The Ins and Outs of Billing for Repairs. Billing for Repairs of Beneficiary Owned Equipment

Transcription

1 Brought to you by: The Ins and Outs of Billing for Repairs Presented By: Andrea Stark Reimbursement Consultant ext.240 AR Allegiance Group is a private pay collection service geared toward patients of HME/DME Businesses, Physicians and Hospitals. Contact: (913) Billing for Repairs of Beneficiary Owned Equipment The Impact of Competitive Bidding on Repairs Colleting Compliant Documentation to Support Your Claims Final Rule Implications for Power Wheelchairs Questions Billing for Repairs of Beneficiary Owned Equipment 3 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 1 of 12

2 The fundamental, guiding principle on billing for repairs requires that Medicare only reimburse repairs to medically necessary equipment that is owned by the beneficiary. Repairs that are required while the equipment is being rented (or while covered under the manufacturer s warranty) are not separately reimbursed under the Medicare Part B benefit. 5 6 In instances where the item was purchased prior to the beneficiary entering the Medicare program, prior to initiating repairs, the supplier must: 1. ensure there is no active warranty coverage, and 2. determine if the item is being used for a purpose that meets Medicare coverage, and 3. obtain the Medicare required documentation to support/verify coverage. Under Medicare guidelines, suppliers are required to furnish equipment that is expected to withstand a five year reasonable useful lifetime for the beneficiary. When considering repairs, if the cost of repairs exceeds the purchase price of the equipment and the equipment is deemed by the Medicare contractor to be unfit to last the full 5 year RUL, then the supplier is responsible for replacing the equipment at no charge to the beneficiary and no charge to the Medicare program. This language was clarified in June 2012 which states that in making the determination on whether the equipment can last for the entire RUL, the Medicare contractor may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 2 of 12

3 On the flip side, there may be instances when the beneficiary has exceeded their 5 year RUL and the equipment is in need of repairs. In these instances, if the beneficiary chooses not to obtain new equipment, the supplier can then repair the existing equipment and bill for the parts and labor, as long as the repair does not exceed the purchase price of the equipment. Routine, periodic maintenance such as testing, cleaning and regulating of patient owned equipment are not covered. Patients are expected to perform this maintenance themselves using the owner s manual. However, extensive maintenance which requires the skills of a technician (e.g. breaking down sealed components or performing specialized testing) can be reimbursed when performed on patient owned equipment. 9 There are three components that may be considered for separate reimbursement when repairs are eligible for separate reimbursement: Labor (billed in ¼ hour increments, 1 unit = 15 minutes of skilled labor) Loaner Equipment (reimbursement equates to 1 month rental, regardless of how long the loaner is in use) Parts The HCPCS for billing labor associated with non-oxygen equipment repairs is K0739 (Repair or non-routine service for durable medical equipment other than oxygen requiring the skill of a technician, Labor Component) K0739 is billed in 15 minute increments so that 1 unit of service is equal to 15 minutes. Suppliers cannot bill for travel time, mileage or any other service charge as a part of the repair. When billing for labor a narrative is required to be submitted with the claim: Description of the nature and medical necessity of the repair Itemization of time taken for each repair (excludes items with set limits see next slide) 2015 rates for SC beneficiaries with K0739 is $14.86/unit. Other labor codes are: L4205 for repairs to orthotics (reimbursed at $22.14/unit), and L7520 for repairs to prostheses (reimbursed at $30.05/unit) Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 3 of 12

4 CMS has also produced a table of maximum allowances for commonly repaired items. In the event that a repair to the beneficiary owned equipment takes longer than one day, there may Part Being Repaired/Replaced Type of Equipment Allowed Units of Service (UOS) be instances when a supplier will need to provide the beneficiary with loaner equipment so they are not without the use of the equipment. Medicare can allow separate reimbursement for this scenario. Pendant Hospital Bed 2 Loaner equipment is billed using HCPCS K0462, one unit of service = one month s rental no matter how Headboard/footboard Hospital Bed 2 long the equipment is in service (from 1 day to 9999 days) Blower Assembly CPAP 2 When billing for loaner equipment, suppliers must include the following in the NTE segment of the 2400 Hand Control Seat Lift 2 loop of the claim: Scissor mechanism Seat Lift 3 1. Information regarding the patient-owned equipment in the form of a HCPCS code or brand name, Hydraulic Pump Patient Lift 2 model name/number of the beneficiary owned equipment, and Batteries (includes cleaning and testing) Power Wheelchair 2 2. Date of purchase/delivery of the beneficiary owned equipment, and Joystick (includes programming) Power Wheelchair 2 3. A description /HCPCS of the replacement/loaner equipment with the manufacturer brand name and Charger Power Wheelchair 2 model name or number, Drive wheel motors (single/pair) Power Wheelchair 2/3 4. A statement of why the replacement/loaner equipment is needed (e.g. repairs to beneficiary owned Shroud/cowling Power Wheelchair 2 equipment). Wheel/Tire (all types, per wheel) Power or Manual Wheelchair 1 The MACs will pay based on the lesser allowance for either the item the patient owns or the loaner Armrest or armpad Power or Manual Wheelchair 1 equipment provided (e.g. pt owns K0001 man w/c, loaner = K0823 PWC, payment will be for the K0001). Anti-tipping device Manual Wheelchair 1 Note: Many of the details surrounding original delivery date and equipment history can be obtained using a same/similar query available via the IVR or mycgs portal. See: When billing for replacement parts for a repair, make sure that you are utilizing the appropriate HCPCS code. There are some instances where a part will not have a specific HCPCS and a miscellaneous code must be used. The following are the two most common miscellaneous HCPCS used for parts: K0108 wheelchair accessory/component not specified E1399 miscellaneous DME equipment Note: anytime that you utilize a miscellaneous HCPCS you must also include several details about the item in the narrative segment of the claim. Narrative should include the item description including the manufacturer name, model/serial number, product name and MSRP of each item being billed. The reviewer is working from a blank sheet of paper and will use your narrative to determine what the item is, how much it costs and how much they should reimburse. If multiple miscellaneous items/parts are provided, each should be billed separately on the claim. Utilize the RB modifier on the claim line for the HCPCS being replaced to signify that this is a replacement part associated with a repair. It is not necessary to secure a separate order for repairs. At a minimum the following must be documented: The treating physician must document that the DMEPOS item 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 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 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 4 of 12

5 Narrative Issues: Missing MSRP on Miscellaneous HCPCS Incorrect date of purchase for base item No breakdown on labor for multiple repairs Jurisdiction A conducted a webinar on repairs in January 2015 that provided several claim examples with sample narratives Replacement Scenarios Scenarios where Replacement equipment will be considered: Lost/Stolen Irreparable damage (in a specific incident not wear and tear) Change in condition Reasonable Useful Lifetime (after irreparable wear and tear causes equipment to malfunction) 20 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 5 of 12

6 Required documentation: Lost/Stolen police reports, fire reports, insurance claims, patient letters Irreparable damage circumstances regarding the specific incident causing damage to the item Change in condition medical records documenting the advancement or deterioration in condition Reasonable Useful Lifetime information about the original setup date and state of equipment necessitating replacement Utilize the RA modifier on the first month claim ONLY for cases where equipment is being replaced. A narrative must accompany the claim to include: Description of the patient owned equipment HCPCS of item being replaced Date of original purchase Reason for replacement (e.g. broken beyond repair) It is necessary to secure a new order/cmn when equipment is being replaced. If the item is subject to FTF, it is also necessary to secure evidence of an office visit that supports the need for the equipment dated within 6 months prior to the replacement order. When you provide capped rental equipment to a patient, you do have an obligation to ensure they have viable equipment for a full five years (the reasonable useful lifetime). Per CMS and reiterated via a Joint DME MAC publication: Under a special rule established for certain patient-owned equipment, such as a power wheelchair for which the title has been transferred to the patient after 13 continuous months of rental, the supplier must replace the equipment free of charge if it does not last the full 5-year period (i.e., is no longer serviceable or needs substantial repairs). This replacement equipment does not need to be new. For more information, refer to 42 Code of Federal Regulations (CFR) Section (e)(4). In 2005 the DRA included a provision that states the following: (4) Supplier replacement of beneficiary-owned equipment based on accumulated repair costs. A supplier that transfers title to a capped rental item to a beneficiary in accordance with (f)(2)* is responsible for furnishing replacement equipment at no cost to the beneficiary or to the Medicare program if the carrier determines that the item furnished by the supplier will not last for the entire reasonable useful lifetime established for the equipment in accordance with (f)(1)**. In making this determination, the carrier may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item. MLN/MLNProducts/downloads/PMD_DocCvg_FactSheet_ICN pdf Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 6 of 12

7 The Impact of Competitive Bidding on Repairs When it comes to repairs and replacement parts for competitively bid equipment there are a few nuances to be aware of. For beneficiaries that reside in a CBA and own a competitive bid piece of equipment in need of repair, that repair can be performed by any willing supplier (contracted or non-contracted). 26 Medicare pays the SPA for replacement parts if the HCPCS is a competitive bid item in the CBA and is used to repair base equipment that is also a CB item in the CBA. Otherwise, the payment is based on the lower of the actual charge or the fee schedule amount for the replacement part. For CB items, the RB modifier is required for replacement parts (this modifier ensures the contracted supplier logic is bypassed when being billed by non-contracted suppliers). Additionally, if the replacement part is a CB item, suppliers must also append the appropriate competitively bid modifier (KG, KK or KY) to identify the replacement part as a CB item. KG item is subject to Round 1 of Competitive Bidding (means that the supply is being furnished for a lower level or more basic item) KK item is subject to Round 2 of competitive Bidding (means that the supply is being furnished for a higher level or more complex item) KY- for wheelchair accessories supplied to a beneficiary residing in a CBA for a complex rehab Group 2 PWC (K0835-K0843) or Group 3 PWC (K0848-K0864) that were bid in Round 1 but not bid in Round Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 7 of 12

8 Medicare created a listing of replacement parts that are in-eligible to be billed by non-contract suppliers when furnished during a repair. For Standard Power and Manual Wheelchairs, Scooters and Related Accessories and Complex Rehabilitative Power Wheelchairs and Related Accessories (Group 2), the following items are never eligible as replacement parts associated with repair of base equipment: Replacement seat cushions (E2601-E2608 and E2622-E2625) Replacement back cushions, unless integral to base equipment (E2611-E2616, E2620, and E2621). Other options and accessories are eligible for repair with beneficiary owned equipment. To see the full list by product category see the education posted here: MLN/MLNProducts/Downloads/DME_Repair_Replacement_Factsheet_ICN pdf For beneficiaries that travel, and do not maintain a permanent residence within a CBA but require replacement of a CB part to a CB base item, that replacement item must be obtained from contracted supplier in the CBA where the beneficiary is traveling. The contracted supplier would then be paid at the fee schedule rate for the state where the beneficiary permanently resides Labor is paid according to Medicare s standard fee schedule rates as labor is not subject to Competitive Bidding. Because replacement parts are subject to CB and labor is not subject to CB, there are additional complexities for claim submission. There may be scenarios in which a contracted supplier is replacing both CB parts and non-competitive bid parts on a competitively bid base item, where the supplier does not wish to accept assignment on the labor and non-cb replacement parts. In these situations a separate claim must be submitted for the labor component and any non-competitively bid replacement parts. Then on a separate claim (where the supplier is accepting assignment) the supplier would bill for the CB replacement parts. Collecting Compliant Documentation to Support Your Claims 31 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 8 of 12

9 Suppliers are not required to obtain a new order or CMN for equipment repairs. Until recently, suppliers were directed to have documentation to support the medical need for the base equipment along with the need for the repairs. However, on August 1, 2014, CMS issued a change request to the auditing contractors regarding how repairs should be considered in an audit scenario. In Change Request #8843, CMS states that in cases where Medicare already paid for the equipment, then the medical necessity of that equipment has been established. The Change Request logic is to be applied to all patient-owned equipment. CMS directs auditing contractors to only review repair claims for the necessity of the repair and not for the initial qualification (medical necessity) of the equipment. This is a big departure from previous education where suppliers were required to produce documentation to support the medical necessity of the equipment itself along with the medical necessity of the repairs. See: This clarification was particularly impactful when considering repairs to former Scooter Store customers. Many suppliers have been cautious when taking on repairs of beneficiary owned equipment that was provided by the Scooter Store due to the circumstances surrounding the supplier s hasty exit from the DME space. In January of 2014, CMS issued a brief statement regarding repairs to Scooter Store equipment. Effective October 24, 2013,The Scooter Store (TSS) transferred titles to capped durable medical equipment (DME) rented to Medicare beneficiaries. Medicare beneficiaries now own this equipment. Medicare can pay for repairs to this equipment performed on or after October 24, 2013, if the contractor determines that the repairs are reasonable and necessary in accordance with Medicare regulations and program instructions. Although this is a win for the DME industry, the administrative burden is not completely alleviated with this policy. Suppliers must still have documentation to support the continued medical need for the equipment from the treating physician that is dated within 12 months of the DOS for repair. The LCD states that there are four ways to document the Continued Medical Need for an item: Timely documentation in the beneficiary s medical record showing usage of the item. A recent change in prescription A recent order by the treating physician for refills ** A properly completed CMN or DIF with an appropriate length of need specified** **Not applicable to wheelchair claims Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 9 of 12

10 When billing for repairs to wheelchair equipment, the four options to support continued medical need offered in the LCD are not all applicable. Suppliers cannot secure a recent order for refills as there are no recurring supplies for wheelchairs. The wheelchair policy does not require a CMN or DIF form, which means the supplier cannot rely on the length of need for continued medical need. Likewise, it is not often that a beneficiary will require a change in prescription that modifies how the equipment is used as may be seen with other equipment. Therefore, the most reliable option for suppliers to support continued medical need for wheelchairs is timely documentation from the medical record showing that the item is being used. This can be documentation from the physician s clinical notes regarding the patient s mobility, perhaps home health notes or notes from a physical therapist. Remember, timely documentation is defined as a record created in the preceding 12 months. Suppliers must also provide documentation to support the medical necessity of the repair itself. This includes having detailed records describing the need for and nature of all repairs. Detailed explanation of the justification for any component or part being replaced Detailed record of the labor time required to restore the item to its functionality to meet the beneficiary s medical need As a part of the final rule published on November 6, Final Rule Implications for PWCs 2014, HHS finalized two demonstrations for standard power wheelchairs for no more than 12 CBAs. These CBAs must: Have a minimum general population of 250,000 Have a minimum of 20,000 Part B beneficiary enrollments, and Not already be subject to Round 1 or Round 2 of Competitive Bidding. 40 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 10 of 12

11 Under these demos, suppliers will compete to be contracted under a bid program to supply Standard Power Wheelchairs. Under the first demo it will be a bundled program where one allowable is paid continuously for everything that patient needs for as long as it is needed, but no separate allowance will be made for accessories, labor, maintenance or repairs.. Under the second demo, the contracted suppliers will bill for the PWCs under the traditional capped rental payment methodology, However, post cap the contracted suppliers will be obligated to continue to provide maintenance, service and repairs for any standard PWC provided by the supplier during their contract period without separate reimbursement. The same rules would apply for any PWC where the title is transferred to the beneficiary during the supplier s contract period. This responsibility would only end when the RUL expires, medical necessity ends or the beneficiary relocates outside of the contracted supplier s CBA. Under the second demonstration, suppliers would not be required to repair a PWC that they did not furnish. For PWCs that were supplied by another supplier (prior to the start of the supplier s contract or prior to the beneficiary entering Medicare), repairs would be reimbursed at the standard fee schedule rate before the special payment rules are applied Special thanks to our sponsor! These demonstrations are slated for rollout after January 1, However, they will be implemented similar to other competitively bid programs including a selection of CBAs for deployment, advance supplier notice and education efforts and a bidding process; all of which are still to come Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 11 of 12

12 Don t tax your resources by filtering through overwhelming listserves trying to decode directives...let us bring that information to you in an easy-to-digest format! Bi-Monthly e-publication pages in length including attachments New! Bi-monthly webinar to highlight noteworthy changes and updates from the publication (for subscribers only) Covers relevant nationwide audit trends Summarizes Medicare updates and directives in plain English Parallels to a full year of educational insights from consultant Andrea Stark Lock in at the current $300 rate for a full year of updates and webinars. Find out more on our website: ual_subscription.html These materials and links to other sources are provided for informational purposes only and are not intended to be and should not be construed as legal advice. MiraVISTA does not guarantee or warrant that the materials are without error or present a complete explanation of all aspects of coverage or billing. Laws and procedures change frequently and are subject to differing interpretations. Content and information is subject to change without notice. 47 Content Current as of 09/2015 All Rights Reserved MiraVista LLC 2015 Page 12 of 12