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(1)

5/31/2016

Oxygen and Oxygen Equipment

Presented by

Noridian Provider Outreach and Education Jurisdiction D DME MAC

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5/31/2016

Disclaimer

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and the Centers for Medicare & Medicaid Services (CMS). The most current edition of the

information contained in this release can be found on the Noridian website and the CMS website.

The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.

• Noridian Medicare Website (https://med.noridianmedicare.com/web/jddme) • CMS Website (https://www.cms.gov)

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5/31/2016

Please Sign into Audio Using Either

Method

• Call Me Option

– Enter your contact phone number

– You will receive a call that connects you

• Call Using Computer Option

– Ensure you have mute off on your • Computer and

• Headphones

3

Noridian Jurisdiction D DME MAC June 2016

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5/31/2016

Sync Your Phone with Your Name

June 2016 Noridian Jurisdiction D DME MAC 4

• Click on Event Info Tab

• Verify Identity code • Enter # your

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Workshop protocol

• Entering Workshop

– Attendee lines are muted upon entry

• Throughout Workshop

– Written questions in Q & A section

• Conclusion of Workshop: Q & A Session

– Use “Raise Hand” feature to ask questions aloud – When question finished, select “Lower Hand” button

• Certificate of Completion

– 1 AAPC CEU is offered for this course

– Certificate of Completion will be sent out to all attendees 2-3 days after workshop based on attendance report

• Presentation was sent via email and can also be found at:

https://med.noridianmedicare.com/web/jddme/education/event-materials

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5/31/2016

How to Ask a Written Question

• Click on the Q and A

tab

• Address “All Panelists”

• Type your question into the box

– Limit 256 characters – Be concise

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5/31/2016

Acronyms

ABG: Arterial Blood Gas

ABN: Advance Beneficiary

Notice of Noncoverage • ACA: Affordable Care Act

ADR: Additional Documentation

Request

CBA: Competitive Bidding Area

CEDI: Common Electronic Data

Interchange

CERT: Comprehensive Error

Rate Testing

CMN: Certificate of Medical

Necessity

CMS: Center for Medicare &

Medicaid Services

CO: Contractual Obligation

DMECS: Durable Medical

Equipment Coding System • DME MAC: Durable Medical

Equipment Medicare Administrative Contractor • DMEPOS: Durable Medical

Equipment Prosthetics Orthotics and Supplies

FAQ: Frequently Asked Question

FFS: Fee for Service

HCPCS: Healthcare Common

Procedure Coding System • HHA: Home Health Agency

• HICN: Heath Insurance Claim Number

(8)

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Acronyms

HMO: Health Maintenance

Organization

IDTF: Independent Diagnostic

Testing Facility

IOM: Internet Only Manual

IVR: Interactive Voice Response

(system)

LCD: Local Coverage

Determination

LPM: Liters per minute

mm Hg: Millimeters of Mercury

M&S: Maintenance and Service

MLN: Medicare Learning Network

NCD: National Coverage

Determination

NSC: National Supplier

Clearinghouse

PA: Policy Article

PHI: Protected Heath

Information

PIM: Program Integrity Manual

POD: Proof of delivery

PTAN: Provider Transaction

Access Number

RA: Remittance Advice

RAC: Recovery Audit

Contractor

RUL: Reasonable Useful

Lifetime

SAT: Oxygen Saturation

SNF: Skilled Nursing Facility

WOPD: Written Order Prior to

Delivery

ZPIC: Zone Program Integrity

Contractor

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Noridian Widespread Review

Non-complex E1390

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Noridian Widespread Review

Complex E1390

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Noridian Widespread Review

Complex E0439 and E0434

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New Noridian Widespread Review

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Frequent documentation errors

• No alternative treatments documented

• No chronic underlying Lung disease documented • Non-Response to ADR letter

• Missing documentation • WOPD not valid

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Agenda

• Oxygen and the ACA

• Coverage Criteria

• Testing Requirements • Coverage Groups

• Certificate of Medical Necessity • Coding and Billing Guidelines • Documentation

• CERT

• Resources and Reminders

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Oxygen and the ACA

(Section 6407)

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MM8304

• Face-to-Face evaluation – Documentation – Authorized to order – Timeliness

• Detailed Written Order

– WOPD

– Required Elements • Physician NPI

• Affected HCPCS/Policies

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Implementation vs. Enforcement

• Implementation Date

– For all requirements – July 1, 2013

• Enforcement Date

– For WOPD requirements

• Date of Service (DOS) January 1, 2014 – For F2F requirements

• To be announced by CMS in 2015

(18)

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Oxygen Specific Items & ACA

Requirements for Order

Do Require WOPD • E0431 • E0434 • E0439 • E0424 • E0441 • E0442 • E0443 • E0444

Do Not Require WOPD

• E1390 • E1392 • K0738

(19)

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Written Order Prior to Delivery

(WOPD)

• Basic elements

– Beneficiary’s name – Physician’s name – Date of the order

– Detailed description of the item(s) – Physician signature and signature date – Physician NPI

– Date stamp (or equivalent) upon receipt

Noridian Jurisdiction D DME MAC

June 2016 19

change Note  change

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DWO: Additional Elements

Items Provided on a Periodic Basis

• Item(s) to be dispensed

• Dosage or concentration, if applicable • Route of administration

• Frequency of use

• Duration of infusion, if applicable • Quantity to be dispensed

• Number of refills

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Acceptable Detailed Written Order

• May be completed by someone other than

physician

– Treating physician must review, sign and date

• Acceptable orders

– Fax

– Photocopy – Electronic

– Original pen and ink

• CMN can serve as the WOPD if sufficiently detailed

(22)

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ACA – Common documentation

errors on a WOPD

• No Date stamp/similar • No NPI # on WOPD

• Date stamp is completed after the date of delivery • Fax line used for date stamp or similar

– No supplier identifier included – No date included

– Illegible

• In these instances the fax line has been covered up partially by several follow-up fax lines

• NPI # added to WOPD after Physician date/signature

– without proper amendment/correction procedures followed by the Physician

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Corrections & Amendments to

Face-to-Face and WOPD

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Prior to Delivery

• Have treating physician properly amend the face-to-face visit or WOPD

• A new face-to-face or a new WOPD

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After Delivery

Prior to Claim Submission

• Supplier may recover the delivered items

• Obtain a compliant face-to-face or WOPD

• Re-deliver items

After Claim Submission

• Supplier may recover the delivered items

• A new supplier must complete the transaction

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Coverage Criteria

National Coverage Determination (240.2)

Local Coverage Determination (L33797) Policy Article (A52514)

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Covered Home Oxygen Therapy

1. Severe lung disease or hypoxia related

symptoms; and

2. Beneficiary’s blood gas study meets specific criteria; and

3. Blood gas study performed by physician or a qualified provider or supplier of laboratory services; and

4. Blood gas study performed under specific conditions; and

5. Alternative treatments ineffective

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FAQ

Q: What is considered to be alternative treatment measures before the oxygen is ordered?

A: Many disease conditions have standard

treatment regimens associated with them. This criterion, together with the requirement that testing be done while the patient is in their chronic, stable state means that the usual treatment modalities need to be optimized before oxygen becomes eligible for reimbursement.

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Home Oxygen – Not

Reasonable and Necessary

• Angina pectoris in the absence of hypoxemia • Dyspnea without cor pumonale or evidence of

hypoxemia

• Severe peripheral vascular disease in absence of systemic hypoxemia

• Terminal illnesses that do not affect respiratory system

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NCD

Conditions for Which Oxygen Therapy May Be Covered

• A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, whether of known or unknown etiology; cystic fibrosis, bronchiectasis; widespread pulmonary neoplasm; or

• Hypoxia-related symptoms or findings that might be expected to improve with oxygen therapy. Examples of these symptoms and findings are pulmonary hypertension, recurring

congestive heart failure due to chronic cor pulmonale,

erythrocytosis, impairment of the cognitive process, nocturnal restlessness, and morning headache.

• While there is no substitute for oxygen therapy, each patient must receive optimum therapy before long-term home oxygen therapy is ordered.

(31)

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FAQ

Q: Are pneumonia or post-surgical hypoxia covered conditions for home oxygen upon discharge from the hospital?

A: Short-term support strictly due to an acute hypoxia need related to Pneumonia or

post-operative recovery would not meet the requirement of a chronic underlying lung condition requiring

long-term Oxygen therapy.

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Testing Definitions

• Blood gas study

– Refers to both arterial blood gas (ABG) studies and pulse oximetry

• Oximetry

– Refers to routine or “spot” pulse oximetry

• Overnight oximetry

– refers to stand-alone pulse oximetry continuously recorded overnight. It does not include oximetry

results done as part of other overnight testing such as polysomnography or home sleep testing

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Blood Gas Study

• Qualifying test covered under Medicare Part A or B

• Test must be performed by provider qualified to bill Medicare:

– Part A Provider – Laboratory

– Independent Diagnostic Testing Facility (IDTF) – Physician

(35)

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FAQ

Q: Can the testing be performed by a home health or hospice nurse at the beneficiary's home or by a Nurse in a SNF?

A: Yes. If the beneficiary’s home health episode was bundled and billed under a Part A episode at the time the home health nurse measured the oxygen saturation, then it would meet the qualified provider standard.

“During a Part A covered stay payment is bundled such that services rendered are covered under a lump sum payment by Medicare.

In this case, oxygen qualification testing performed in a hospital, nursing facility, home health or hospice or other covered Part A episode meets the "qualified provider" standard.

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Testing

• Types of qualifying tests:

– Arterial blood gas (ABG) – below 60 mm Hg – Blood oxygen saturation (SAT) – below 90%

• Group I 88% or below • Group II 89%

– Most recent study prior to CMN initial date (w/in 30 days)

(37)

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Testing

• Study can be performed:

– At rest

– During sleep – During exercise

• Can be formal exercise or exertion while performing daily activities

• Three separate readings must be taken

• Record reading taken during exercise breathing room air on CMN

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Testing Conditions

Inpatient Hospital Stay

• Closest to, but no earlier than 2 days prior to the hospital discharge date • Last test prior to discharge

Outpatient

• Must be performed while the beneficiary is in a chronic stable state • Not during acute illness or

exacerbation of underlying disease

(39)

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FAQ

Q: Would a blood gas obtained during an

Observational status from the Emergency room qualify for inpatient testing?

A: No, nor would it meet chronic stable state requirements.

– If using two days prior to hospital discharge for testing conditions – the beneficiary must have been in a true inpatient hospital stay. The patient must have had an order for Hospital inpatient services as stated under Medicare Part A.

(40)

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Sleep Oximetry Studies

• Oximeter must be:

– Stand-alone overnight pulse oximetry – Tamper proof

– Capable of downloading data that allows

documentation of duration of O2 desaturation below specified value

(41)

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Sleep Oximetry Studies

• Home based overnight oximetry tests

– Performed under direction of Medicare enrolled IDTF – Can be delivered by supplier or shipping entity if:

• Ordered by physician

• Test results accessible only by IDTF

• CMN Q1(b) = lowest value during 5-min qualifying period

(42)

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Concurrent Use

Oxygen and PAP

(43)

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Overnight Oximetry,

OSA AND PSG

• Testing must be done in Chronic Stable State • Both oxygen LCD and PAP LCD must be

followed

• OSA sufficiently treated and lung disease unmasked

(44)

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Overnight Oximetry,

OSA AND PSG

(2)

• Overnight oximetry during home sleep test not eligible to be used for oxygen qualification.

• Testing may only occur during a Titration Study and

1. Minimum 2 hours

2. During titration specific reduction in AHI/RDI criteria met

3. Only performed after optimal PAP settings determined

4. Nocturnal oximetry conducted during PSG shows <88% for 5 minutes.

(45)

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Titration Example

PAP Cm H2O Total  Sleep  Time (min)

TIB (min) Sleep Eff  % Hypopneas # Central  Apneas Obstructive Apneas AHI Mean  SPO2 Time O2 88% or  under (min) 0 Baseline 124 208 59.6 79 0 49 61.9 86 70 5 23.5 28 83.9 16 0 2 46 89 10 6 13 13.5 96.3 8 0 3 50.8 88 9 7 26 26 100 6 0 4 23.1 88 22 8 17.5 18 97.2 9 0 1 34.3 87 16 9 18.5 23 80.4 8 0 6 42.2 89 7 10 13.5 13.5 100 3 0 0 13.3 81 13.5 11 122 172 70.9 4 0 7 5.4 88 83 Total  minutes 358 502 June 2016 Noridian Jurisdiction D DME MAC 45

(46)

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FAQ

Q: The Sleep Physician sends an order for

overnight oxygen, the medical records state the beneficiary is scheduled for a Polysomnogram (PSG) to test for Obstructive Sleep Apnea (OSA). Is Oxygen covered until the PSG is completed? A: No, if OSA is suspected it must either have been ruled out or treated to confirm that the oximetry is done while the beneficiary is in their chronic stable state during a titration study.

(47)

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FAQ

Q: If the patient is on PAP and then is tested for continuous Oxygen with a daytime at rest/exercise saturation test and qualifies for 24hr a day Oxygen do they also need a titration study to use the

Oxygen with PAP at night?

A: No, Obstructive Sleep Apnea (OSA) is not

present in the daytime so if the qualification is for continuous oxygen use that would qualify the

beneficiary and an additional titration would not be necessary.

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(49)

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Coverage Groups

Group I

• ABG at or below 55 mm Hg or SAT at or below 88% 1. At rest, or

2. During exercise (3 tests)

3. During sleep (at least 5 minutes) 4. During sleep (signs of hypoxemia)

1. Decrease in ABG more than 10 mm Hg or a decrease in SAT more than 5% from baseline for at least 5 minutes taken during sleep

• Initial coverage limited to 12 months

(50)

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Coverage Groups

Group II

• ABG between 56 – 59 mm Hg or SAT at 89% – Same testing requirements as Group I

• AND beneficiary has one of following conditions: – Dependent edema, suggesting congestive heart failure; or – Pulmonary hypertension or cor pulmonale; or

– Erythrocythemia with a hematocrit greater than 56% • Initial coverage limited to 3 months

(51)

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Portable Oxygen

• Beneficiary must be mobile within the home • Qualifying study performed at rest or during

exercise

– Study performed during sleep – not reasonable and necessary

• Separately payable if coverage criteria met

– Reimbursement is the same regardless of quantity dispensed

(52)

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High Liter Flow

• High liter flow (greater than 4 LPM)

– Must meet Group I or II criteria when tested at 4 or more LPM

• If not, payment limited to standard allowance

– Higher allowable for stationary but portable not separately payable

(53)

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(54)

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Initial CMN

1. First claim to DME MAC

– Testing and physician evaluation within 30 days of initial date

2. Break in need during 36 month rental period

– Testing and physician evaluation within 30 days of initial date

(55)

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Initial CMN

(2) 3. Replacement due to RUL

– No new testing or new physician visit required per LCD

• ACA section 6407 items require new F2F

4. Replacement due to irreparable damage, theft, or loss of the originally dispensed equipment

– No new testing or new physician visit required

(56)

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Recertification

5. Group I patients – 12 months after initial

– Most recent qualifying test prior to 13th month

6. Group II patients – 3 months after initial

– Most recent qualifying test between 61st – 90th day

• Other requirements for 5 and 6:

– Re-evaluation within 90 days prior to recertification – Above criteria not met, but use continues, coverage

resumes when requirements are met

(57)

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Recertification

• Recertification for replacement equipment:

– Same timeframes apply

– Repeat testing and re-evaluation not required – Use most recent qualifying value and test date

(58)

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Revised CMN

7. Change in flow rate category

– Less than 1 liter per minute (LPM) – 1-4 LPM

– Greater than 4 LPM

8. Length of need expired

• Revised CMN does not change recertification schedule

(59)

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Revised CMN

9. Portable added to stationary 10. Stationary added to portable

11. New treating physician - oxygen order is the same

12. New supplier does not have the prior CMN • Revised CMN does not change recertification

schedule

(60)

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Other CMN Notes

• CMN Sections B and D completed by physician

– Signature and date stamps are not acceptable for use on CMNs and DIFs

– Form CMS-484 (11/11):

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS484.pdf

• Misc. changes not requiring new CMN or testing

– Flow rate changes but remains in same category – Change of modality

– New written order is required though

(61)

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Other CMN Notes

• Making Changes to a CMN

– Two options

• Draw line through error

– Treating physician must initial and date correction – Must have similar capability for electronic CMN

• Complete new CMN – Whiteout not acceptable

(62)

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(63)

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FAQ

Q: Can I bill code E0439 in the same month with code E1390?

A: No. Both the E0439 and E1390 are stationary oxygen items and are considered similar

(64)

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Modifiers

• RR – Monthly rental

• Q0 – Investigational, approved clinical research study (replaced QR)

• QE – Flow rate less than 1 LPM

• QF – Flow rate is greater than 4 LPM and portable oxygen is prescribed

(65)

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Modifiers

• QG – Flow rate is greater than 4 LPM and portable oxygen is not prescribed

• QH – Oxygen conserving device is being used with an oxygen delivery system

• RA – Replacement of DME item, first month rental only

(66)

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Months 1-36

• Supplier who furnishes equipment in 1st month must continue for entire 36-mo rental period unless:

– Beneficiary relocates or elects a new supplier

– Individual case exceptions made by CMS or the DME MAC

– Item becomes subject to competitive bidding

(67)

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Months 1-36

• Contents, maintenance, supplies and

accessories all included in rental allowance

– Exception: contents separately allowed if beneficiary only uses portable liquid or gas

(68)

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Months 1-36

• Relocation

– Supplier responsible for providing equipment for remainder of current rental month

– For subsequent rentals months, home supplier encouraged to continue to provide equipment or assist the beneficiary in finding another supplier to take over

(69)

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Months 37-60

• No further payment for remainder of the 5 year RUL

• Continue providing equipment, supplies,

accessories, maintenance during remainder of 5 year RUL

• New 36-mo rental can only begin if equipment lost, stolen or irreparably damaged

– No new 36-mo cap for normal wear and tear, changes of modality, breaks in need or billing or change of

suppliers

(70)

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Months 37-60

• Relocation

– Home supplier required to provide or make arrangements for another supplier to provide equipment and all related items/services

(71)

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Travel

• Beneficiary responsible for airline oxygen services

• Beneficiary responsible for services provided outside the United States

(72)

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Break in Service

• Break less than 60 days = break in billing

– Does not start a new 36-mo cap

– Continue existing rental where left off until 36 rental payments made

• Break greater than 60 days

– New 36-month cap begins

– Requires new testing, order and initial CMN

– Include narrative on claim for new rental explaining why medical necessity ended

(73)

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Contents Billing Chart

Equipment Furnished in Month 36 Monthly Contents Payment after  Stationary Cap Oxygen Concentrator (E1390, E1391, or  E1392) None Portable Gaseous Transfilling Equipment  (K0738) None Portable Liquid Transfilling Equipment  (E1399) None Stationary Gaseous Oxygen System  (E0424) Stationary Gaseous Contents (E0441) Stationary Liquid Oxygen System (E0439) Stationary Liquid Contents (E0442) Portable Gaseous Oxygen System (E0431) Portable Gaseous Contents (E0443) Portable Liquid Oxygen System (E0434) Portable Liquid Contents (E0444) June 2016 Noridian Jurisdiction D DME MAC 73

(74)

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Contents

• Payment included in fee schedule allowance for stationary equipment during 36-month cap

• Can begin billing contents for liquid/gas systems after end of 36-month stationary cap

(75)

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FAQ

Q: Since the contents code E0443 requires a WOPD/F2F if this code is not listed on our

initial/recertification CMN does the patient require a new order/F2F before we can start billing for contents after the equipment has capped?

A: Yes. You can't bill contents initially, but you can include them on the recertification CMN in preparation for when they will be needed. If they are not on the recertification CMN, you need a new WOPD and F2F before billing.

(76)

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Maintenance and Service

• Applies to concentrators and transfilling

equipment

– No M&S payment for gaseous or liquid equipment

• No separate payment for M&S during 36-month cap

(77)

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Maintenance and Service

• M&S billable every 6 months starting 6 months after end of 36-month cap or end of warranty, whichever is later

– Supplier must actually make a visit to bill the service – Only one M&S payment made regardless of number

of visits made during 6-month period

– See MLN Matters 6792 and 6990 for more information

(78)

5/31/2016

FAQ

Q: When can Maintenance and Service be billed for oxygen?

A: If a beneficiary was using a stationary concentrator, portable concentrator, or trans-filling equipment during the 36th rental month, Medicare will pay for a

maintenance and service visit no more often than every 6 months, beginning no sooner than 6 months following the end of the rental period. A supplier must actually make a visit to bill the service.

There is no maintenance and service payment for gaseous or liquid equipment.

(79)

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Reasonable Useful Lifetime

• RUL = 5 years

– Supplier responsible for furnishing all accessories, contents, repairs during RUL

• Options once RUL reached

– Make arrangements to pick up equipment and discontinue servicing beneficiary

– Replace equipment and begin new 36-month cap and RUL – Continue servicing beneficiary, billing only for contents and

M&S

• Stationary equipment governs RUL-based rules – MLN Matters MM7213

(80)

5/31/2016

Reasonable Useful Lifetime

• Payment allowed when original equipment is:

– Lost (includes replacement due to bankruptcy) – Stolen

– Irreparably damaged (due to a specific incident) – RUL reached

• Replacement rules:

– New 36 month cap and RUL begins

– Must include RA modifier on 1st rental of replacement equipment and narrative explaining why replacement is being provided

– Need new detailed written order and initial CMN

• A new reasonable useful lifetime or 36 month rental period does not start when:

– Equipment modalities are changed

– Equipment needs to be replaced due to not functioning properly – Beneficiary switches to new supplier and/or new equipment

(81)

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FAQ

Q: Which modifier is used on the first months claim for replacement of oxygen equipment with dates of service on or after January 01, 2009?

A: The RA modifier must be appended to the first months’ claim for replacement of oxygen

equipment.

(82)

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(83)

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Standard Documentation

Requirements

• Dispensing Order

– If item was delivered based on dispensing order or for supplier-created DWO/WOPD

• Detailed Written Order (DWO)

• Written Order Prior to Delivery (WOPD) – Based on policy/ACA requirements • Beneficiary Authorization • Proof of Delivery • Continued Use • Continued Need • Refill Requirements – Items dispensed on a periodic basis • Medical Records June 2016 Noridian Jurisdiction D DME MAC 83

(84)

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Proof of Delivery (POD)

• Supplier Standard 12

• Signed POD required to verify beneficiary received DMEPOS item

• Must be available upon request

– If not provided, claim denied, overpayment requested – If no documentation provided on consistent basis,

may be referred to Office of Inspector General (OIG)

• Maintain documentation for seven years

Noridian Jurisdiction D DME MAC

(85)

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Comprehensive Error Rate

Testing (CERT)

(86)

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CERT Letter

June 2016 Noridian Jurisdiction D DME MAC 86

(87)

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CERT

• Randomly select submitted claims

• Request medical records from provider/supplier that submitted claim

• Review claims and medical record for compliance with Medicare to include:

– Coverage – Coding – Billing rules

Noridian Jurisdiction D DME MAC

(88)

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CERT 2015 Improper Payment Rates

• CERT Improper Payment Rate webpage

( https://www.cms.gov/Research-Statistics-Data- and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/index.html)

June 2016 Noridian DME Outreach and Education 88

Service Type Improper Error Rate Improper Payment Amount  (2) Inpatient Hospitals 6.2% $7.0 Billion Durable Medical Equipment 39.9% $3.2 Billion Physician/Lab/Ambulance 12.7% $11.5 Billion Non‐Inpatient Hospital  Facilities 14.7% $21.7 Billion Overall 12.1% $43.3 Billion

(89)

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CERT Error Categories

• Insufficient documentation

• No documentation

• Service incorrectly coded

• Medically unnecessary service • Other

Noridian Jurisdiction D DME MAC

(90)

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Decrease CERT Errors

• Educate staff

• Train coders/billers

• Submit correct information

– Beneficiary name, social security number, Medicare number, date of service

• Submit legible and complete records

– Dates, required signatures, etc.

• CERT Inquiries

Noridian Jurisdiction D DME MAC

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CERT Inquiries

• jddmecert@noridian.com

• Email should include:

– CERT Claim Identification (CID) – In Subject Line – Supplier name and address

– Telephone number

– Explanation of the issues, concern or question

• DO NOT send Protected Health Information (PHI)

• Response within 2 business days

(92)

5/31/2016

Common CERT Oxygen Errors

• Missing the treating physician’s clinical records to support beneficiary’s condition that requires oxygen use and that the beneficiary continues to need and use supplemental home oxygen proximal to billed date of service (DOS). • Missing the signed and dated order from the physician

that reflects the change in oxygen liter flow rate.

• Missing a copy of the qualifying oxygen saturation study that applies to the conditions stated on the CMN.

• Missing the treating physician's re-evaluation within 90 days of the recertification CMN supporting the

beneficiary's lung disease or hypoxia-related symptoms that improve with oxygen therapy.

(93)

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(94)

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Resources

• LCD/Policy Article

(https://med.noridianmedicare.com/web/jddme/p olicies/lcd/active)

• Noridian Supplier Manual

(https://med.noridianmedicare.com/web/jddme/e ducation/supplier-manual)

• “Dear Physician” Letters

(https://med.noridianmedicare.com/web/jddme/p olicies/physician-resources)

(95)

5/31/2016

Resources (cont.)

• Documentation Checklists (https://med.noridianmedicare.com/web/jddme/p olicies/documentation-checklists) • Acronyms

– Noridian Acronym List

(https://med.noridianmedicare.com/web/jddme/help/a cronyms-glossary)

– CMS Acronym List

(https://www.cms.gov/apps/glossary/)

(96)

5/31/2016

2016 MSI Survey

Evaluate Our Services in 10 Minutes!

The MAC Satisfaction Indicator (MSI) is the best way to share your opinions of our service directly with the Centers for Medicare & Medicare Services (CMS). This survey should only take about 10 minutes of your time and helps us understand how we can better serve you. To take the survey, click on the URL.

https://cfigroup.qualtrics.com/SE/?SID=SV_bp9wfwWbjvyXhiJ&MAC=J D DME – Noridian¿&MAC_BRNC=4

(97)

5/31/2016

Browse By DMEPOS Category

Oxygen

(98)

5/31/2016

Beneficiary Authorization

• Beneficiary must authorize supplier to bill

Medicare

– Sign and date Item 12 on CMS-1500 claim form – Supplier-created Signature On File

• One-time authorization

• Statement from beneficiary authorizing Medicare benefits to be paid to themselves or supplier

• One-time Authorization Sample Language

( https://med.noridianmedicare.com/web/jddme/claims-appeals/claim-submission/signature)

(99)

5/31/2016

New Supplier Education Curriculum

• General and policy

specific

• Short presentations grouped by relevance • Quiz at conclusion

with certificate

• Great for new and existing suppliers

• Suppliers encouraged to view both general and policy specific curriculum • New Supplier Education Curriculum Webpage (https://med.noridian medicare.com/web/jd dme/topics/welcome) June 2016 Noridian DME Outreach and Education 99

(100)

5/31/2016

Denial Code Guidance

• Each denial code webpage includes:

– Claim adjustment reason code and description – Claim adjustment remark code and description – Common reason why Noridian uses that

reason/remark code

– Next step (re-file, redetermination, reopening, etc.) – How to avoid these types of denials

– Applicable resources

• Denial Code Guidance Pages

(https://med.noridianmedicare.com/web/jddme/t opics/ra/denial-guidance)

(101)

5/31/2016

PECOS Requirement

• Claims may be denied if:

– The ordering physician is NOT in PECOS

– The ordering physician is not of the specialty to order – If the physician's name submitted on the claim does

not match their name in PECOS

• PECOS Edit

(https://med.noridianmedicare.com/web/jddme/cl aims-appeals/claim-submission/pecos-edits)

• View the PECOS DME on Demand

(http://www.brainshark.com/noridian/vu?pi=zHlz qyKBpz87uMz0)

(102)

5/31/2016

What is an ABN?

• Written notice of non-coverage

– Informs beneficiary that Medicare may not pay for item

• Allows beneficiary to make informed decision • Protects supplier from liability

• Can only be used for beneficiaries enrolled in the Medicare Fee-For-Service program

• Can be used for PAP month 4 and beyond if beneficiary not compliant or face-to-face after the 31st day has not occurred

(103)

5/31/2016

Electronic Submission of Medical

Documentation (esMD)

• Transmit documentation electronically for review • Who accepts documentation via esMD?

– DME MAC (Noridian)

• Complex Medical Review and PMD PAR – CERT

– Recovery Auditor – ZPIC

• CMS esMD Webpage ( www.cms.gov/Research- Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/index.html?redirect=/esmd)

(104)

5/31/2016

MREP

• Medicare Remit Easy Print

– Free software!

– View, search and print remits – Print and export reports

• CMS Brochure (www.cms.gov/MLNProducts/downloads/Medica reRemit_0408.pdf) • MREP Software (www.cms.gov/AccesstoDataApplication/02_Me dicareRemitEasyPrint.asp) June 2016 Noridian DME Outreach and Education 104

(105)

5/31/2016

Medicare Learning Network (MLN)

• Guides • Articles • Educational Tools • Booklets Brochures • Fact Sheets • Training Presentations • Web-Based Training • And more! • MLN Webpage (www.cms.gov/Outrea ch-and- Education/Medicare- Learning-Network-MLN/MLNGenInfo/ind ex.html) June 2016 Noridian DME Outreach and Education 105

(106)

5/31/2016

Noridian Medicare Portal

• Replaced Endeavor – Same functionality as Endeavor – Endeavor was decommissioned May 1, 2016 • Five roles: – Provider Administrator

• Must register first

– Provider End User – Vendor Administrator – Vendor End User – Dual Role

• More information

including training and registration: • Noridian Medicare Portal webpage (https://med.noridian medicare.com/web/jd dme/topics/nmp) June 2016 Noridian DME Outreach and Education 106

(107)

5/31/2016

DME on Demand

• NEW - Noridian Medicare Portal specific – Additional Documentation Requests

– Appeal Status – Appeal Submission

– Automatic Password Reset – Claim-Specific Remit – Claim Status – Eligibility – Financials – Overpayments – PMD PAR – Registration – Same or Similar Noridian Jurisdiction D DME MAC https://med.noridianmedicare.com/web/jddme/education/event-materials 107 June 2016

(108)

5/31/2016

ALJ Appeal Status Info System

(AASIS)

• Check the status of an ALJ appeal

June 2016 Noridian Jurisdiction D DME MAC 108

(109)

5/31/2016

ICD-10 Questions?

• ICD-10 Implementation took place 10/1/15 • ICD-10 Resources

– Noridian Medicare ICD-10 Webpage

(https://med.noridianmedicare.com/web/jddme/topics/i cd-10)

– CMS ICD-10 Webpage

(https://www.cms.gov/medicare/coding/icd10/index.ht ml)

– “Road to 10” Website (www.roadto10.org)

(110)

5/31/2016

Email Updates

• Tuesday and Friday

• Latest updates and announcements • Customizable

• Sign-up in the lower right corner of our website

• Click “subscribe”

(111)

5/31/2016

Website Survey

• Your feedback is valuable

• Click “Yes, I’ll give feedback”

(112)

5/31/2016

Education Request

June 2016 Noridian Jurisdiction D DME MAC 112 1‐on‐1 Training • With a  knowledgeable   Noridian  representative Customized  Education • Tell us what  you’d like to  learn Convenient  Scheduling • We’ll set‐up a  time/date that  works for you

Submit an Education Request today!

https://med.noridianmedicare.com/web/jddme/for ms

(113)

5/31/2016

Education Opportunities

• Web-Based Workshops

• Q & A Sessions

– 2nd Monday of each month @ 3 p.m. CT

• DME On Demand • Education Request

• Ask the Contractor Teleconference (ACT) • Education and Outreach Webpage

(https://med.noridianmedicare.com/web/jddme/e ducation)

(114)

5/31/2016

Education Opportunities

• Web-Based Workshops • DME On Demand

– Oxygen Maintenance and Service

– Dear Physician Prescribing Home Oxygen – Concurrent use of Oxygen and PAP – Oxygen: Testing Requirements – Oxygen: Coverage Guidelines

– Oxygen: Coding and Billing Guidelines – Oxygen: CMN Requirements

– Continued Use/Continued Need – DWO and Face to Face Requirements – Break in Service/Break in Billing

• Medicare Midterms

– Oxygen

– Medical Review Program

Noridian Jurisdiction D DME MAC

(115)

5/31/2016

Live Online Q&A

• Online question and answer sessions

with members of the Education staff via written/verbal communication • One hour sessions

• 2nd Monday of every month • 3:00pm CT

• Next session June 13th

https://med.noridianmedicare.com/web/jddme/education

(116)

5/31/2016

Upcoming Web-Based Workshops

• June 8

– Patient Lifts 3PM CST • June 9

– AFO and KFO 1PM CST • June 23

– Manual Wheelchair Bases 11AM CST – DME Modifiers 1PM CST

• June 28

– Hospital Beds 3PM CST • June 29

– General Documentation 11AM CST

https://med.noridianmedicare.com/web/jddme/education/training-events

116 Noridian Jurisdiction D DME MAC

(117)

5/31/2016

Ask the Contractor Teleconference

• Upcoming ACT: June 9th 3 p.m. CT

• dmeworkshops@noridian.com

• Call Information

– Phone Number: (800) 230-1085

– After placing the call for the ACT, suppliers need to provide the following:

• Conference Name: Noridian Ask the Contractor Teleconference

• Name

• Name of the company represented • State

Noridian Jurisdiction D DME MAC 117 June 2016

(118)

5/31/2016

Fee Schedule Lookup

June 2016 Noridian Jurisdiction D DME MAC 118

https://med.noridianmedicare.com/web/jddme/article-detail/-/view/2230715/dme-fee-schedule-lookup-tool-update

(119)

5/31/2016

One-on-One Medical Review

Education

(120)

5/31/2016

Single Toll Free Line

• 877-320-0390

– Interactive Voice Response (IVR) – Supplier Contact Center

– Telephone Reopenings

• Monday – Friday • 8 a.m. – 6 p.m. CT

(121)

5/31/2016

Beneficiary Contact Information

• Suppliers please use Noridian Contact Center

number for supplier inquiries only

• Beneficiaries who need assistance can be directed to:

– 1-800-Medicare (800-633-4227)

• Question on claims and coverage of equipment – Social Security Administration (800-722-1213)

• Update name/address, questions on premiums, Medicare entitlement

– Benefits Coordination Recovery Center (800-999-1118) • Primary insurance information update

(122)

5/31/2016

(123)

5/31/2016

Sync the Audio to Ask a

Verbal Question

• Click on Event Info tab

• Verify Identity code • Enter # you number #

on your telephone keypad

(124)

5/31/2016

Asking a Verbal Question

• To ask verbal

question:

– Click on the Participant tab

• Click on the hand icon – The telephone

handset or computer headset must be present beside your name

(125)

5/31/2016

How to Ask a Written Question

• Click on the Q and A

tab

• Address “All Panelists”

• Type your question into the box

– Limit 256 characters – Be concise

(126)

5/31/2016

References

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