Monthly Archives: August 2017

Understanding your HIPAAwise Resources

As the saying goes, “Those who do not learn from history are doomed to repeat it.” Here at HIPAAwise, we’re firm believers of learning from history and taking that knowledge and using it to your advantage.

As you work to become HIPAA compliant you may wonder what you could be fined for or how patient health information could be involved in a breach. We understand HIPAA compliance can be confusing at times, and something may be overlooked which could be the difference between being fined and being in compliance.

To better help others understand, we have provided resources to review all HIPAA Fines imposed from 2015 to current. The most recent fines include the mishandling of patient information, the lack of understanding of HIPAA compliance, and no audit controls when employees are terminated or leave the company. To see the full list of the Office of Civil Rights click here. The settlement will take you to the Health Information Privacy for a longer description of the violation.

​In 2016, the number of security breaches increased 40 percent of over 2015. Breaches occur every day including, loss, theft, hacking or IT incidents and unauthorized access to patient information. Employees should be properly trained to help prevent breaches including but not limited to, knowing not to click on links from email addresses they aren’t familiar with, properly disposing of patient records, and working with business associates to ensure all policies and procedures are being followed properly. To view the list of Office of Civil Rights Breach Report, click here. Due to the sheer amount of breaches, you can filter by the type of breach in the top left hand corner.

If you’re looking to avoid situations found within the resources, sign up for a demonstration of HIPAAwise Powered by The van Halem Group. Our system is easy to use, and will take you beyond the four fundamentals of HIPAA, to ensure HIPAA compliance is met. If you have more questions please contact us here. 

ABN instructions – Special Guidance for Non-Participating Suppliers and Providers

CMS recently updated their ABN Form and accompanying instructions. For non-participating suppliers that issue an ABN for unassigned items/services you must do the following two things in order for the ABN to be considered a valid notice.

First, in the Options: Blank (G), you must strike the last sentence in the Option 1 paragraph with a single line so that it appears like this:

If Medicare does pay, you will refund any payments I made to you, less copays or deductibles.

This single line strike can be included on ABNs printed specifically for issuance when unassigned items and services are furnished. Alternatively, the line can be hand-penned on an already printed ABN.

The sentence must be stricken and can’t be entirely concealed or deleted.

Secondly, when the above sentence is stricken in (G), the supplier must include the following CMS-approved unassigned claim statement in the (H) Additional Information section:

“This supplier doesn’t accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier’s charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier’s charge.”

This statement can be included on ABNs printed for unassigned items and services or it can be handwritten in a legible 10 point or larger font.

An ABN with the Option 1 sentence stricken must contain the CMS-approved unassigned claim statement as written above to be considered valid notice. Similarly, when the unassigned claim statement is included in the “Additional Information” section, the last sentence in Option 1 should be stricken.

To review these instructions, and to access the updated ABN form click here.

UPDATE: Targeted Probe and Educate (TPE) Pilot

UPDATED: October 6, 2017

In October 2017, the TPE Pilot is now open to all four DME MAC Jurisdictions. Suppliers will be chosen based on the following criteria:

  1. Items that pose the greatest financial risk to the Medicare Trust Fund – HCPCS with high national error rates, high dollar equipment, etc.
  2. Individual suppliers with high error rates

HCPCS that were currently under widespread prepayment reviews will likely be the first group included in the TPE selection.

Lastly, the goal of the TPE program is to eventually replace all other DME MAC audits, meaning widespread prepayment and documentation reviews will eventually be phased out entirely.


In recent months, the CMS has been touting its new “provider friendly” approach, which is, in part, a way to decrease the ever-mounting appeals backlog. And they have introduced several initiatives to do just that, including limiting the scope of review of Redeterminations and Reconsiderations and adjusting serial claims found favorable in the appeals process. The next item on the list, however, may be positive or negative, depending on what side of the coin you fall on. Let me explain.

The DME MACs have recently began to roll out the Targeted Probe and Educate (TPE) Pilot program. Beginning on July 3, 2017, CMS authorized the DME MACs to conduct the Targeted Probe and Educate (TPE) Pilot review process. This pilot is currently open to Jurisdictions B and D DME MACs. TPE includes up to three rounds of supplier-specific prepayment probe reviews followed by education to improve identified errors. The goal of TPE is to improve the claims payment error rate and reduce the volume of appeals through claim review and education.

Suppliers chosen for the TPE program can expect the following:

  • DME MACs will utilize data analysis to select the suppliers in the probe. The identified suppliers will receive written notification that will include the topic being reviewed, data reasons for the selection and the process of the review.
  • The first-round prepayment probe review will begin following notification to the supplier. The DME MAC will request 20 – 40 claims for audit.
  • Suppliers with a high error rate on their prepayment probe review will receive an offer for one-on-one education relative to the specific errors identified through the probe review.
  • Following education, suppliers are expected to make necessary adjustments/process changes with sufficient improvement. This will be demonstrated through a second round of claim reviews to occur several months later during a second-round probe review. The probe review will again contain 20 – 40 claims for audit.
  • If improvement in the second-round probe review is not sufficient, suppliers will undergo another round of education followed by another probe review.
  • Following three rounds of probe and education, suppliers that do not demonstrate sufficient improvement in their error rate will be referred to CMS for possible further action.
  • Once a supplier has reached an acceptable error rate, the TPE process will end and the DME MAC will notify the supplier of successful completion.

It’s important to note that if selected for review, suppliers are not excluded from other Medical Review activities, such as, automated reviews, other pilot review programs, prior authorization, etc. as directed by CMS or other contractor reviews.

The DME MACs have indicated that if a high error rate persists following the maximum rounds of review and education, they will refer the supplier to CMS for possible further action. What does that include? Referrals to the ZPIC/UPIC for concerns related to potential fraud/abuse and Recovery Auditor (RA) for collaboration of vulnerability and to ensure there is no duplication of reviews.

One thing that is missing from the published articles and TPE letters: The potential for revocation of your Medicare supplier number. The Final Rule, effective December 3, 2014, states in part that, under authority of the ACA, CMS can and will deny or revoke enrollment of entities and individuals that pose a program integrity risk to Medicare for “… providers and suppliers that have a pattern and practice of billing for services that do not meet Medicare requirements.  This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program. “We saw contractors start adding this language into overpayment demand letters over the past year, which leads us to believe they would eventually like to use this as a tool to suppliers they feel pose too much of a risk.

Now more than ever, suppliers must be vigilant in the claims they submit to Medicare. Documentation should be reviewed prior to claim submission to ensure the LCD guidelines have been met. It is also necessary to educate your staff – from intake to billers. If you are selected for the TPE program you will be required to present documentation that supports the medical necessity for the equipment provided. Be sure that you have what you need to be considered “compliant” in your billing practices. TPE allows you three chances to “get it right”. Then you could face extrapolations, RAC audits that go back three years, or worse, revocation.

Data analysis will look for high error rates, high reimbursement dollars, and top billers by area. Don’t wait for the DME MAC to send you a letter advising that you are a chosen participant in the TPE pilot. Taking a proactive approach could save your business. The van Halem Group can help. We offer a variety of proactive services that will identify issues, educate your staff, and help you make the necessary corrections going forward. Don’t wait until you get the TPE notification letter.

Audit Alert: AFO & KAFO Orthoses

On July 5, 2017, Performant Recovery, the National DMEPOS RAC, added AFO and KAFO orthoses to their approved issues list. According to their website, Performant Recovery will perform complex reviews of these claims to determine if basic coverage criteria outlined in the Local Coverage Determination (LCD) for AFO/KAFO Orthoses was met. Performant will review medical documentation provided to determine that services were reasonable and necessary.

Codes inlcuded in the audit are: L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128.

Per the LCD, Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

    1. Require stabilization for medical reasons, and
    2. Have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

Remember that for custom fabricated orthoses (L1904, L1907, L1920, L1940-L1950, L1960, L1970, L1980-L2034, L2036-L2038, L2106-L2108, L2126-L2128, L4631), there must be detailed documentation in the treating physician’s records to support the medical necessity of custom fabricated rather than a prefabricated orthosis. This information will be corroborated by the functional evaluation in the orthotist or prosthetist’s records and must be available upon request.

The RAC can look back three years from the claim paid date for claims in this audit.

Who else is watching?

Both Noridian and CGS have had AFOs and KAFOs on prepayment review for some time. Denials for these claims are mostly documentation related, in that the provided documentation does not meet the coverage criteria in the LCD or support that the orthosis provided was custom fit. It is important that you review the documentation prior to claim submission, and when necessary, refer back to the ordering physician if additional notes are required to support the orthosis.

This LCD also requires a KX modifier for certain HCPCS codes. Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in
the “Coverage Indications, Limitations and or Medical Necessity” section in the related LCD have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

By appending the KX modifier to your claim, you are attesting to the fact that you have documentation to support the code billed to Medicare is medically necessary.

The van Halem Group can help! 

The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment.

Even more beneficial to you, is to allow our team to work for you proactively. Our clinical prescreen program provides reassurance that your documentation meets coverage criteria before you bill the claim. Our clinical team will review your claim prior to billing and work with you to obtain essential documentation from the ordering physician. Prescreens are charged on a per file fee.

For more information, contact us today!




AFO/KAFO Policy Article