What’s New at Your DME MACWhat’s New at Your DME MAC

Adrian M. Oleck, M.D.Adrian M. Oleck, M.D.Medical Director, DME MAC, Medical Director, DME MAC,

Jurisdiction B Jurisdiction B September 30, 2010September 30, 2010

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Presentation OutlinePresentation Outline• DME MAC Overview• Role of Medical Director• Medical Policy Development• HCPCS Coding• CERT• Documentation Requirements• Audits – Therapeutic Shoes, Knee

Orthoses

Geographic Jurisdiction

Benefit Categories

• $11.6 billion allowed charges – National; annualized

• Durable medical equipment – $8 Billion– Oxygen – $2.1 B– Glucose monitor supplies – $1.5 B– Wheelchairs - $1.2 B– Nebulizers and inhalation drugs – $800

Million– All other – $ 2.4 B

Benefit Categories

• Prosthetic devices - $1.2 B– Parenteral and enteral nutrition - $640 M– Eyeglasses/contacts post cataract surgery

- $67 M– Urological supplies - $176 M– Ostomy supplies - $194 M– Breast prostheses – $46 M

Benefit Categories• Limb prostheses – $628 M• Immunosuppressive drugs –

$576 M• Braces – $440 M• Therapeutic shoes – $276 M• Oral anticancer drugs – $224 M• Surgical dressings – $184 M

Role of DMAC Medical Director

• Development of medical policy

• Implementation of medical policy

• Education related to medical policy

Role of DMAC Medical Director

• Implementation of medical policy– Automated system edits

• K modifiers for lower limb prostheses• Bundling• KX modifier• Other – quantity, frequency, etc.

– Medical review

Role of DMAC Medical Director

• Education related to medical policies– Internal

• Medical Review, Provider Outreach and Education, Appeals

– External – Suppliers• Bulletin articles

– External – Other contractors• PSC (Program Safeguard Contractors)/ ZPIC (Zone

Program Integrity Contractors) – fraud and abuse• RAC (Recovery Audit Contractors) – post payment

review

Role of DMAC Medical Director

• DMD collaboration– Conference calls; emails– Consistent interpretation of policies– Consistent implementation

Medical Policy Development

• Currently 54 policies– Ankle-Foot and Knee-Ankle-Foot Orthoses– Knee Orthoses– Lower Limb Prostheses– Orthopedic Footwear– Spinal Orthoses– Therapeutic Shoes for Diabetics

Medical Policy Development

• Medical policy = LCD + PA– Local Coverage Determination (LCD)

• Medical necessity coverage criteria• HCPCS codes and modifiers• ICD-9 diagnosis codes• Documentation requirements

– Policy Article (PA) • Statutory coverage criteria• Coding guidelines – code definitions

Medical Policy Development

• Reasons for a formal policy– High dollar volume– Disproportionate increase in utilization– Inappropriate utilization– New technology

Medical Policy Development

• New policy development process– Data analysis– Literature review– Informal consultation with suppliers,

clinicians, manufacturers– Draft policy for public comment – 45 days– Review of comments and policy revision– Final policy – 45 days notice prior to

implementation

Medical Policy Development• Policy revision – minor

– No public comment– HCPCS code changes– ICD-9 diagnosis code changes– Clarifications of coverage criteria– Revised documentation

requirements– New/revised coding guidelines

Medical Policy Development

• Policy reconsideration process– Submit request to the DMDs– Include rationale, supporting

documentation, literature

• Policy revisions – major– Restrictions in medical necessity coverage

criteria– Similar process to new policy

development, including public comment

Medical Policy Activity – O&P

• Lower limb prostheses– Functional levels– High $ components

• Data analysis

HCPCS Codes

• PDAC – Pricing, Data Analysis, and Coding Contractor– Coding Verification Review

• Mandated – specified in certain policies – e.g., TSD

• Optional• Involvement of DMDs• DMECS (Durable Medical Equipment

Coding System) – PDAC web site

HCPCS Codes

• PDAC (cont.)– Informal coding guidance

• Help desk– Development of new codes– DME MAC representative on CMS A-N

Workgroup• Participate on DMD calls

HCPCS Codes• CMS HCPCS Alpha-Numeric Workgroup

– Composition• CMS staff (Medicare and Medicaid), VA,

commercial insurers, PDAC– Yearly cycle

• Application for new/revised codes• Review and preliminary decision

– Involvement of DMDs

• Open meeting• Final decision

– Quarterly updates

HCPCS Codes

• DMD initiated coding changes– Work through PDAC and A-N WG

• Coding issues– Correct coding

• Upcoding– Unbundling

CERT

• Comprehensive Error Rating Testing Program

• DME MAC error rates– May 08: 9%– Nov 09: 52%– Nov 10 (est): > 70%

CERT

• What changed??– OIG report – Aug. 08– CMS guidance to contractors

• Assess every required element• Strict interpretation• No exceptions

Documentation

• Orders– Dispensing order– Detailed written order

• Prior to claim submission

Documentation

• Medical records– Ordering physician– Chart notes – Office, hospital, nursing

home– Justification for category of item – e.g., BK

prosthesis, AFO, TLSO, etc.– Justification for specific code category –

e.g., joint laxity in Knee Orthoses policy

Documentation

• Supplier records– Justification for specific type of device and

additions– Documentation of functional level for LLP– Proof of delivery

Medical Review

• Prioritization of policies– CERT errors– Allowed $ - current– Allowed $ - trends – short term and long

term

• Widespread (all suppliers) or supplier-specific

• Pre-payment review

Therapeutic Shoes

• Policy revision and bulletin articles• Documentation requirements

– Orders– Medical records

• Certifying physician – MD/DO who manages diabetes• Diabetes management• Qualifying condition

– Documented in MD/DOs own records; or– Review, sign, date, indicate agreement with

podiatrist’s note

Therapeutic Shoes

• Documentation Requirements (cont.)– Statement of certifying physician

•Not a substitute for medical records– Fitting/selection visit– Delivery visit– Proof of delivery

• Sequence/ timing requirements

Therapeutic Shoes

• Recommendation – obtain medical records prior to claim submission

Knee Orthoses

• For contractures• For ambulation

– Document knee instability; objective description of joint laxity• In physician records

– Symptoms and/or diagnoses by themselves are not sufficient

Knee Orthoses

• Custom fabricated– Documentation of physical characteristics

which preclude use of prefabricated brace• Deformity of leg or knee• Size of the thigh and calf• Minimal muscle mass on which to suspend

the brace– Documentation may be in physician or

supplier records

Knee Orthoses

• Elastic orthoses – noncovered• Reasonable useful lifetime• Addition codes

– Eligible for separate payment– Not medically necessary– Bundled; not separately payable– Incompatible

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QUESTIONSQUESTIONS