification – required at the end of the initial certifying

period to reaffirm the need for oxygen therapy


Oxygen Coverage – CMNs

Suppliers may complete Sections A and C

• Section A – supplier, beneficiary and physician information

• Section C – narrative description of items being ordered

Physicians must complete Sections B and D

• Section B – Question set used to show test conditions and test results

(may be completed by physician employee)

• Section D – Physician’s signature and signature date

Please note – CMN may serve as the detailed written order

if Section C is appropriately completed


CERT Errors –

Continued Use and

Continued Need


Common Errors -

Continued Use and Continued Need

No documentation of continued use in the beneficiary’s medical record or

records from the supplier

Illegible records submitted

No evidence of continued oversight or medical management

No documentation submitted indicating beneficiary is mobile within the

home (when portable prescribed)

No evidence of re-evaluation before the recertification CMN was signed by

the treating physician


Oxygen Policy

Requirements –

Continued Use and

Continued Need


Oxygen Coverage –

Continued Use

Continued Use is the ongoing utilization of supplies or rental item by

the beneficiary.

Examples of Continued Use:

Evidence of portable tank exchange in the supplier’s documentation

Evidence of supply provisions (i.e., tubing) or concentrator maintenance in

supplier documentation

Treating physician’s chart notes indicating current oxygen therapy utilization


Oxygen Coverage –

Continued Need

Continued Need is the proof of medical necessity for oxygen therapy by

the beneficiary.

Examples of Continued Need:

Medical records or chart notes by the treating physician stating ABG or

SAT results and continued need for oxygen therapy

Medical records or chart notes by the treating physician showing

continued need for oxygen therapy prior to the recertification CMN

being signed.


Questions?


Thank you!

Thank you for participating in this

DME CERT Outreach and Education

Task Force Presentation.


Disclaimer

The DME CERT Outreach and Education Task Force consists of representatives from each of the

DME MACs and is independent from the CMS CERT Team and CERT Contractors, who are

responsible for the calculation of the Medicare Fee-for-Service Improper payment rate.

The DME CERT Outreach and Education Task Force has produced this material as an informational

reference for providers furnishing services in our contract jurisdictions. The DME CERT Outreach

and Education Task Force employees, agents, and staff make no representation, warranty, or

guarantee that this compilation of Medicare information is error-free and will bear no responsibility

or liability for the results or consequences of the use of this material. Although every reasonable

effort has been made to assure the accuracy of the information within these pages at the time of

publication, the Medicare program is constantly changing, and it is the responsibility of each

provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or

guidelines cited in this publication are subject to change without further notice. Current Medicare

regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at

http://www.cms.gov.


http://www.cms.gov/

CERT Oxygen Errors - CGS Medicare · Common Errors - Detailed Written Orders No detailed written...

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Transcript of CERT Oxygen Errors - CGS Medicare · Common Errors - Detailed Written Orders No detailed written...