Author Archives: Kelly Grahovac

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.

https://med.noridianmedicare.com/web/jea/education/calculators-tools

https://www.cgsmedicare.com/jc/help/tools.html

Fact or Fiction: 3 HIPAA Myths Debunked

Whether it be denial, or a simple misunderstanding, there are quite a few myths out there when it comes to HIPAA compliance and how it applies to your business or entity. While we could spend all day debunking the myths we hear people churn out, we thought we’d cover three we believe are at the top of the charts. Let’s get to debunking!

Myth 1: We’re too Small

This is a situation where the old adage, size doesn’t matter, is true. No matter what size your business or practice is, if you handle, transmit or receive personal health information, HIPAA applies to you.

If you think because you’re a small business you can fly under the radar of the Office of Civil Rights, think again. In reality, small businesses and practices are hit the hardest with fines. With only around 30 percent of small businesses and practices having a compliance plan in place, the Office of Civil Rights knows who they need to be looking at for compliance regulations.

 

Myth 2: We’re Exempt

Like we mentioned above, if you handle, transmit or receive personal health information, HIPAA applies to you. Whether you’re a healthcare provider, health plan provider, clearinghouse, HME/DME supplier, or a business associate, you still need to remain in compliance and have the proper plans in places for breaches.

Since healthcare information can provide someone with a stolen identity, it’s critical to protect patient information with the utmost care. Believing that a business is exempt from the rules puts your patients and customers at risk. Make sure you have plans in place to prevent and mitigate breaches.

 

Myth 3: All the Liability rests with the Business Associate

Even though you may have a Business Associate Agreement in place, the liability is shared with the covered entity and the business associate. Don’t assume if a breach was to occur, you wouldn’t be responsible for fines and penalties because you have a business associate agreement in place. One way to help limit your liability is to only share need-to-know information with the business associate.

 

If you believed in one of these myths, HIPAAwise can help make the compliance process smooth and easy to achieve. To learn more about HIPAAwise visit our website here or contact us directly for a demonstration!

OIG Announces reviews on OTS orthotic devices

As part of the Office of the Inspector General’s (OIG) ongoing work plan efforts, off-the-shelf (OTS) orthotic devices were added to the active work plan items list last week. The OIG announced that, since 2014, claims for three OTS orthotic devices (L0648, L0650, and L1833) have grown by 97 percent and allowed charges have grown by 116 percent, reaching $349 million in 2016. Per the OIG website:

The Social Security Act states that no payment may be made under Medicare Part B for any expenses incurred for items that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” A Medicare Administrative Contractor (MAC) has identified improper payment rates as high as 79 percent for L0648, 88 percent for L0650, and 91 percent for L1833 within its jurisdiction. A top concern of the MAC is a lack of documentation of medical necessity in patients’ medical records. We will examine factors associated with questionable billing for the three orthotic devices, and describe the billing trends for these devices from 2014 – 2016. Specifically, we will evaluate the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim and will analyze billing trends on a nation-wide scale.

What you need to know:

The van Halem Group has seen increases in orthotics audits from the ZPICs and UPICs. These audits are both prepayment and postpayment audits, both of which add additional burdens to your daily workload. Additionally, the DME MACs have continued targeted audits of suppliers providing orthotic devices.

The OIG specified that they will be evaluating “the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim”. Although the LCDs do not specifically require this encounter, it is a best practice to reach out to the beneficiary’s physician to request supporting documentation prior to dispensing the products. This will ensure that coverage criteria is met.

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 ZPIC/UPIC, DME MAC, or 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 denial.

To ensure your documentation meets coverage requirements prior to billing, let our clinical staff conduct a  prescreen review.  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.

Contact us for more information!

CMS roll out ‘Patients over Paperwork’

In October, CMS Administrator Seema Verma announced the “Patients over Paperwork” initiative, which is in accord with President Trump’s Executive Order that directs federal agencies to “cut the red tape” to reduce burdensome regulations. Through “Patients over Paperwork,” CMS established an internal process to evaluate and streamline regulations with a goal to reduce unnecessary burden, to increase efficiencies, and to improve the beneficiary experience. In carrying out this internal process, CMS is moving the needle and removing regulatory obstacles that get in the way of providers spending time with patients.

How does “Patients over Paperwork” work?
Steering Committee: Patients over Paperwork is well underway. CMS has established an executive level Burden Reduction Steering Committee, which will take the lead on coordinating burden reduction across all of CMS. This Steering Committee oversees and prioritizes these reform efforts and ensures CMS has the right collaboration across the Agency to drive results.

Customer Centered Workgroups: CMS established customer-centered workgroups focusing first on clinicians, beneficiaries, and institutional providers. The job of these workgroups is to learn from and understand the customer experience, internalize it, and remember these perspectives as they do this work. Over time, CMS will establish similar workgroups for health plans, states and suppliers.

Journey Mapping: CMS will use tools to capture customer perspectives, like human-centered design and journey mapping the customer experience. Also, they will establish mechanisms to share across CMS what is learned from their customers so everyone benefits from that input. CMS will develop multiple stakeholder journey maps over the coming months.

What CMS is hearing: CMS has listened and is starting to address burden areas based on the what they have heard the most about:

  • Payment policy,
  • Quality measures,
  • Documentation requirements,
  • Conditions of participation, and
  • Health IT.

Listening Sessions: CMS has already begun and will continue to hold listening sessions, meetings, customer centered workgroups and other gatherings across the country. CMS has indicated the value in hearing directly from healthcare providers and beneficiaries, and their commitment to keeping patients first, in that they must hear firsthand from them and the people who care for them every day.

Reducing burden through rule making: As part of our commitment to hearing from stakeholders about the burden of regulations, CMS solicited comments on specific ideas to reduce those burdens through several Requests for Information in 2017. Thousands of comments were received and CMS is actively reviewing them to determine which ones can be addressed  through rule-making in 2018.

Sub-regulatory Changes: While much of the burden providers experience is due to CMS regulations, CMS acknowleges that there are many policy changes that could be made to address provider pain points that do not require rule-making. These are called these sub-regulatory changes. CMS has recieved a number of ideas on ways to ease burden on providers that can be implemented on a faster timeline through updated guidance, FAQs or other mechanisms. CMS is actively working to identify and implement these improvements.

What’s Next?
Sign up to receive regular Patients over Paperwork initiative newsletters. These newsletters will
provide you with the latest updates, policy changes, and resources that CMS has on burden
reduction and regulatory reform. Share the newsletters with your partners and colleagues and have them sign up for future emails. To subscribe to the email click here.

CMS has developed a central webpage to share updates and news related to Patients over
Paperwork.

 

Good Documentation Resolutions for 2018

By Kay Ellen Koch, OTR/L, ATP, RESNA fellow, Rehab Clinical and Education Consultant

At the beginning of the New Year most of us make resolutions. Whether it is for health, exercise, fiscal or general life improvements, resolutions can be good for us. Resolutions for documentation can be beneficial too. No matter if it is a requirement or best practice, the following resolutions may be good to share with your staff.

  • Check to see if your documentation signatures are legible. If the auditor cannot read the signature on your documentation, a denial may result. A signature log or signature attestation can provide clarity when illegible signatures are present.
  • Date of receipt. Although this is not a requirement for all documentation, it is a best practice to date stamp documentation as it is received from the referring provider. Date stamps should not obscure other information on the document, however, they should be dark enough to be readable and show the correct date.
  • For power wheelchairs, the physician who performed the face-to-face should also be the one that creates the 7 element order. It could be a cause for denial if it appears someone other than the physician created the 7 element order
  • When submitting a multiple page evaluation, it is best practice for the patient’s name to be on each page and/or be all pages to be clearly numbered (i.e. 1/10, 2/10, etc.) in case they get separated during the review process.
  • When documenting the home evaluation for wheelchairs, although beneficiary’s address is not a Medicare requirement, documentation on where the wheelchair will be used is. It is best practice to include the beneficiary’s address on the home evaluation to provide clarification on where it will be used.
  • Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary. Be certain you have progress notes or therapist documentation that support what is being provided. Remember certain items for Medicare (wheelchair seating, certain support surfaces, and orthotics) are diagnosis driven, which must be listed in the medical documentation provided.
  • Use documentation checklists. Both the CGS and Noridian websites provide multiple checklists for all types of equipment.
  • Invest time in training or educating your staff, so everyone works efficiently. Make a resolution to provide your patient with the best possible equipment, delivered timely and the claim processed correctly.

 

Need some assistance training your staff on documentation requirements, best practices, or policy guidelines? The van Halem Group can help! Our trained consultants can provide both online and onsite training designed specifically for your needs. Contact us today for more information!

 

RAC AUDIT ALERT: VENTILATORS SUBJECT TO DWO REQUIREMENTS

On January 11, 2018, Performant Recovery, the National DMEPOS RAC, added ventilators to their approved issues list. According to their website, Performant Recovery will perform complex reviews on ventilator claims subject to DWO requirements on or after January 1, 2016 to determine if coverage criteria and/or medical necessity requirements were met.

Codes included in the audit: E0465, E0466

Applicable policy references:

  • Social Security Act, Section 1833. [42 U.S.C. 1395l] (e)
  • Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries
  • 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
  • 42 CFR 424.57(a)(12)
  • Title XVIII, Social Security, §1862(a)(1)(A)
  • CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9
  • CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20
  • CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1
  • CMS Policy Article A55426 for Standard Documentation Requirements for All Claims

 

Want some help? Come to the experts! 

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.

Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator 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 ventilator 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.

RAC Issues: Proposed and Approved

On December 12, 2017, CMS posted the second, monthly list of review topics that have been proposed, but not yet approved, for RACs to review. These topics are listed, on a monthly basis, on the CMS RAC Provider Resources page. For the month of December there is only one topic proposed for RAC review affecting DMEPOS suppliers, listed below.

Ventilators Subject to DWO requirements on or after January 1, 2016

Description: Documentation will be reviewed to determine if ventilators meet coverage criteria and/or are medically reasonable and necessary

State(s)/MAC regions where reviews will occur: All states

Review type: Complex review

Provider type: DME Supplier

Affected code(s):

  • E0464 – Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
  • E0465 – Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

Applicable policy references:

  • Social Security Act, Section 1833. [42 U.S.C. 1395l] (e)
  • Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 12, § 40.3 Claims Review for Global Surgeries
  • 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
  • 42 CFR 424.57(a)(12)
  • Title XVIII, Social Security, §1862(a)(1)(A)
  • CMS, IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 110
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS, IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9
  • CMS, IOM Publication 100-04, Medicare Claims Processing Manual Chapter 20
  • CMS, IOM Publication 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, §280.1
  • CMS Policy Article A55426 for Standard Documentation Requirements for All Claims

Currently CMS has approved the following issues for the RAC to review:

Complex Date Posted
Respiratory Assist Device 12/17/2017
PAP Devices for the treatment of OSA 9/19/2017
Spinal Orthoses 8/2/2017
Chest Wall Oscillation Devices 2/8/2017
Tracheotomy suction catheters, suction pumps, catheters and other supplies 2/8/2017
AFO/KAFO 7/7/2017
Negative Pressure Wound Therapy Pumps 4/28/2017
PMDs not subject to PA Demonstration 6/6/2017
Nebulizers 4/14/2017
Osteogenesis stimulators 2/14/2017
Group 2 Support Surfaces 2/15/2017
Blood Glucose Monitors with Integrated Voice Synthesizer 5/12/2017
Enteral Nutrition Therapy 5/11/2017

 

Automated Date Posted
CPAP without OSA Diagnosis 9/8/2017
Nebulizers 2/2/2017
Hospital beds with mattresses billed with Group I or Group II support surfaces 4/12/2017
Group 3 PWC Underpayments 5/17/2017
DME while beneficiary is in an inpatient stay 2/16/2017
Spring Powered Devices Billed for >1 in a 6 Month Period 1/5/2017
CPM Billed without Total Knee Replacement 2/2/2017
Glucose Monitor 1/5/2017
Multiple DME Rentals in one month 3/31/2017

Approved issues can be found on Performant Recovery’s website, here.

Want to feel confident that the ventilators you are providing meet coverage criteria? Sign up for our ventilator prescreen program.

Before you put out the equipment, let our clinical staff review your documentation to ensure the ventilator 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 ventilator prescreen program.

Be prepared before you receive a RAC audit. Ensure that your ventilator program is in compliance with Medicare regulations. Contact us to find out more information!If you receive a RAC audit

 

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