Face to Face and

Documentation Review:

How Do You Get It All?

Ronda Buhrmester, CRT

VGM / US Rehab

O: 888-665-6518

F: 855-262-3821

ronda.buhrmester@vgm.com

Learning Objectives:

1. Identify documentation that is required to be in the

patient’s file prior to delivery of equipment and prior to

claim submission.

2. Discuss the face-to-face requirements related to the ACA

6407.

3. Identify the difference between orders and what

information is necessary.

4. Discuss recommendations for educating the referral sources

on documenting in the medical record.

Documentation Review,

What is Needed?

Basic coverage for Medicare

BASIC coverage determination for all audit entities:

Must not bill Medicare more than you would any other

entity

Item must be Medically Necessary for use within the

home

Medicare will pay for least costly alternative

Must provide the item prior to billing

An item is considered as DME if--

1. It can withstand repeated use, and

2. Is primarily and customarily used to serve a medical

purpose, and

3. Generally is not useful to a person in the absence of an

illness or injury;

4. Is appropriate for use in the home.

Program Integrity Manual (on line only manual) www.cms.hhs.gov/pim

Who can order DME? The ordering practitioner can be:

• Physician

• Nurse practitioner

• Physician assistant

• Clinical nurse specialist

BUT: Must have own NPI & must be allowed to practice medicine in the state they are treating the patient for the condition the item is being provided for.

AND: They are practicing under the supervision of a doctor of medicine or doctor of osteopathy

Supplier Standards • Must meet to receive and maintain billing privileges

• Became effective December 11, 2000

• DMEPOS suppliers have the option to disclose the following statement in order

to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a

copy of the standards to the beneficiary.

“The products and/or services provided to you by supplier legal business name or

DBA are subject to the supplier standards contained in the Federal regulations

shown at 42 Code of Federal Regulations Section 424.57(c). These standards

concern business professional and operational matters (e.g., honoring warranties

and hours of operation). The full text of these standards can be obtained at

http://ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the

standards.”

• Make sure all staff has read and understands the Supplier Standards

---review annually

Most LCD policies now contain this notice

For any item to be covered by Medicare, it must 1) be eligible for a

defined Medicare benefit category, 2) be reasonable and necessary for

the diagnosis or treatment of illness or injury or to improve the

functioning of a malformed body member, and 3) meet all other

applicable Medicare statutory and regulatory requirements. For the

items addressed in this local coverage determination, the criteria for

"reasonable and necessary", based on Social Security Act §

1862(a)(1)(A) provisions, are defined by the following coverage

indications, and limitations and/or medical necessity.

PIM 5.7- Documentation

“For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type & quantity of items ordered & for the frequency of use or replacement (if applicable). ----- However, neither a physician’s order nor a CMN nor a DIF nor a physician attestation statement by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. ----”

Changes to the PIM regarding documentation

• On March 15, 2013, Section 3.3.2.1(C) of the amended PIM states that “physicians/LCMPs [licensed/certified medical professionals] who fail to submit documentation upon a supplier’s request may trigger increased MAC or RAC review of the physician/LCMP’s evaluation and management services”

Intake and Assessment • Need a strong, knowledge intake department

• Assures proper documentation is collected and meets coverage requirements

• Make sure understand what is required

• Encourage them to ask questions

• Make sure the date of the F2F is on the intake sheet or part of the intake questionnaire:

When did you see your ordering practitioner for this item being billed to your insurance?

Make sure it’s within the last 6 months—If applicable, Oxygen (E1390, E1392, K0738) are still at 30 days or 2 days prior to discharge

• Use documentation checklists and Dear Physician letters available: Jurisdiction C: www.cgsmedicare.com

Jurisdiction D: www.noridianmedicare.com

VGM & US Rehab websites

Know your policies

• HOSPITAL BED: In order for a hospital bed to be covered by Medicare there are certain specific details that are required in the patients’ medical record.

• For a fixed height hospital bed: Pt requires positioning of the body in ways that can not be accomplished with a regular bed ie: needs head of bed elevated greater than 30 degrees (CHF / Respiratory cond./ aspiration problems ) – pillows or wedges must have been considered and ruled out. *** Removed: August 2013****

• Requires positioning to alleviate pain which can not be done with ordinary bed – (arthritis/ CA etc) or pt needs traction which can only be attached to a hospital bed

• The variable height is covered if meets one of above and needs the variation in height to effect transfer to chair/ wheelchair or standing position --- The semi-electric – same as above but requires “frequent changes and or has an “immediate” need for change in body position; such as the patient who has the upper respiratory problems or acute discomfort and would require more frequent changes in position.

• The information can be a simple statement such as : _______ is in need of a semi electric hospital bed because she has had a stroke with dysphasia and requires elevation of bed greater than 30 degrees to prevent aspiration and needs frequent repositioning to alleviate pain and discomfort and prevent skin breakdown. Pillows/wedges were considered and ruled out.

• This information can be in discharge summaries from nursing homes, hospitals, home health notes and any other type of clinical records. The ordering practitioner needs to be aware of the equipment being ordered for their patient.

Documents needed in patient’s file What do I need??

What is needed “in your files”?

• Patient Profile: Order Intake Form • Verification of current & permanent address • Representative information if patient did not sign

• Attending physicians full name, address, NPI

• Assignment of Benefits (AOB) • Release of Information form

• HIPAA • Privacy rules

• Certificate of Medical Necessity (CMN), if applicable

• DME Information Form (DIF) and/or Physician Order, if applicable

• Detailed written order

• Medical records notes, and any other necessary supporting documentation

Documents needed in patient’s file

Patient Profile / Intake

Verification of insurance benefits and address

Release of information form

-- HIPAA / Privacy rules

Dispensing / Verbal Order

Detailed Written Order

F2F notes,

Physicians address, NPI

Assignment of Benefits

Representative information,

if patient did not sign

Documentation showing patient has received education on equipment by supplier

ABN, if applicable

Proof of capped rental notification, or purchase option letter

Proof of warranty provided to patient

Proof Supplier Standards were explained

CMN, if applicable

Proof of Delivery

Initial Claim ---

Proof of Delivery

Method 1 and Method 2 POD records

require: Beneficiary’s name Delivery address

Address of where items were delivered to or picked up

Sufficiently detailed description of the item(s) being delivered (e.g., brand name, serial number, narrative description)

Quantity delivered Date delivered Remember those lots numbers—for recall

purposes

In addition, Method 1 requires: Beneficiary (or designee) signature and date of

signature Suppliers signature and date

In addition, Method 2 requires: Delivery service’s package identification number,

supplier invoice or alternative method that links the supplier’s delivery documents with the delivery service’s records.

Evidence of delivery

Method 3 requires: If supplier delivers directly to nursing facility—

follow Method 1 When a delivery service/mail order is used to for

delivery---follow Method 2

Method 1 = Direct delivery to beneficiary by the supplier Method 2 = Delivery via shipping or delivery service directly to beneficiary Method 3 = Delivery to a nursing facility on behalf of a beneficiary

Who can sign POD record? A designee is defined as:

“Any person who can sign and accept the delivery of durable medical equipment on behalf of the

beneficiary.” • Legal guardian • Representative payee—a person designated by the Social Security Administration or other governmental

agency to receive an incapable beneficiary’s monthly cash benefits • Authorized representative—acts on behalf and in best interest of the beneficiary and is usually a parent,

legal guardian of minor, or legal guardian of an adult who has been declared incompetent • Designee • Relative • Friend • Representative of an institution providing care or support • Governmental agency providing assistance

The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier.

The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.

Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary.

Proof of Delivery

• Documentation must be maintained for 7 years

• Delivery date is bill date

• Tracking slip should reference each individual package if sent to a facility with multiple beneficiaries

• Note you should down load the delivery document from your delivery service for proof of delivery – The delivery companies usually keep for 1 year—after that—GONE!

Service Date • Hospital/SNF/Rehab discharge date is date of service

• Shipping - date of service is the actual shipping date • The date of service can not be earlier than date of delivery • Delivery can be up to two days prior to discharge if it is for

the ***benefit of *** fitting or training, date of discharge is the date of service

Warranty Information Form • Warranty Information Form ABC Company Anywhere USA • Every DME product sold or rented by our company that carries a warranty

will be identified by our staff and beneficiaries will be notified of warranty coverage. ABC company will honor all warranties under applicable law.

• _____________ will repair or replace, free of charge, parts for Medicare covered equipment that is under warranty. Labor is not included in most manufacturers warranties. You will receive information relating to the applicable warranty on products you receive from our company.

• ABC company is not responsible for any repairs/replacement of equipment due to user neglect or abuse. If continued neglect/abuse of equipment is noted the supplier may pick up the equipment and refer the user to another supplier and the information will be reported to the appropriate insurance carrier.

• I have been instructed and understand the warranty coverage on the _________ I have received.

• Beneficiary’s Signature _______________ Date: ______

Capped Rental 13 Months A 2 Z Medical Supply Dear ____________ • As of January 1, 2006 CMS has changed their policy in the way they pay for

some types of Durable Medical Equipment. The ________ that has been provided (will be provided) to you is now paid under a capped rental format.

• Previously you would have the choice to continue to rent or to purchase this item in the 10th month. Medicare will now pay for rental for 13 months and than the ________ becomes yours.

• This means that during the 13 months you/or your secondary will be responsible for 20% co-pay monthly until the cap has been reached. A 2 Z Medical is responsible for maintenance and service needed during the 13 months. Once the 13 months payment is completed it will than become your equipment & Medicare will pay for repairs of patient owned equipment as long as it remains medically necessary.

• I have read and understand the above explanation of payment for the ___________ I have (am being) been provided.

• Beneficiary Signature ______________________ Date _________ • (Authorized Representative) {why patient unable to sign}

What does KX Mean:

• When you add a KX modifier on a line item you are telling Medicare that you “KNOW” this patient meets criteria for the item you are billing.

• Documentation has to be in clinical notes – hospital discharge- progress notes – SNFs, Hospitals, Home Health Chart (notes) IMPORTANT FOR SUPPORT SURFACES E0277s

• PT/OT evaluations/clinical /dieticians/ Prosthetist/Orthotist/lab tests, sleep studies

LCDs With a KX Modifier Requirement Orthopedic Footwear

Patient Lifts

Pneumatic Compression Devices

Positive Airway Pressure Devices

Power Mobility Products

Pressure Reducing Support Surfaces

Refractive Lenses

Respiratory Assist Devices

Speech Generating Devices

Therapeutic Shoes for Persons with Diabetes

Transcutaneous Electrical Nerve Stimulators

Urological Supplies

Walkers

Wheelchair Options and Accessories

Wheelchair Seating

Ankle-Foot/Knee-Foot Orthosis

Automatic External Defibrillators

Cervical Traction Devices

Commodes

External Infusion Pumps

Glucose Monitors

High Frequency Chest Wall Oscillation Devices

Hospital Beds

Immunosuppressive Drugs

Knee Orthoses

Manual Wheelchair Bases

Nebulizers

Negative Pressure Wound Therapy Devices

Oral Antiemetic Drugs

Oral Appliances for OSA

COMMON ERRORS

COMMON ERRORS- illegible • Illegible medical records

• Illegible physician signatures

– Signature attestations

– Signature logs

– “I, ____________________[print full name of the physician/practitioner], hereby attest that the medical record entry for _________[date of service] accurately reflects signatures/notations that I made in my capacity as _______[insert provider credentials, e.g., M.D.] when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”

• Stamped signatures

• Invalid electronic signatures

• Missing patient identification on multiple pages of medical or supplier records without indication of page numbers

• If you can’t read a note, more than likely no one else can either---ask physician to transcribe note, the nurse is able to transcribe as well—have physician sign and date transcription

Top Denial Reasons for PAPs (E0601) & RADs (E0470)

Medical record provided did not include documentation of F2F clinical evaluation by treating physician prior to sleep study assessing for OSA

DWO was on a blanket order form that did not allow ordering physician to individualize the equipment & supplies being ordered

Signature was missing or illegible

Sleep study not interpreted by physician with correct credentials

Proof of delivery was not provided or incomplete

Item delivered before receiving dispensing order

Diagnostic sleep study not provided

Supplier records did not document beneficiary/caregiver received instruction in proper care of device and accessories

Date of service submitted on claim did not match the date the beneficiary signed for delivery

No clinical evaluation by treating physician for those seeking replacement equipment following the 5 year RUL or when requesting coverage upon entering Medicare FFS

Clinical re-evaluation failed to demonstrate improvement in OSA symptoms and receiving continued benefit for therapy

DWO was missing and DWO was prior to the sleep study

Example 1

Unacceptable Blanket Order Does not provide a detailed list of each separately billed item and the replacement instructions are non-specific

Example 2

Unacceptable Blanket Order Order form lists supplies and accessories in a way that does not allow the physician to pick and choose the specific items being ordered for this beneficiary

Example 3

Acceptable order Order form lists supplies and accessories in a way that the physician can pick and choose the specific items being ordered for this beneficiary. Note: NPI needs to be on order.

Patient: John Doe

Start Date: 08/01/2011

Length of Need - Lifetime (99) CPAP Device at 10 cmH20

Heated Humidifier Bi-Pap Equipment (mask, accessories, disposable and reusable filters) - replace as needed

Charles Smith

August 15,2011 Charles Smith, M.D.

Patient: John Doe

Start Date: 08/01/2011

Length of Need - Lifetime (99) Bi-Pap w/o BU - IPAP 12 cm H20, EPAP 10 CM H20

Heated Humidifier PAP Oral Interface

Repl Exhalation Port for PAP Combi Oral/Nasal Mask 1/3 Mo

Full Face Mask 1/3 Mo

Replacement Face Mask 1/1 Mo

Nasal Application Device 1/3 Mo

PAP Headgear 1/6 Mo

PAP Chinstrap 1/6 Mo

PAP Tubing 1/3 Mo

PAP Non-disposable Filter 1/6 Mo

Humidifier Chamber 1/6 Mo

Oral Cushion 2/1 Mo

Repl Nasal Pillow Comb Mask 2/1 Mo

Replacement Nasal Cushion 2/1 Mo

Replacement Nasal Pillows 2/1 Mo

PAP Disposable Filter 2/1 Mo

Charles Smith

August 15,2011 Charles Smith, M.D.

Patient: John Doe

Start Date: 08/01/2011

Length of Need - Lifetime (99) CPAP Device at 11cmH20

Heated Humidifier Mask - Nasal Pillow 1/3 Mo

Mask - Full Face 1/3 Mo

Oral Mask Interface 1/3 Mo

Nasal Mask cushion 2/1 Mo

Full Face Mask Cushion 1/1 Mo

Nasal Pillows 2/1 Mo

Tubing 1/3 Mo

Chinstrap 1/6 Mo

Headgear 1/6 Mo

Filter, Disposable 2/1 Mo

Filter, Non-Disposable 1/6 Mo

Humidifier Chamber 1/6 Mo

Other ____________________

Charles Smith

August 15,2011 Charles Smith, M.D.

NPI: 1234567890

Valid Physicians order

Good Diagnosis---OSA 327.23

F2F prior to sleep study

Correct Sleep study---diagnostic (PSG) signed

Documentation of medical necessity in medical record

F2F—if needed to meet F2F ruling

Completed DWO

Proof of delivery

Summary of Documentation for PAP

• The actual oxygen saturation test indicated on the CMN must be provided in an audit. Although it can be indicated on the order, must be supported in the medical record.

• The date of the physician’s signature on the CMN/order is after the date of service on the claim and the verbal/dispensing order was not provided.

• The POD is prior to the date of service on the claim or the POD submitted is invalid.

• Documentation was not provided to support that alternative treatment measures have been tried or considered and deemed clinically ineffective.

• Documentation was not provided to support that the treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy

Top Denial Reasons for Oxygen

Dispensing Order vs Detailed Written Order O2

Dispensing Order: • Can be either written or verbal • If verbal make sure to include the name and title of the person giving the order and the name

of the person at your office taking the order

Detailed Written Order: • Must include the following information:

Patient’s name Narrative of items being ordered (any billable items—such as O2 Content) Date of order, and start date if different than order date Liter flow Frequency of use Method of delivery Length of need Ordering practitioner’s printed name Ordering practitioner’s signature and signature date Ordering practitioner’s NPI

• CMN can serve as DWO if contains all necessary information in section C—such as method of delivery and frequency of use

Summary of Documentation for O2 Valid Physicians order

Diagnosis needs to be severe lung disease or hypoxia related symptom

Qualifying Testing: Done while in CSS or 2 days prior to discharge

Documentation of medical necessity in medical record

Completed CMN and DWO

Is portable ordered—make sure documentation includes patient mobile in home

Have alternative treatments been tried/considered and rule out

Proof of delivery

Release on 8/28/14 from Jur. A : E0464 (non-invasive) under prepayment review

Documentation must include the following:

1. Physician order for the item

2. Information from the medical record that demonstrates the reasonable and

necessary coverage criteria for the item(s) are met.

3. Proof of delivery.

4. Any other pertinent information that would justify payment for the item(s) provided.

5. Advanced Beneficiary Notice (ABN) if one was obtained, this must be submitted

with the above requested documentation.

Be prepared!

Vents under Prepayment Review

Ventilators

• National Coverage Determination (280.1)

E0463/E0464

• Categorized as Frequent & Substantial Servicing

• Monthly rental includes payment for supplies and accessories

• Humidifiers are considered accessory; cannot be billed separately

• Monthly rental includes payment for repair and maintenance

• Supplier is required to have emergency plan, back up plan in the event primary ventilator breaks down

Generally Covered for Treatment of:

• Neuromuscular Disorders

• Thoracic Restrictive Diseases

• Chronic Respiratory Failure

Examples of diagnosis: ALS, MS, tracheostomy complication, COPD, etc.

Medical Record must state:

• Why the ventilator is medically necessary, and

• Why a CPAP/BiPAP is insufficient

Documentation

Orders Dispensing Order: Patient’s name Prescribing Physician’s name Date of order Description of the item Start date of the order, if different from date of the order Practitioner’s signature (if written order) or supplier signature (if verbal order)

Detailed Written Order: Patient’s name Treating Practitioner’s name (printed or typed) Start date of order – if start date is different than order date Order for ventilator with description/brand/model/ and settings Any other billable items Practitioner signature Practitioner signature date and NPI Length of need Frequency of use

Documentation to support medical necessity includes:

Valid Physicians order

Good Diagnosis

Documentation of medical necessity in medical record

Ventilator settings

Documentation of supplier’s back up plan

Proof of delivery

Face to Face Ruling

1. Federal Register Vol. 77 no. 146

• Proposed Rule: July 30, 2012

• Final Rule: November 16, 2012

2. Med Learn Matters #MM8304 dated May 31, 2013

• CR8304 in chapter 5 of PIM implements these changes

3. Revised MLN article released June 27, 2013 (MM8304) • Indicating enforcement delay until October 1, 2013

4. Announcement released Sept. 9th, now delayed until “a date” in 2014

5. Date is here: Announcement released December 19, 2013 that DME MACs will begin enforcement effective January 1, 2014

6. Release on August 20, 2014: F2F encounter-enforcement date delayed

until “a future date”

**This rule is separate from the F2F rules for Power Mobility Devices and O &P **

When Did This Start

What is happening?

Effective July 1, 2013

Medicare will require that specific items of DME will require:

1. Written Order Prior to Delivery (WOPD)

aka: Detailed Written Order Prior to Delivery

2. Face to Face (F2F) encounter completed by ordering practitioner

Key phrase is “PRIOR TO DELIVERY”

The days of delivering on a dispensing/verbal order are gone! (under the F2F rules)

What does this mean…

• A referral must document and communicate to the DME supplier that a F2F encounter with the beneficiary by the physician or NP or PA or CNS.

• Which means you have to have documentation that a face to face with the ordering practitioner occurred within 6 months prior to date of detailed order.

• If NP or PA or CNS does the F2F, the physician must sign off and date on their progress notes:

– will receive an additional payment for signing off (G0454)

– the physician does not have to sign the actual detailed order. This can be done by the NP or PA or CNS

As Stated in the Federal Register

During the F2F encounter the Physician, PA, NP, or CNS must have evaluated the beneficiary, conducted a needs assessment for the beneficiary, or treated the beneficiary for the medical condition that supports the need for each covered item of DME. The information would be part of medical record, which identifies the practitioner who provided the F2F assessment. We believe that requiring the F2F encounter that supports the need for the covered item of DME would reduce the risk of fraud, waste, and abuse since these visits would help ensure that a beneficiary’s condition warrants the covered item of DME.

List includes 166 HCPCS Codes requiring F2F encounter as of 7-1-2013

Some of the main items include: • Oxygen and related equipment • All Manual Wheelchairs & accessories • All Hospital Beds & accessories included heavy duty beds • Overlays • TENS Units • Rollabout Chairs • Blood Glucose Monitors • Traction-Cervical Equipment • Ventilators • PAP and RAD devices • All Nebulizers • Seat Lift Mechanisms • And other items

“The List”

Does NOT include stationary concentrator (E1390), Portable Concentrator (E1392), & Portable Gas System -home compressor for filling tanks (K0738)

Does include Stationary Liquid (E0439) and Stationary Compressed Gas (E0424) And includes portable liquid (E0434) and portable gas (E0431)

Remember, the oxygen policy states:

In-person visit with treating physician within 30 days before initial date of service, and

Qualifying test must have been within 30 days prior or within 2 days prior to discharge from a facility

PMD not included which already have existing F2F requirements

List will be updated annually

In the future will add to the list any item of DME that appears on the fee schedule with a

price ceiling at or greater than $1000.

More On “The List”

Type of Equipment HCPCSAutomatic External Defibrillator K0606

Cervical Traction Devices E8040, E0849, E0850, E0855, E0856

External Infusion Pumps E0782-E0784, E0786

High Frequency Chest Wall

Oscillation DeviceE0483

Home Blood Glucose Monitors E0607

Hospital Beds

E0250, E0251, E0255, E0256, E0260,

E0261, E0265, E0266, E0290-E0297, E0300-

E0304

Manual In-exsufflation Devices E0482

Manual Wheelchairs and Transport

Chairs

E1031, E1037-E1039, E1161, E1232-

E1238, E2227, K0001-K0007, K0009

Nebulizers E0570, E0575, E0580, E0585, K0730

Neuromuscular Stimulators E0744-E0745, E0764, E0765

Osteogenesis Stimulators E0747-E0749, E0760

OxygenE0424, E0431, E0433, E0434, E0439,

E0441-E0444

Patient Lifts E0636, E1035, E1036

Pelvic Floor Stimulator E0740

Pneumatic Compression DevicesE0650-E0652, E0655-E0657, E0660, E0665-

E0669, E0671-E0673, E0675

166 Codes requiring F2F encounter as of July 1, 2013

Positive Airway Pressure Devices E0601, E0470

Pressure Reducing Support Surfaces E0185, E0188, E0189, E0194, E0197-E0199

Respiratory Assist Devices E0470-E0472

Seat Lift Mechanisms E0627-E0629

Speech Generating Devices E2502, E2506, E2508, E2510

TENS Units E0720, E0730, E0731

Transcutaneous Electrical Joint

StimulatorE0762

Ventilators E0450, E0460, E0461, E0463, E0464

Wheelchair Options and Accessories

E0958-E0961, E0966-E0969, E0971,

E0973, E0974, E0978, E0980-E0986,

E0990, E0992, E0994, E1014, E1015,

E1020, E1030, E1227, E1228, E1296-E1298

Check Shell E0457

Chest Wrap E0459

Rocking Bed with or without side rail E0462

Percussor electric/pneumatic home

modelE0480

Oscillatory positive expirator device,

non-electricE0484

Whirlppol non-portable E1310

Type of Equipment HCPCS

166 Codes requiring F2F encounter as of July 1, 2013—continued…..

What we know as of today…..

1. There must be clear documentation of a face to face encounter which documents that the encounter included an evaluation or treatment for a condition that supports the item(s) of DME ordered.

2. This can be performed by a physician, a PA (physician assistant) NP (Nurse Practitioner) or CNS (Clinical Nurse Specialist ) BUT the physician must sign and date the progress note from the NP, PAs and CNS.

3. They can document for multiple items at same encounter but the encounter must occur within 6 months of detailed written order.

• Mentioned in Dear Physician Letter dated 5/29/2014

• Following 2 slides have HCPCS codes that will be updated once CMS

releases the revisions

Codes that have been deleted or that were made not valid for

Medicare

Codes with narrative changes

• Bottom line: keep an eye on the codes; watch for release from

CMS

Update to Codes

Codes that have been deleted or that were made not valid for Medicare:

E0968: Commode Seat, wheelchair

E0969: Narrowing device wheelchair

E0978: Manual W/C accessory positioning belt/safety belt/pelvic strap

E0980: Manual w/c accessory safety vest

E0994: Arm rest

E1227: Special height arm for w/c

E1228: Special back height for w/c

E1296: Special sized w/c seat height

E1297: Special sized w/c seat depth by upholstery

E1298: Special sized w/c seat depth and/or width by construction

Updates to Codes:

E0983: power add on to convert manual to motorized, joystick control

E0984: power add on to convert manual to motorized, tiller control

E0986: push activated power assist

E0990: elevating leg rest

E0992: elevating leg rest solid seat insert

E1028: manual swing away, retractable or removable mounting

hardware for joystick, other control interface or positioning

accessory

E1029: Ventilator tray

E1030: Ventilator tray, gimbaled

Manual wheelchair accessories: E0958: one-arm drive attachment

E0959: adapter for Amputee

E0960: shoulder harness/strap

E0961: wheel lock brake extension handle

E0966: headrest extension

E0967: hand rim with projections

E0971: anti-tipping device

E0973: adjustable height detachable armrest

E0974: anti-rollaback device

E0981: seat upholstery, replacement only

E0982: back upholstery, replacement only

Codes that have had narrative changes

Other codes: E1035: Multi-positional patient transfer system with integrated seat

operated by caregiver

E1036: Patient transfer system

E1038: Transport chair, adult size up to 300lb

E1039: Transport chair, adult size heavy duty >300lb

E1233: W/C, pediatric size, tilt-n-space, folding, adjustable without

seating system

E1310: whirlpool, non-adjustable

E2502: SGD, prerecord messages between 8-20 minutes

E2506: SGD, prerecord messages over 40 minutes

E2508: SGD, message through spelling, manual type

E2510: SGD, synthesized with multiple message methods

E2227: Rigid pediatric wheelchair adjustable

K0606: AED garment with electronic analysis

CMS –2 Updates Regarding the F2F Ruling sent May 29, 2014

1st Update:

• Face-to-Face encounter DOES NOT need to be the prescriber writing the DWO (WOPD)

• Prescriber of the DME item can be a different practitioner

• DOES state that the prescriber of the DME item must have knowledge and documentation of the F2F examination that was conducted

• Make sure there is communication between the prescribing practitioner and the practitioner that performed the F2F evaluation AND the DME supplier

• Should make hospital discharges more streamlined—be very cautious and make sure there is communication

CMS –2 Updates Regarding the F2F Ruling sent May 29, 2014

2nd Update:

• DME MACs currently are allowed to audit on WOPD but not the F2F encounter

• Enforcement of actively auditing on the WOPD effective January 1, 2014

• Now—RAC, ZPIC, and Program Safeguard Contractors NOT allowed to audit on F2F encounter retroactive July 1, 2013.

• This does not apply to CERT auditors

• Remember: CERT auditors are auditing the DME MACs

Supplier Manual updated….. ................................................................................................................

Written Orders Prior to Delivery (WOPD) A written order prior to delivery is required for:

• Any HCPCS Subject to the Affordable Care Act (ACA) Face-to-Face Requirement

• Negative Pressure Wound Therapy

• Seat Lift Mechanisms

• Support Surfaces

• TENS Units

• Power Mobility Devices (PMD)

• Wheelchair Options and Accessories used with a PMD

DME MACs may identify other items for which we will require a written order prior to delivery and

suppliers should confirm the requirements in the specific Local Coverage Determination (LCD). For

items requiring a WOPD, the supplier must have received a written order that has been both signed

and dated by the treating physician, and meets the requirements for written orders, before dispensing

the item. If a supplier bills for an item without a written order, when the supplier is required to have a

written order prior to delivery, the item will be denied as not meeting the benefit category and is

therefore not appealable by the supplier.

Medical Policies Updated—March 6, 2014

with effective date of July 1, 2013

The Detailed Order Must Contain: F2F July 1, 2013 Detailed Written Order Must contain:

At a minimum from Federal Register Nov. 16, 2012

• Patient name

• Item ordered

• Ordering Practitioner signature **signature must be dated**

• Ordering Practitioner NPI

• Date of order

May need to include additional information such as:

• Start Date, if different than order date

• Diagnosis related to condition requiring the item-- if the item is diagnosis driven

• Length of need ---if required per policy

• Method of usage, required on some items, such as Oxygen via nasal cannulas/mask

• Other items according the medical policy

The requirements listed in the F2F regulation do not supersede other CMS requirements for a DWO.

Detailed Order 1. All Medicare items require an order

2. Must be signed and dated by ordering practitioner & include NPI

3. F2F items require the order be completed “PRIOR” to delivery (WOPD)

4. Description of item can be narrative or brand name –

5. Make sure you date stamp the order and medical records

6. Go by date of order, when start date is different than date of order, DME MACs go by date of order.

Sometimes items require delivery prior to discharge so start date may be different, and date

order received by supplier will be different, but Medicare will go by date of order. For example, ventilators.

7. Once the detailed order is signed by the ordering practitioner, it cannot be altered by the supplier. If a correction is needed, the ordering practitioner needs to make correction and then initial/date that correction or get a new order.

The Supplier can complete the detailed written order, then have the ordering practitioner review, sign, and date.

Reminders

• If a new order is required, then a new face to face is required

• All of the HCPCS codes listed in the F2F rule (166 codes) fall into the definition of a WOPD as there are some items listed under this category such as TENS, Group Support Surfaces, Seat Lift Mechanisms, etc. Cannot deliver these items based on a dispensing/verbal order anymore.

• The law requires that at in person visit with the treating practitioner whom documents the need for the item. If a PT, OT, etc., recommends a piece of equipment that is on the list of codes, the treating practitioner CANNOT use these notes as the face to face visit. Can be used as supporting documentation, but the patient is required to have an in person visit with the ordering practitioner.

• Medical record information does not go on prescription, has to be in the normal charting format in the notes.

On August 7, 2014 a new update was released:

I. If errors in the WOPD are found prior to delivery, the supplier has two options:

A. The WOPD may be properly amended following the guidance in the Program

Integrity Manual (Internet-Only Manual, Publ. 100-08), Chapter 3, Section

3.3.2.5; or,

B. A new WOPD may be created and sent to the physician for signature and

date.

II. If errors in the WOPD are found after delivery of the item, the supplier has two

options:

A. If the error is discovered prior to claim submission, the original supplier

may recover the delivered item(s), obtain a compliant, complete WOPD and

then may re-deliver the item(s) to the beneficiary; or,

B. If the error is discovered after submitting a claim, the original supplier can

recover their items and a new supplier must complete the transaction after

complying with all requirements.

Written Order Prior to Delivery

New Order Required

• Change of supplier

• Change in the item (s), frequency of use, or amount prescribed

• Change in length of need or previously established length of need expires

• State law requires a prescription renewal

• Under the F2F ruling—supplier does not need to obtain a new F2F

evaluation

• From the ACT call with Jurisdiction A on 9-17-14

NOTE: When a new order is required, then a new face to face is required

TEMPLATES

• Although CMS does not prohibit the use of templates or check lists we will caution all of our suppliers that these are frequently denied in review.

• Templates tend to not cover the true needs of the individual patient and are not thorough enough to sufficiently determine coverage.

• Use of the DMEMAC physician educational letters has been found to be useful to many suppliers.

• We are confident that the DME Medical Directors will assist us on this educational effort as they have in the past with many difficult LCDs.

Education Hints • Make sure your entire staff understands the F2F requirements, including on-call staff

• Educate all referral sources: doctors, discharge planners, social workers, nurses, medical assistants, case management – anyone that is involved in that patient’s care

• Use “Dear Physician Letter”

• Remind referrals ---this is nothing new—documentation in medical records always required

• Use Documentation Checklist

• Make sure intake/staff reviews information upon receiving referral

• Review claim information before submitting the claim

• Use VGM/US Rehab Reimbursement Team to assist with educating

• Explain to referrals that information is needed PRIOR TO DELIVERY

• If information received after delivery, then cannot go start billing Medicare—patient will have to switch to another supplier

• Get the patient and/or their family members involved from the beginning

• Explain to them exactly what would be needed

• The first interview they get when they go into the clinic is the nurse. Use them to

assist with gathering information needed

• Have the patient state to the nurse exactly what they need and why

• The nurse would then put this information on the chart; and will give the

practitioner a head’s up for what is needed

• Example: the patient state they tried using cane and walker, but mobility is still

limited trying to get from bedroom to kitchen because of degenerative joint

disease in knees has caused them to fall and needs a wheelchair.

• Example: Patient inquiring about a hospital bed, mentions having problems

sleeping flat and has tried positioning in different ways; has a history of CHF—

needing a HB

• Remember this is a subjective statement and would need to be followed up with

objective measurements

Getting The Patient Involved:

Remember CMS is the one doing this however, it comes from direction they have received through the Affordable Care Act 6407.

Effective January 1, 2014 DME MACs are enforcing the WOPD (or DWO) under the F2F requirements. The actual F2F encounter is still under “delay of enforcement”, but we strongly encourage that suppliers get both the WOPD and medical records prior to delivery!

Which means the DME MACS are not to “actively audit” on the actual F2F encounter; however, the DME MACS are not only auditors in the industry.

Remember, the law was implemented July 1, 2013

Call your Congress!

Prevention • Education -- Compliance

• To staff – referral sources – beneficiaries

• Good order intake - CSRs

• Medical Records – Get them and READ THEM!

• Clinical documentation is important from all sources

• Use the documentation check off sheets that are provided by some DME MACs

• Have desk procedures and make sure they are followed; (compliance plans are important and will be required)

• Review medical policies (LCD) and articles

• Files need to be legible and in order

• ALL Signatures must be legible

• DATE STAMP when received

• Delivery tickets/name/model/serial #s LEGIBLE signatures—watch dates

• Self Audits are a must –do yourself or have outside party

INSUFFICIENT DOCUMENTATION

• Work with Office Managers/social workers/ discharge planners/ nurses and explain the need for the documentation to remain compliant in order for the patient to receive needed equipment

• Advise physician and their staff that without documentation, Medicare may deny the claim and the patient may be responsible for payment

• Get the patient involved and explain that they may be liable without physician records

• Use properly executed ABNs - do not use these as a “way out”

Documentation is key!!

How to respond to the Letter!

1. Read the letter carefully to know what they are asking for and due date. Also to know where to send the information. Respond only once – no duplications.

2. Gather all the documentation. Make sure you are sending the correct documentation and all related information. Review the information being sent using a checklist.

3. There will be a bar code cover sheet to use a first page when responding.

4. Number each page like 1 of 20, 2 of 20, etc

5. Do not highlight anything!! Documents are scanned and highlights will block out the information. Underline or use asterisks to indicate important notes.

6. Make sure signatures are legible. Can send attestation statement from physician.

7. Send each claim separately, do no bundle.

8. Copy everything being sent. Send only what is related to the item being reviewed.

How do I respond?

9. Clinical documentation is a must in all situations -If you do not send it you will get a denial. – don’t stop billing but adjust your work flow ---

10. Review all documentation (using a check off sheet) before sending

11. Check dates on documentation- has be prior to delivery of equipment –

12. Keep a contact log with all information –use a spreadsheet

13. Check address to send to and make sure you send copy of letter received back to contractor. If you do not have it all send what you have and keep researching for additional documentation. (Get a return receipt requested)

14. Make sure you know all physicians’ patient is seeing –

15. ON the High End Rehab make sure that if your claim was sent to ADMC that you include that response with your audit

16. If unfavorable response received, follow same appeals process.

Appeal Levels

Regardless of who denies the audit you still follow the same review process.

Education with Referral Sources

Medicare Quick Reference Guide:

• Tool created to assist with educating your referral sources

• The reimbursement team is available to partner with educating

your referral sources via webinar or on-site consulting

Resources Available Jur A: www.medicarenhic.com

Jur B: www.ngsmedicare.com

Jur C: www.cgsmedicare.com

Jur D: www.nordianmedicare.com

Competitive Bid: www.dmecompetitivebid.com

VGM: www.vgm.com www.usrehab.com www.dclink.com PDAC: www.dmepdac.com CMS: www.cms.hhs.gov PECOS: https://pecos.cms.hhs.gov NSC: www.palmettogba.com

Ronda Buhrmester

ronda.buhrmester@vgm.com

O: 888-665-6518

F: 855-262-3821

Thank you!