Category: DME

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

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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

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CGS to begin claim adjustments to reflect competitive bid rates in non-CBAs

CGS announced yesterday that they will begin mass claims adjustments to reflect the revised 2016 DMEPOS fee schedule amounts for certain DME items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DME. CGS will adjust 40,000 claims each day for 24

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Improvements to the Adjudication Process of Serial Claims

A major win for DME Suppliers was announced yesterday, as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items. Prior to April 2017,

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Audit Alerts

DME contractors perform pre- and post-payment reviews on a continual basis. Through data analysis, the medical review department determines the codes they will review and then sends Additional Documentation Request (ADR) letters to suppliers that bill those codes. The following list includes those codes currently being reviewed amongst all four DME jurisdictions. Positive Airway Pressure

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Beneficiary Upgrade and Advanced Beneficiary Notice (ABN)

By Kim Turner, RN – Clinical Consultant An upgrade is an item with features that go beyond what is medically necessary. DME upgrades involve situations in which the upgraded item or component has a different HCPCS code than the item that will be covered by Medicare. An option/accessory that is beneficial primarily in allowing the

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Do’s and Don’ts: Amending a signed and dated Legal Document

By: Nancy Conant, Clinical Consultant Are you finding yourself challenged explaining how to properly amend the record to a therapist or practitioner, particularly when the document has been previously signed? DO The proper way to amend a Licensed Certified Medical Professional Specialty Evaluation and Face to Face Mobility Examination is to strictly adhere to CMS’s

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DMEPOS Order Requirements for Changing Suppliers

Effective April 24, 2017, MACs to accept timely orders and medical documentation (so long as it meets Medicare requirements), regardless of whether the supplier received the documentation directly from the beneficiary’s eligible practitioner or from another, transferring supplier. Be aware that a new order is required in the following situations: There is a change in

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Refill Requests: What to Include and When to Complete

By: Christina Colegrove, RN,BSN – Clinical Consultant Here are some things to remember when completing a refill request to avoid denials.  Documentation of a refill request must be either a written document received from the beneficiary or a written record of a phone conversation between the supplier and beneficiary.  The request must include the beneficiary’s

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Prior Authorization Condition of Payment for K0856 and K0861

By: Kim Turner, RN – Clinical Consultant CMS has announced that two items of durable medical equipment will be subject to required prior authorization beginning with dates of service/delivery March 20, 2017 for the following durable medical equipment: K0856: Power wheelchair, group 3 standard., single power option, sling/solid seat/back, patient weight capacity up to and

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