Investigation of APNT Optimized DME/DME Network Using Current
DME CERT Task Force Webinar – December 18, 2013 · 12/18/2013 · The DME MAC CERT Task Force...
Transcript of DME CERT Task Force Webinar – December 18, 2013 · 12/18/2013 · The DME MAC CERT Task Force...
DME CERT Task Force Webinar – December 18, 2013
Revised December 6, 2013. © 2013 Copyright. 1
Michael Hanna, CERT Task Force Coordinator
Jurisdiction A: Denise Winsock Provider Outreach & Education Consultant
Jurisdiction B: Nina Gregory Provider Outreach & Education Consultant
Jurisdiction C: Mia Gott Provider Outreach & Education Consultant
Jurisdiction D: Jody Whitten Provider Outreach & Education Consultant
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All registrants received an e-mail from: Medicare Webinar by National Government Services [[email protected]]
Click on the link within the e-mail to join the Web presentation
Using your telephone, dial into the conference call using the number and access code provided in the e-mail
Once you are connected to the audio, the PIN displays
Input the PIN on your screen into your telephone
Dial in number and PIN are unique for each attendee
The DME MAC CERT 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 CERT Task Force has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. The CERT 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.
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Physician’s Name
Beneficiary’s Name
Description of the Item
Start Date
Physician’s Signature
Why is this dispensing order invalid for a lightweight wheelchair?
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Dr. Bruce Smith M.D. Dr. Paul Clark M.D. Dr. Julia Pain D.O.
Illegible Signature
No detailed written order submitted or the order is illegible
Order missing one or more of the required elements
Detailed written order did not include all items ordered
The length of need on the order has expired
Start date is after the date of service
CMN was used as an order and section C was not sufficiently detailed
Signature requirements not met:
• Illegible Signature
• Signature Stamp used
Detailed written order was not dated by the treating physician or a date stamp was used
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Beneficiary’s Name
Physician’s Name
Order Date
Length of Need/Refills
Description of the Items and Quantity
Physician’s Signature and Date
Dosage and Frequency
Order For Nebulizer and Supplies – What is missing?
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Missing the description of all items ordered
Missing the length of need/number of refills for supplies
Why is this glucose supply order invalid?
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Unclear frequency of testing
Remember: Orders will be less clear after faxing. If you can not read it…neither can the reviewers!
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A CMN can serve as the order as long as Section C is sufficiently detailed. What is missing from Section C of this Oxygen CMN?
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Dr. James Davis 05 30 13
E1390 $250.00/month $198.40/month
E0431 $250.00/month $31.79/month
Missing Narrative Description
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Beneficiary’s Name
Physician’s Name
Order Date
Length of Need/Refills
Description of the Items and Quantity
Physician’s Signature and Date
Dosage and Frequency
NPI 1234567890
NPI is required on all items which require a face to face
under the ACA
No 7-Element order submitted
Order missing one of the 7 elements
No confirmation the supplier received a copy of the 7-Element order within 45 days after completion of the Face-to-Face
7-Element order and detailed product description are on the same document
7-Element order is dated prior to the Face-to-Face evaluation
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Valid 7 Element Order
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5/15/12
• Beneficiary’s name • Description of the item that is
ordered • Date of the face-to-face
examination • Pertinent diagnoses/conditions
that relate to the need for the POV or power wheelchair
• Length of need • Physician’s signature • Date of physician signature
Why is this 7 element order invalid?
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No Physician’s Signature Date
No Pertinent Diagnoses/ Conditions
No Date Stamp to Document Receipt
Continued use describes the ongoing utilization of supplies or a rental item by a beneficiary
Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies
Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary
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Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary: Timely documentation in the beneficiary’s medical record showing
usage of the item, related option/accessories and supplies
Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements (sufficient to document continued use for the base item, as well)
Supplier records documenting beneficiary confirmation of continued use of a rental item
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Initial justification for medical need is established at the time the item(s) is first ordered
Beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription
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There must be information in the beneficiary’s medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary
A recent order by the treating physician for refills
A recent change in prescription
A properly completed CMN with an appropriate length of need specified
Timely documentation in the beneficiary’s medical record showing usage of the item
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Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy
This applies to both continued use and continued medical need
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Records are not within 12 months of the date of service reviewed
Illegible Signature
• Electronic protocol for electronic signature
• Signature log for hand written signatures
Records submitted do not make reference to the item ordered.
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Medicare Program Integrity Manual 100-08 Chapter 5 Section 5.2.5:
“For DMEPOS items and supplies that are provided on a recurring basis, billing must be based on prospective, not retrospective use.”
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Physician writes an order for enteral nutrition that translates into the dispensing of 100 units of nutrient for one month
100 units delivered
Date of service = date of delivery
100 units billed
Acceptable!
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Physician writes an order for enteral nutrition that translates into the dispensing of 100 units of nutrient for one month
100 units delivered but claim is not billed
Supplier determines at the end of the month the beneficiary used 90 units of the 100 delivered (adjusted future shipment accordingly)
Claim is submitted after the used amount is determined with a date of service as the date of delivery indicating 90 units
Not acceptable!
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Medicare Program Integrity Manual 100-08 Chapter 5 Section 5.2.6: • Suppliers must contact the beneficiary prior to dispensing the refill and not
automatically ship on a pre-determined basis:
– Ensure the refilled item remains reasonable and necessary
– Existing supplies are approaching exhaustion
– Confirm any changes/modifications to the order
• Contact must take place no sooner than 14 calendar days prior to the delivery/shipping date.
• Supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product regardless of which delivery method is utilized
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Consumable:
• “Yes” or “No” questions only regarding whether a refill is needed/wanted
• Documentation only providing information regarding the amount of supplies being requested
• Documentation only stating less than the threshold is remaining
Non-consumable
• Need for refill not justified
*Identical refill language for each beneficiary raises question on whether an individual assessment was conducted
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Submit individualized and detailed records that quantify or assess the functional status of remaining supplies
Actual count is recommended but not necessary however evidence of an individual assessment is required
*Auditor must be able to determine quantity or functional status was assessed and approaching exhaustion or non-functional on the delivery date
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Supplier Standard 12
Required for all items provided
Verifies beneficiary received item
Must be available upon request
Assists in coding verification and billing information
• If the service provided does not have appropriate proof of delivery from the DME supplier, the claim in question will be denied and/or overpayment will be requested
Maintain for seven years
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Signed delivery slip must include:
• Beneficiary’s name
• Delivery address
• Sufficiently detailed description to identify the item(s)
• Quantity delivered
• Date delivered
• Beneficiary (or designee) signature and date of signature
Date of signature must be date beneficiary or designee received item
Date of service must be date of delivery
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Proof of delivery can be signed by: Beneficiary Beneficiary’s designee
• Relationship to beneficiary must be noted on delivery slip
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Proof of delivery cannot be signed by: Suppliers Employees of suppliers Anyone with financial interest in
delivery of item
Jane Dodo
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Proof of delivery requirements:
Beneficiary’s name
Delivery address
Delivery service’s package ID number (or any alternative method that links the supplier’s delivery documents with the delivery service’s records)
Detailed description of the item(s) delivered
Quantity delivered
Date delivered
Evidence of delivery
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Suppliers may use return postage-paid invoice from the beneficiary/designee
• This type of delivery record must contain the information outlined on the previous slide
Date of service must be shipping date
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This example is valid as the order number is on the UPS tracking information and on the packing slip. The items shipped can be verified from all documents related to the shipment.
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Delivery to a nursing facility on behalf of the beneficiary
• Direct deliveries, follow Method 1 delivery requirements
• Delivery service/mail, follow Method 2 delivery requirements
Facility records must show beneficiary actually received and used the items delivered
• Must be available on request
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This valid example includes documents presented through Slide 48. There is evidence of a consistent number across the documents and proof the enteral nutrition was held for the Medicare beneficiary in question
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Items may be delivered to a hospital or nursing facility for fitting or training up to 2 days prior to anticipated discharge
• Date of service must be date of discharge
Items may be delivered to beneficiary’s home in anticipation of discharge approximately 2 days prior to discharge
• Date of service must be date of discharge
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Direct delivery invoice missing date signed
Date of service on the claim does not match date of direct delivery or ship date
Items dispensed to the home two days prior to discharge do not list discharge date as date of service on the claim
No proof items delivered to a nursing home was received by the beneficiary
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