Monthly Archives: February 2018

The value of prescreen review prior to a Medicare Request for Prior Authorization

By Kim Turner, RN, Clinical Consultant and Lisa Eick, RN, Clinical Consultant

If you provide complex rehabilitative equipment to Medicare beneficiaries, you are likely familiar with the Medicare Prior Authorization Requests program for the K0856 (Group 3 standard, single power option) and the K0861 (Group 3 standard multiple power option) wheelchairs. The program began for all suppliers for the K0856 and K0861 for dates of service on or after July 17, 2017.

While this is undoubtedly a valuable service, what is widely misunderstood is that, as a condition of payment for Prior Authorization, the DME MACs review the specialty evaluation “to determine the beneficiary’s medical necessity for the “power wheelchair base unit only”. The prior authorization process does not include review of the specialty evaluation to determine the beneficiary’s medical necessity for the related wheelchair options and accessories and/or wheelchair seating.  Further, similar to the review procedures for Advanced Determination of Medicare Coverage (ADMC), the prior authorization process for K0856 and K0861 does not include the consideration of same/similar equipment already in use and on file with Medicare.

Lack of a complete and thorough review of the medical records for wheelchair options and accessories, leaves the supplier vulnerable for potential overpayments in the event of a post payment audit. The van Halem Group is here to help you reduce the risk of costly denials and potential overpayments.

What are benefits of our prescreen services prior to sending documents to prior authorization?

  • Same/similar equipment review
    • Any same/similar equipment already in use that may be less than 5 years old.
    • Also, if there is same/similar equipment already in use, we review your medical records to ensure that they clearly document a significant change or decline in the beneficiary’s’ condition that would justify and support new equipment in less than 5 years.
  • Face to face examination and the LCMP specialty evaluation review
    • Our clinicians determine if the recommended (or ordered) power wheelchair base, all related options and accessories, and/or all wheelchair seating are sufficiently justified and supported in the medical records.
    • This allows the supplier to include the required KX modifier with confidence that the medical records document sufficient justification should Medicare or another audit entity requests the medical records during a pre- or post-payment claim audit.
  • ATP Evaluation review to ensure that the ATP’s participation in the selection of equipment is properly documented and satisfies Medicare ATP guidelines.
  • Review of the home evaluation to ensure the document contains all the required information, such as room measurements, and the document has been signed and dated.

What are the consequences of insufficient medical records in the post-payment environment?

  • Extra time and work to prepare and submit for appeal.
  • Full or partial overpayment of monies allowed in error. If you receive an overpayment, you are obligated to refund the money. It is in your best interest to immediately refundthe requested amount. This will help you avoid an offset and accruing interest.
  • Risk of denial for improper use of KX modifier. Many policies use the KX modifier to indicate compliance with specified coverage criteria.

An additional benefit of vHG prescreen review, is the valuable staff education regarding the Medicare coverage and payment guidelines and recent updates to the LCDs, policy articles, and HCPC billing codes.

Want to feel confident that the power wheelchairs and accessories you are providing meet coverage criteria? Sign up for our clinical prescreen services.

Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our prescreen program.

Contact us for more information!


*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.

CMS Provides Clarification on Proof of Delivery and Signature Requirements

By Nancy Conant, RN Clinical Consultant

Last month we told you about one of CMS’ newest initiatives, Patients over Paperwork. Started in December 2017, CMS plans to send out this newsletter on a regular basis, informing its readers about the progress being made on regulatory reform.  Through this initiative, CMS wants to place their focus on the “patient first” and ease the governing burden that is “destroying the doctor/patient relationship”.  Their plan is to evaluate and streamline regulations to “reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience”.

CMS is holding listening sessions, meetings, and customer centered workgroups across the US in an effort to hear your concerns about the issues impacting your business practice and client relationships.  They want to solicit specific ideas to reduce the burden.  CMS wants you to know they are listening to your concerns and have started to address some of the higher burden areas such as payment policy, quality measures, documentation requirements, conditions of participation and Health IT.

In the January issue of Patients over Paperwork (the 2nd issue), CMS provided clarification and guidance on two sections of the CMS Program Integrity Manual in their effort to simplify signature requirements and documentation requirements for DME. The updated sections were related to Proof of Delivery and Signature Requirements.

Clarified Proof of Delivery Requirements

Before: The Durable Medical Equipment (DME) Medicare Administrative Contractors
(MACs) help CMS to administer the DME benefit. Some DME MACs were routinely
asking suppliers for proof of delivery for every DME claim reviewed. Suppliers often find
it hard to respond to requests for this paperwork.

After: New guidance in the CMS Program Integrity Manual advise MACs to request
proof of delivery documentation for only those DME items that require a written order
prior to delivery, such as Power Mobility Devices. While suppliers are still required to
keep proof of delivery for every item they bill, this should reduce the amount of
paperwork suppliers submit to MACs during medical review.

Change Request CR10324

Clarified Signature Requirements

Before: CMS contractors occasionally denied claims when a nurse initialed a medication
administration log instead of including a full signature.

After: CMS clarified guidance in the Program Integrity Manual, such that providers
ultimately responsible for the beneficiary’s care must sign the medical record; however,
claims won’t be denied if a support care provider (such as a nurse documenting
chemotherapy) doesn’t sign part of the record.

Change Request CR10322


These newsletters are created to keep you up to date and informed about CMS’ initiatives to reduce the burden and provide regulatory reform.  If you haven’t yet, be sure to subscribe to the monthly newsletter.


Big Win for the O & P Industry

On Friday, February 9, 2018, it was announced that legislation was passed that CMS will now consider othotists and prosthetists notes as part of the patient’s medical record. Specifically, 13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m (h)) has been amended by adding at the end the following new paragraph:

‘‘(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

Note that this change does not eliminate the requirement that the physician order the equipment and appropriately document the medical need for it in his notes. It is imperative that practitioners continue to remain consistent in their notes with those of the physician’s.

There is still the need for LCDs, IOMs and other CMS publications to be appropriately updated, however, the bottom line is that the Orthotist and Prosthetist notes are now officially part of the medical record for purposes of Medicare medical necessity and claims audits!

The van Halem Group is working to obtain more information on the implementation and effective dates of updated policies. Continue to follow our blog and check back for more information on this change, as it becomes available.

The Value of MAC Online Tools

By Lisa Eick, RN – Clinical Consultant

Navigating the sea of Medicare requirements for DME suppliers is often overwhelming for even the most seasoned suppliers. In an effort to ensure suppliers have access to non-complex information CMS mandates the contractors have a method for suppliers to easily access the information. These valuable tools can alleviate the need to contact the customer service advocate.

The online tools offered by each contractor vary, but both have similar tools for calculating a variety of deadlines and tools for identifying what type of documentation is required to support a Medicare claim. These tools provided are an excellent resource for training and educating new staff, as well as providing a refresher for long term staff.

CGS recently added a Documentation Identification Tool which included valuable information and reminders to avoid highlighting or circling information on medical records to bring attention to the Medicare reviewer. The pre-designed divider sheets are intended to be a place marker in front of the specific documents submitted for review.

Noridian recently added a Nebulizer Drug Calculator, which displays the number of units that the supplier can bill in a 31 or 90-day period by entering the name and strength of the medication, the vial size dispensed and the frequency the patient takes the medication.

These are just two examples of the types of online tools the MACs have available to the supplier in an effort to ensure suppliers have quick access to timely and pertinent information on Medicare requirements.

The following are the links to both Noridian and CGS which provide the supplier with a wealth of information.