December 17, 2015 A Collaborative Webinar Power Mobility Devices

Transcription

1 December 17, 2015 A Collaborative Webinar Power Mobility Devices

2 Presenters Kari O Hara NHIC, Corp. Jurisdiction A Tamara Hall National Government Services Jurisdiction B Michael Hanna CGS Administrators, LLC Jurisdiction C Diana Duchscherer Noridian Healthcare Solutions Jurisdiction D 2

3 Webinar Access All registrants received an from: Medicare Webinar by National Government Services Click on the link within the to join the web presentation Using your telephone, dial into the conference call using the number and access code provided in the 3

4 Today s PowerPoint Presentation Once you are connected to the webinar, select Handouts Select the PowerPoint to download the presentation 4

5 Audio Once you are connected to the audio, the PIN displays Input the PIN on your screen into your telephone Dial in number and PIN are unique for each attendee 5

6 Disclaimer The Medicare contractors have produced this material as an informational reference for providers furnishing services in our contract jurisdictions. The Medicare contractors employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at 6

7 Acronyms ABN Advance Beneficiary Notice of Noncoverage ADMC Advance Determination of Medicare Coverage ADR additional documentation request CMS Centers for Medicare & Medicaid Services DME durable medical equipment DMEPOS durable medical equipment, prosthetics, orthotics, and supplies F2F face-to-face HCPCS Healthcare Common Procedure Coding System HICN Health Insurance Claim Number LCD local coverage determination LCMP licensed/certified medical professional MAC Medicare Administrative Contractor 7

8 Acronyms MRADL mobility-related activities of daily living MSRP manufacturer's suggested retail price PA policy article PAR prior authorization request PMD power mobility device POV power operated vehicle RUL reasonable useful lifetime UTN unique tracking number 8

9 Agenda PMD Base Coverage Criteria PMD Documentation Requirements Advance Determination of Medicare Coverage Prior Authorization Request Demonstration Advance Beneficiary Notice of Noncoverage and Upgrades Repairs and Replacements 9

10 PMD Coverage Criteria 10

11 General Coverage Criteria The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: Prevents the beneficiary from accomplishing an MRADL entirely, or Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or Prevents the beneficiary from completing an MRADL within a reasonable time frame. 11

12 General Coverage Criteria The beneficiary s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. The beneficiary does not have sufficient upper extremity function to self-propel an optimallyconfigured manual wheelchair in the home to perform MRADLs during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate nonpowered accessories. 12

13 POV Additional Coverage Criteria The beneficiary is able to: Safely transfer to and from a POV, and Operate the tiller steering system, and Maintain postural stability and position while operating the POV in the home, and The beneficiary s mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are sufficient for safe mobility using a POV in the home, and The beneficiary s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided. 13

14 POV Additional Coverage Criteria The beneficiary s weight is less than or equal to the weight capacity of the POV that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class POV i.e., a heavy duty POV is covered for a beneficiary weighing pounds, and Use of a POV will significantly improve the beneficiary s ability to participate in MRADLs and the beneficiary will use it in the home, and The beneficiary has not expressed an unwillingness to use a POV in the home. 14

15 PWC Additional Coverage Criteria The beneficiary has the mental and physical capabilities to safely operate the PWC that is provided; or If the beneficiary is unable to safely operate the PWC, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the PWC that is provided 15

16 PWC Additional Coverage Criteria The beneficiary s weight is less than or equal to the weight capacity of the PWC that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC i.e., a heavy duty PWC is covered for a beneficiary weighing pounds, and The beneficiary s home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the PWC that is provided, and Use of a PWC will significantly improve the beneficiary s ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver, and The beneficiary has not expressed an unwillingness to use a PWC in the home. 16

17 Documentation Requirements Face-to-Face Examination 17

18 F2F Examination F2F examination has two components: 1. Decision component An in-person visit between the beneficiary and the ordering physician to document the decision to order a PMD; and, 2. Medical evaluation component A medical examination to document the beneficiary s mobility and functional condition. 18

19 F2F Examination The F2F examination of the beneficiary must occur prior to the clinician ordering a PMD and the supplier must receive this report within 45 days following the evaluation. The exception to this rule is if the examination is performed during a hospital or nursing home stay. In this instance, the supplier must receive the report of the evaluation within 45 days after discharge. The PMD 7-element order must be in writing and signed and dated by the physician or treating practitioner who performed the F2F examination. 19

20 F2F Examination The F2F examination should be tailored to the individual beneficiary and the medical condition(s) causing mobility difficulty. The physical examination should focus on the systems causing the mobility deficits. There should be statements indicating why other mobility equipment (cane, walker, manual wheelchair) will not meet the beneficiary s needs. The F2F examination should be written in detail in the format used for other entries. A date stamp or equivalent is required by the supplier indicating date of receipt. 20

21 Additional F2F Instructions The F2F exam does not necessarily have to occur at a single visit and is not always performed by a single individual. The physician may refer the beneficiary to a LCMP such as a physical or occupational therapist. The LCMP may not be an employee of the supplier or have a financial relationship with the supplier. 21

22 Subjective vs. Objective When a Medicare contractor looks at supporting documentation, they are looking for objective, measurable information concerning the beneficiary s clinical condition. Subjective statements are less informative because they are not measurable and therefore are more open to individual interpretation. The beneficiary s condition should be described with enough detail that the reviewer can apply the principles of the LCD and make an individual determination that the beneficiary needs the item prescribed to safely perform MRADLs within the home. 22

23 Documentation Requirements Seven-Element Order 23

24 Seven-Element Order Requirements A seven-element order is required for all PMDs and it must include the following information: Beneficiary s name Description of the item that is ordered Date of completion of the F2F examination Pertinent diagnoses/conditions that relate to the need for the power mobility device Length of need Physician s signature Signature date 24

25 Additional seven-element Order Instructions If the supplier receives the seven-element order that does not contain the elements specified on the previous slide, the supplier must clarify this by obtaining a new sevenelement order. However, the new/revised seven-element order must be signed and dated by the treating physician and received by the supplier prior to the DPD and before the PMD is delivered to the beneficiary. This revised order must also be received within 45 days of the F2F examination. 25

26 Additional Seven-Element Order Instructions A date stamp or equivalent must be used to document the receipt date by the supplier. The seven-element order cannot be dated before the F2F examination. Podiatrists cannot prescribe any type of power mobility device. PMDs prescribed by a podiatrist will be denied as noncovered 26

27 What is the F2F Examination Date? Face-to-Face Examination Date on Seven- Element Order for Power Mobility Devices Scenarios article available on DME MACs websites 27

28 Common Scenario The ordering physician completes the decision component of the F2F examination at the initial in-person encounter with the beneficiary. The beneficiary is referred to another LCMP who has experience and training in mobility evaluations, to perform all or a portion of the medical evaluation of the F2F examination. The F2F examination date listed on the sevenelement order is the date the physician signed, dated and indicated concurrence or disagreement with the LCMP mobility evaluation. 28

29 Common Scenario The F2F examination has been completed, but the physician later identifies that there is information not properly documented in the medical record about the beneficiary which is necessary to support coverage criteria for a PMD. If the physician provides an amendment, correction or addenda to the F2F examination with information that arose from the previously performed F2F examination, the F2F examination date does not change on the seven-element order. The amendment, correction or addenda to the F2F examination should appear in the beneficiary s medical record. 29

30 Common Scenario The F2F examination has been completed, but the physician later identifies that there is information that was not addressed during the F2F examination which is necessary to support coverage criteria for a PMD. The physician must provide this new information in the medical record but since this was not a part of the original F2F, this does require a new in-person visit for the beneficiary with the physician. This new in-person visit date becomes the F2F date on the seven-element order. 30

31 Amendments, Corrections or Addenda 31

32 Amendments, Corrections or Addenda Amendments, corrections or addenda must: Clearly and permanently identify any amendment, correction or delayed entry as such, and Clearly indicate the date and author of any amendment, correction or delayed entry, and Clearly identify all original content, without deletion. Medicare Program Integrity Manual, Chapter 3, Section Guidance/Guidance/Manuals/Downloads/pim83c03. pdf 32

33 Paper Medical Records Corrections Use a single line strike through so that the original content is still readable Author of the alteration must sign and date the revision Amendments or delayed entries Clearly signed and dated upon entry into the record Amendments or delayed entries to paper records may be initialed and dated if the medical record contains evidence associating the provider s initials with their name 33

34 Electronic Health Records Distinctly identify any amendment, correction or delayed entry, and Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record. 34

35 Documentation Requirements Detailed Product Description 35

36 PMD DPD Once the supplier has finalized the specific PMD that will be provided to the beneficiary, the supplier must prepare a written document (termed a DPD) that lists: The specific base (HCPCS code or manufacturer name/model) and all options and accessories that will be separately billed to Medicare. 36

37 DPD The order date must be on the DPD The physician must sign and date this DPD and the supplier must receive it prior to delivery of the PWC or POV A date stamp or equivalent must be used to document the receipt date by the supplier Note: This DPD must comply with the requirements for a detailed written order as outlined in the supplier manual and Medicare Program Integrity Manual, Chapter 5. 37

38 Documentation Requirements Home Assessment 38

39 PMD Home Assessment Prior to, or at the time of delivery of a PMD, the supplier must perform an onsite evaluation of the beneficiary s home to verify that the beneficiary can adequately maneuver the device considering physical layout. There must be a written report of this evaluation available on request. If ruling out a POV, the documentation should include notations of doorway width, corridor width, room size, etc. to indicate how the supplier came to the conclusion that the maneuvering space was insufficient for the use of a POV. 39

40 PMD Home Assessment A PMD will be denied if: An assessment of the home environment does not support that the maneuvering space in the home is inadequate for PMD use. 40

41 Advance Determination of Medicare Coverage 41

42 ADMC Determination prior to delivery Voluntary Nationwide Except PAR states for codes subject to demonstration Able to resubmit once in a six month period Second ADMC request must be received within 6 months of the date of the letter from the first denial 42

43 ADMC PMD HCPCS Codes Group 2, 3 or 5 single or multiple power option wheelchair K0835 K0843 K0856 K0864 K0890 K0891 Group 3 no power option wheelchair K0848 K0855 With alternative drive control interface Custom wheelchair K

44 ADMC Process Submit request to appropriate jurisdiction for review Submit all required documentation DME MAC determines if equipment is reasonable and necessary Within 30 calendar days Written decision Eligible base submitted Options and accessories ordered will be eligible 44

45 ADMC Rejections Not a denial Able to submit another ADMC No time limit 45

46 ADMC Decisions Negative Decision Resubmit once in six months Additional medical documentation received If submit claim Normal appeals process Affirmative Decision Valid for six months from date of determination 46

47 ADMC Resources Jurisdiction A aspx Jurisdiction B e-lob/supplier-manual/chapter%209%20- %20advance%20determination%20of%20medicare%20cover age/admc%20determination Jurisdiction C Jurisdiction D 47

48 Prior Authorization Request Demonstration 48

49 PAR 25% reduction in payment if no PAR Unlimited resubmissions Extended to August 31, 2018 Jurisdiction A Jurisdiction B Jurisdiction C Jurisdiction D Maryland Illinois Florida Arizona New Jersey Indiana Georgia California New York Kentucky Louisiana Missouri Pennsylvania Michigan North Carolina Washington Ohio Tennessee Texas 49

50 PMD PAR HCPCS Codes What PMD items are affected? All power operated vehicles (K0800 K0802 and K0812) All standard power wheelchairs (K0813 thru K0829) All Group 2 complex rehabilitative power wheelchairs (K0835 thru K0843) All Group 3 complex rehabilitative power wheelchairs without power options (K0848 thru K0855) Pediatric power wheelchairs (K0890 and K0891) Miscellaneous power wheelchairs (K0898) Exclusions: Group 3 complex rehabilitative power wheelchairs with power options (K0856 thru K0864) 50

51 PAR Process Submit request to appropriate jurisdiction for review Submit all required documentation. DME MAC determines if equipment is reasonable and necessary Within 10 calendar days initial request Within 20 calendar days subsequent requests Written decision Review limited to the base code only 51

52 Nonaffirmed PAR Decision Detailed determination letter UTN Next step Resubmit PAR Submit claim for denial Include UTN Appeal rights engaged Submit to secondary insurance 52

53 Affirmed PAR Decision Decision letter UTN Follows the beneficiary Next step Home assessment Deliver equipment (document) Submit claim with UTN 53

54 PAR Not Submitted Stopped for review ADR letter sent Payment reduction will apply Exception Base subject to competitive bid Competitive bid supplier paid at single payment amount 54

55 PAR Resources Jurisdiction A Jurisdiction B e-lob/pages/complianceandaudits/medical-review/medicalreview-focus-areas/dme_pmd%20par Jurisdiction C Jurisdiction D 55

56 Determining ADMC or PAR Resides in PAR demonstration state? Yes Is HCPCS subject to PAR? No Is HCPCS eligible for ADMC? Yes Submit PAR No Is HCPCS eligible for ADMC? Yes Able to submit ADMC No Submit claim as normal Yes Submit ADMC No Submit claim as normal 56

57 Advance Beneficiary Notice of Noncoverage 57

58 ABNs Situations requiring an ABN (not all inclusive): Not medically reasonable and necessary Prohibited, unsolicited telephone contacts No supplier number ADMC denial Noncontract suppliers providing a competitively bid item for a competitive bidding area Allows beneficiary to make informed decision Protects supplier from liability Properly execute prior to delivery of item(s) 58

59 ABN Completion Reminders Blank (C) Identification Number: Enter an identification number for the beneficiary that helps to link the notice with a related claim when applicable. The beneficiary s Medicare number or HICN is not permitted. Not a required field Blank (D): Explain what item(s) is not medically necessary Blank (E) Reason Medicare May Not Pay: Explain a valid reason why the item(s) is not covered by Medicare Blank (F) Cost: Estimated cost of what the beneficiary will have to pay out of pocket for the item(s) Valid once beneficiary/designee signs and dates ABN. Valid for one year from signature date. 59

60 Modifier Usage with ABNs GA: Waiver of liability statement issued as required by payer policy, individual case Valid ABN on file GZ: Item or service expected to be denied as not reasonable and necessary No ABN on file or ABN is invalid/incomplete GY: Noncovered May execute an ABN as a voluntary notice of noncoverage GA or GZ and GY never reported on same claim line 60

61 GA or GZ Modifier Expectation of a medical necessity denial All documentation meets requirements per medical policy however, medical necessity not established for PMD beneficiary receiving 61

62 Upgrades: Charging the Beneficiary Usage of the GK modifier Actual item/service ordered by physician, item associated with GA or GZ modifier Line 1 K0813RRKHGA Billed Amount $ Will result in PR-50 denial, with $ payment responsibility Line 2 K0823RRKHKXGK Billed Amount $ Will process for payment 62

63 Upgrades: Not Charging the Beneficiary Usage of the GK modifier Actual item/service ordered by physician, item associated with GA or GZ modifier Line 1 K0813RRKHGZ Billed Amount $ Will result in CO-50 denial, with $ payment responsibility Line 2 K0823RRKHKXGK Billed Amount $ Will process for payment 63

64 Upgrades: Not Charging the Beneficiary or Medicare Usage of the GL modifier Medically unnecessary upgrade provided instead of standard item, no charge, no advance beneficiary notice (ABN) Line 1 K0813RRKHKXGL Will process for payment Note Segment Specific make and model of the item actually furnished (the upgrade item) and the reason behind the upgrade. 64

65 EY Modifier PMDs dispensed and/or billed that do not meet the prescription requirements must be submitted with an EY modifier added to each affected HCPCS code. 65

66 GY Modifier Statutorily excluded item/service LCD or PA advises to use in specific situations, including but not limited to seven-element order invalid or not received within 45 days of F2F examination F2F examination documentation not received prior to delivery of PMD PMD delivered without a valid DPD on file PMD being used solely outside of the home PWC with a seat elevator (K0830, K0831) provided Should not report the GY modifier with the KX, GA or GZ modifier 66

67 Replacement 67

68 Replacement Basic Payment Rules Substitute an item for another that is broken, inefficient, lost or no longer working or yielding what is expected Replacement of PMD may occur in cases of loss, irreparable damage, or a change in beneficiary s condition Loss/stolen Irreparable Damage Specific accident or a natural disaster Beneficiary s condition changes to necessitate a different type of equipment 68

69 Replacement Basic Payment Rules Replacement of PMD may occur in cases of irreparable wear after the reasonable useful lifetime has expired Irreparable Wear Deterioration sustained from day-to-day usage over time Replacement due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment Note: Replacement due to wear and tear before the reasonable useful lifetime is not covered 69

70 Replacement Documentation Prior to five year RUL Loss or irreparable damage New DPD New F2F examination is not required Exception of items subject to the Affordable Care Act, section 6407 All other applicable documentation After five year RUL New F2F examination New seven-element order New DPD All other applicable documentation 70

71 Replacement Basic Payment Rules Useful Lifetime In no case can it be less than five years Computation is based on when the PMD was delivered 71

72 Replacement Modifier RA: Replacement of a DME item Denotes instances where an item is furnished as a replacement for the same item which has been lost, stolen or irreparably damaged RA only needs to be appended to first month claim for rental items 72

73 Documentation Requirements for Replacements When billing for replacement PMDs, the following documentation (not all inclusive) must be kept on file and made available upon request: Reason for replacement New Order Medical records Police reports Written explanation from the beneficiary 73

74 Narrative Requirements for Replacement There must be specific information notated in the NTE 2300 or 2400 segments of the electronic claim in order for Medicare to consider coverage of a replacement item. This includes all of the following information: The description of the beneficiary owned PMD that is being replaced The HCPCS code of the PMD The date of purchase of the PMD Reason for replacement Example: RPL K0823 PMD PUR BBR 74

75 Repairs 75

76 Repairs Basic Payment Rules To fix or mend and to put the equipment back in good condition after damage or wear Covered when necessary to make the PMD serviceable Repairs may be covered on PMDs obtained by a beneficiary prior to Part B enrollment 76

77 Repairs Basic Payment Rules Repairs are covered up to the cost of replacement for medically necessary equipment owned by the beneficiary The beneficiary is expected to perform routine maintenance such as testing, cleaning, regulating, and checking the equipment If more extensive maintenance needs to be performed by authorized technicians, or if the maintenance requires the use of specialized testing equipment that is not normally available to the beneficiary, then the maintenance is covered as a repair for owned equipment A new physician s order is not required for repairs 77

78 Repairs Basic Payment Rules Repairs are not covered during rental periods Capped Rentals, Frequently Serviced, Inexpensive/Routinely Purchased and Oxygen and Oxygen Equipment Payment for parts and labor that are covered under a manufacturer or supplier warranty will not be included in the payment for maintenance and repairs Not covered for previously denied equipment No Medicare payment for travel time or equipment pick-up and/or delivery/set-up Any Medicare enrolled supplier can perform repairs 78

79 Standard Documentation Language Revision Joint DME MAC Publication In the case of repairs to a beneficiary-owned DMEPOS item, if Medicare paid for the PMD initially, medical necessity for the PMD has been established With respect to Medicare reimbursement for the repair, there are two documentation requirements: The treating physician must document that the PMD being repaired continues to be reasonable and necessary; and Either the treating physician or the supplier must document that the repair itself is reasonable and necessary 79

80 Standard Documentation Language Revision Joint DME MAC Publication The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality 80

81 Repairs Coding and Modifiers K0739 Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes One unit of service = 15 minutes Claims for labor must include narrative information itemizing: The nature and medical necessity for each repair The time taken for each repair Certain common repairs have standardized labor times 81

82 Repairs Coding and Modifiers K0108 billed as replacement part incident to repair K0108 Wheelchair component or accessory, not otherwise specified Claim must include: Product Name The brand name can be abbreviated by using just the first five letters Make/Model of Item Do not abbreviate the model/part number MSRP Example: RPL toggle MFR PRIDE MD FRMASMB272 MSRP If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K

83 Repairs Coding and Modifiers K0462 temporary replacement for patientowned equipment being repaired, any type Requirements Appropriate complete item must be provided, or Swapping out individual components 83

84 Repairs Coding and Modifiers Claim must include: Narrative description, manufacturer, and brand name/number of the PMD being repaired, and Date of purchase of the PMD being repaired, and Narrative description, manufacturer, and brand name/number of the PMD provided as a temporary replacement, and Description of what was repaired, and Explanation of why the repair took longer than one day 84

85 Repairs Coding and Modifiers All other DME items E1399 billed as replacement part incident to repair E1399 Durable medical equipment, miscellaneous Claim must include: Product Name The brand name can be abbreviated by using just the first 5 letters Make/Model of Item Do not abbreviate the model/part number MSRP Example: RPL HUMIDIFIER MFR PEGAS MD P35000 MSRP If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code E

86 Repairs Coding and Modifiers RB: Replacement of a part of DMEPOS furnished as part of a repair Indicates replacement parts of DMEPOS furnished as part of the service for repairing the DMEPOS item (base equipment/device) Be sure to append the RB to any replacement parts as part of a repair in competitive bid areas to prevent unnecessary claim rejections 86

87 Resources 87

88 Jurisdiction A Resources Website: LCD Decision Desktop Provider Services Portal Physician s Corner Newsletter and Supplier Manual Educational Events and Offerings DME MAC A ListServe Subscription Live Line Chat Provider Customer Service Provider IVR: Provider CSR:

89 Jurisdiction B Resources Policy Medical Policy Center Policy Education Topics Training Current and past training events Compliance & Audits Medical Review Supplier Manual NGSConnex: Provider Contact Center: Monday Friday: 8:30 a.m. 5:30 p.m. ET Training Closure Time: Fridays 2:30 4:30 p.m. ET IVR:

90 Jurisdiction C Resources Website: Local Coverage Determinations mycgs web portal: Jurisdiction C DME Supplier Manual: Calendar of Events: Customer Service: Monday through Friday: 7:00 a.m. 5:00 p.m. CST IVR Unit:

91 Jurisdiction D Resources Website: Local Coverage Determinations: Supplier Manual: Educational Tools: Web Portal: Customer Service/IVR/Telephone Reopenings Monday Friday 8 a.m. 6 p.m. CT

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