RAC Issues: Approved and Proposed

On November 13, 2017, CMS began posting a list of review topics that have been proposed, but not yet approved, for RACs to review. These topics will be listed, on a monthly basis, on the Provider Resources page. So far there is only one topic proposed for RAC review affecting DMEPOS suppliers, listed below.

Respiratory Assistive Devices: Meeting Requirements to be considered Reasonable and Necessary

Description: Review for reasonable and necessary requirements, including but not limited to the following:

  • treating practitioner had a face-to-face examination with the beneficiary in the six (6) months prior to the date of the written order for the specified items of DME
  • a completed, signed and dated 5-Element Order for Respiratory Assist Device dated on or before the delivery date of the item
  • the 5-Element Order contains ALL of the following:
    • Beneficiary’s name
    • Item of DME ordered – this may be general – e.g., “hospital bed” – or may be more specific
    • Signature of the prescribing practitioner
    • Prescribing practitioner’s National Practitioner Identifier (NPI)
    • The date of the order
    • proof of delivery, such as a delivery slip, which is signed and dated (on or before the date of service and on or after the initial order date) by the beneficiary or his/her designee

The proof of delivery documentation contains the following elements:

  1. Beneficiary’s name;
  2. Delivery address;
  3. Sufficiently detailed description to identify the item(s) being delivered (i.e. brand name, model number, narrative description);
  4. Delivery service’s package identification number, supplier invoice, or alternative method that links the supplier’s delivery documents with the delivery service’s records;
  5. Quantity delivered; and
  6. Date delivered

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

Review type: Complex review

Provider type: DME Supplier

Affected code(s):

  • E0470 – Respiratory Assist Device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
  • E0471 – Respiratory Assist Device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

Applicable policy references:

  • 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
  • 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
  • Related LCDs and Policy Articles

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

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
Complex Date Posted
PAP Devices for the treatment of OSA 9/19/2017
Spinal Orthoses 8/2/2017
Chest Wall Oscillation Devices 2/8/17
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

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

If you receive a RAC audit, The van Halem Group can help! Contact us to find out more information!