Reimbursement guide for LTV series ventilators

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Reimbursement guide for LTV

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Table of contents

Section I: Reimbursement essentials... 1

General.Medicare.information... 1

Centers.for.Medicare.and.Medicaid.(CMS):.Regional.offices... 2

General.information.on.coding,.coverage.and.payment... 3

Section II: Sites of service—home, LTACH and SNF... 5

Site.of.service... 5

Home... 5

LTACH... 7

SNF... 8-9 Section III: Coverage, coding and payment for LTV® ventilators...10 Process.for.utilizing.the.LTV.series.ventilators...10 Site.of.service...11 Home...11 LTACH...15 SNF...15

Section IV: Coding verification competitive products...17

Coding.verification...17

Section V: Accessory coding and payment...18

How.are.accessories.to.ventilators.coded.and.paid?...18

Glossary of Medicare terms...19

Abbreviations and acronyms...20

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The.practice.of.medical.billing.and.reimbursement.is.very.complex..Home.Medical.Equipment.(HME),.Long-Term.Acute.Care.(LTAC).and.Skilled.Nursing.Facilities.(SNF). providers.alike.must.stay.abreast.of.coding.changes,.develop.sound.billing.practices.and.provide.supporting.documentation.along.every.step.of.the.way..To.expedite. the.reimbursement.process,.all.claims.should.be.submitted.with.the.proper.information,.including.initial.consultation,.history.and.physical.(H&P).and.diagnostic.findings.. Appropriate.use.of.the.ICD-9-.CM.codes.and.HCPCS.Level.I.and.II.codes.will.help.minimize.denials.due.to.lack.of.documentation.or.improper.billing..Additionally,.providers. may.elect.to.routinely.contact.insurance.carriers.for.pre-authorization.prior.to.providing.service..HMEs.may.check.http://www.dmepdac.com.for.information.related.to. product.listings.under.appropriate.HCPCS.codes.and/or.to.code.search.

Section I—Reimbursement essentials

General Medicare information

The.Centers.for.Medicare.and.Medicaid.Services.(CMS).is.the.agency.located. in.Baltimore,.Maryland.that.administers.the.Medicare.and.Medicaid.programs.. Medicare.was.enacted.under.the.1965.Amendments.to.the.Social.Security.Act... It.was.formerly.called.the.Health.Care.Financing.Administration.(HCFA). Medicare.is.the.federal.health.insurance.program.for: •. People.age.65.or.older •. People.under.age.65.with.certain.disabilities •. People.of.all.ages.with.end-stage.renal.disease.(permanent.kidney.failure.requiring. dialysis.or.a.kidney.transplant).

Parts of the Medicare program and coverage

Part A Hospital Insurance: Most.people.do.not.pay.a.premium.for.Part.A.because. they.or.a.spouse.already.paid.for.it.through.their.payroll.taxes.while.working.. Medicare.Part.A.(Hospital.Insurance).helps.cover.inpatient.care.in.hospitals,.including. critical.access.to.hospitals.and.skilled.nursing.facilities.(not.custodial.or.long-term. care)..It.also.helps.cover.hospice.care.and.some.home.healthcare..Beneficiaries.must. meet.certain.conditions.to.get.these.benefits.

Part B Medical Insurance:.Most.people.pay.a.monthly.premium.for.Part.B.. Medicare.Part.B.(Medical.Insurance).helps.cover.doctors’.services.and.outpatient. care..It.also.covers.some.other.medical.services.that.Part.A.doesn’t.cover,.such. as.some.of.the.services.of.physical.and.occupational.therapists,.and.some.home. healthcare..Part.B.helps.pay.for.these.covered.services.and.supplies.when.they.are. medically.necessary.

Part D Prescription Drug Coverage:.Most.people.will.pay.a.monthly.premium.for. this.coverage..Starting.January.1,.2006,.new.Medicare.prescription.drug.coverage. was.available.to.everyone.with.Medicare..Everyone.with.Medicare.can.get.this. coverage.that.may.help.lower.prescription.drug.costs.and.help.protect.against. higher.costs.in.the.future..Medicare.Prescription.Drug.Coverage.is.insurance..Private. companies.provide.the.coverage..Beneficiaries.choose.the.drug.plan.and.pay.a. monthly.premium..Like.other.insurance,.if.a.beneficiary.decides.not.to.enroll.in.. a.drug.plan.when.they.are.first.eligible,.they.may.pay.a.penalty.if.they.choose.to. join.later.

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Region I:.Connecticut,.Maine,.Massachusetts,.New.Hampshire,. Rhode.Island.and.Vermont.

Centers for Medicare & Medicaid Services (CMS): Region I JFK.Federal.Building.

Room.2325. Boston,.MA.02203. Phone:.617.565.1185

Region II:.New.York.and.New.Jersey

Centers for Medicare & Medicaid Services (CMS): Region II 26.Federal.Plaza,.38th.Floor.

New.York,.NY.10278. Phone:.212.264.3657

Region III:.Delaware,.Maryland,.Pennsylvania,.Virginia,.West.Virginia. and.the.District.of.Columbia.

Centers for Medicare & Medicaid Services (CMS): Region III Public.Ledger.Building,.Suite.216. 150.South.Independence.Mall.West. Philadelphia,.PA.19106. Phone:.215.861.4140 Region IV:.Alabama,.North.Carolina,.South.Carolina,.Florida,.Georgia,. Kentucky,.Mississippi.and.Tennessee.

Centers for Medicare & Medicaid Services (CMS): Region IV Atlanta.Federal.Center.

61.Forsyth.Street,.S.W.,.Suite.4T20. Atlanta,.GA.30303-8909.

Phone:.404.562.7500

Region V:.Illinois,.Indiana,.Michigan,.Minnesota,.Ohio.and.Wisconsin Centers for Medicare & Medicaid Services (CMS): Region V 233.North.Michigan.Avenue,.Suite.600.

Chicago,.IL.60601. Phone:.312.886.6432

Region VI:.Arkansas,.Louisiana,.New.Mexico,.Oklahoma.and.Texas Centers for Medicare & Medicaid Services (CMS): Region VI 1301.Young.Street,.Suite.714.

Dallas,.TX.75202. Phone:.214.767.6423

Region VII:.Iowa,.Kansas,.Missouri.and.Nebraska

Centers for Medicare & Medicaid Services (CMS): Region VII Richard.Bolling.Federal.Building,.Room.235. 601.East.12th.Street. Kansas.City,.MO.64106. Phone:.816.426.5233 Region VIII:.Colorado,.Montana,.North.Dakota,.South.Dakota,.Utah. and.Wyoming.

Centers for Medicare & Medicaid Services (CMS): Region VIII Colorado.State.Bank.Building.

1600.Broadway,.Suite.700. Denver,.CO.80202. Phone:.303.844.2111

Region IX:.Arizona,.California,.Hawaii.and.Nevada

Centers for Medicare & Medicaid Services (CMS): Region IX 75.Hawthorne.St.,.Suite.408.

San.Francisco,.CA.94105. Phone:.415.744.3501

Region X: Alaska,.Idaho,.Oregon.and.Washington

Centers for Medicare & Medicaid Services (CMS): Region X 2201.Sixth.Avenue,.Suite.911.

Seattle,.WA.98121. Phone:.206.615.2306. .

More information on the individual regional offices can be obtained from the Centers for Medicare and Medicaid website at http://www.cms.gov.

Centers for Medicare and Medicaid (CMS): Regional offices

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Medicare Administrative Contractors (MACs) These.are.private.insurers.under.contract.with.CMS.for.provider/supplier.enrollment,. claims.payment.and.appeals..There.are.two.different.entities: •. .A/B.MACs.are.transitioning.from.Fiscal.Intermediaries.and.Part.B.Carriers.and. cover.15.distinct.areas. •. DME.MACS.cover.four.distinct.regions.and.process.Durable.Medical.Equipment. (DME).products.and.supplies.(more.details.under.Site.of.service:.Home)..The. beneficiary’s.residence.determines.which.DME.MAC.processes.the.claim.

General information regarding coding, coverage

and payment

Definitions:. Coverage:.Terms.and.conditions.for.payment. Coding:.Unique.identifiers.for.diagnoses,.procedures,.devices.&.diagnostics,. inpatient.services.and.outpatient.services Payment:.Remuneration.by.health.insurance.plans,.government-funded.programs The difference between these concepts

•. Coverage.. –. Is.not.guaranteed.when.you.receive.FDA.approval/clearance –. Does.not.guarantee.a.new.or.favorable.billing.code –. Does.not.guarantee.favorable.reimbursement. •. Coding –. Links.coverage.and.payment –. Does.not.guarantee.coverage. –. Does.not.guarantee.favorable.reimbursement •. Payment –. Function.of.coverage.and.coding –. May.be.subject.to.limits –. May.be.standalone.or.bundled –. May.be.driven.by.breakthrough.or.existing.technologies. General information about coding

The.Healthcare.Common.Procedural.Coding.System.(HCPCS).provides.a.standardized. system.for.billing.Medicare.for.drugs,.devices.or.procedures. HCPCS.consists.of:. •. Level.I.Current.Procedure.Terminology.(CPT).codes.. •. Level.II.national.codes HCPCS.codes.must.be.used.when.billing.Medicare.carriers.and,.in.some.states,. when.billing.Medicaid.carriers..Due.to.HIPAA,.HCPCS.codes.are.the.national.code. set.and.used.by.all.insurance.carriers. Level.I.codes:.HCPCS.mainly.consists.of.CPT.codes..These.five-digit.codes.provide.a. standardized.means.of.reporting.services.or.procedures.performed.by.a.physician. Level.II.codes:.Codes.describe.drugs.and.devices.and.those.services.not.covered.in. Level.I..Most.DME.products,.including.those.used.for.ventilators,.are.billed.with.a. Level.II.code.

What are the Place of Service (POS)/Site of Service (SOS) codes? •. HIPAA.qualified.Medicare.as.a.covered.entity.and.thus,.as.a.covered.entity,.

must.use.the.place.of.service.(POS).codes.from.the.National.POS.code.set.for. processing.its.electronically.submitted.claims.

•. POS.has.a.payment.rate.designation.of.F.for.facility.and.NF.. for.nonfacility.

How does the SOS payment policy affect provider payments?

•. Providers.billing.professional.services.are.paid.at.one.of.two.maximum.allowable. fees,.depending.on.where.the.service.is.performed.

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General information about coverage Overview Medicare.provides.coverage.for.items.and.services.for.more.than.43.million. beneficiaries..The.vast.majority.of.coverage.is.provided.on.a.local.level.and. developed.by.medical.directors.and.the.contractors.that.pay.Medicare.claims.. In.some.cases,.Medicare.deems.it.appropriate.to.develop.a.National.Coverage. Determination.(NCD).for.an.item.or.service.to.be.applied.on.a.national.basis.for.. all.Medicare.beneficiaries.meeting.the.criteria.for.coverage. Medicare.coverage.is.limited.to.items.and.services.that.are.reasonable.and.necessary. for.the.diagnosis.or.treatment.of.an.illness.or.injury.(and.within.the.scope.of.a. Medicare.benefit.category)..National.coverage.determinations.(NCDs).are.made. through.an.evidence-based.process,.with.opportunities.for.public.participation.. In.some.cases,.CMS’.own.research.is.supplemented.by.an.outside.technology. assessment.and/or.consultation.with.the.Medicare.Evidence.Development.&. Coverage.Advisory.Committee.(MEDCAC)..In.the.absence.of.a.national.coverage. policy,.an.item.or.service.may.be.covered.at.the.discretion.of.the.Medicare. contractors.based.on.a.local.coverage.determination.(LCD). •. Medical.necessity:.Services.or.supplies.that.are.proper.and.needed.for.the. diagnosis.or.treatment.of.a.medical.condition;.are.provided.for.the.diagnosis,. direct.care.and.treatment.of.a.medical.condition;.meet.the.standards.of.good. medical.practice.in.the.local.area.and.aren’t.mainly.for.the.convenience.of.the. patient.or.physician..Medical.necessity.is.established.by.answering.the.“why”. question:.“Why”.does.the.patient.require.this.therapy/equipment? •. Certificate.of.Medical.Necessity.(CMN):.A.form.required.by.Medicare.that.allows. the.patient.to.use.certain.durable.medical.equipment.prescribed.by.the.physician. or.one.of.the.physician’s.office.staff..It.documents.the.“Why.does.the.patient. require.this.equipment”.question.

General information about payment

Each.site.of.service.has.its.own.payment.structure:. •. Home. •. LTACH. •. SNF. Therefore,.reimbursement.for.ventilators.may.vary.based.on.the.setting.in.which.the. product.is.being.used..Each.site.of.service.will.be.discussed.in.the.respective.sections. of.this.manual.

How are the payment amounts for CPT Level I codes established for professional services performed in facility and non-facility settings? •. Based.on.the.Resource-Based.Relative.Value.Scale.(RBRVS).methodology,.. CPT.fee.schedule.amounts.are.established.using.three.relative.value.unit.. (RVU).components:.. 1.. Work 2.. Practice.expense 3.. Malpractice.expense •. Two.levels.of.practice.expense.components.determine.the.fee.schedule.amounts. for.reimbursing.professional.services..This.may.result.in.two.RBRVS.maximum. allowable.fees.for.a.procedure.code..These.are: 1.. Facility.setting.maximum.allowable.fees.(FS.fee):.Paid.when.the.provider. performs.the.services.in.a.facility.setting.(e.g.,.a.hospital.or.ambulatory.surgery. center)..The.cost.of.the.resources.are.the.responsibility.of.the.facility. 2.. Non-facility.setting.maximum.allowable.fees.(NFS.fee):.Paid.when.the.provider. performs.the.service.in.a.non-facility.setting.(e.g.,.office.or.clinic),.and.typically. bears.the.cost.of.resources,.such.as.labor,.medical.supplies.and.medical. equipment.associated.with.the.service.performed. •. Some.services,.by.nature.of.their.description,.are.performed.only.in.certain. settings.and.have.only.one.maximum.allowable.fee.per.code..Examples.of.these. services.include: 1..Evaluation.and.management.(E&M).codes,.which.specify.the.site-of-service. (SOS).within.the.description.of.the.procedure.codes.(e.g.,.initial.hospital.care). 2..Major.surgical.procedures.that.are.generally.performed.only.in.hospital.settings.

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1. Site of service: Home

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Durable Medical Equipment Medicare Administrative Contractors (DMEMACs)

In.an.effort.to.provide.greater.efficiency.in.the.Medicare.program.as.it.applies.to.Durable.Medical.Equipment,.Prosthetics,.Orthotics.and.Supplies.(DMEPOS),.CMS.awarded. contracts.to.four.insurance.carriers.who.serve.as.its.contractors,.known.as.Durable.Medical.Equipment.Medicare.Administrative.Contractors.(DME.MACs)..Among.their. many.responsibilities.are.processing.claims.as.well.as.writing.local.coverage.policies.for.DMEPOS. Each.DME.MAC.covers.a.specific.geographic.region.of.the.country,.noted.below,.and.only.processes.Medicare.claims.for.DMEPOS.items..CMS.has.established.a.very. informative.section.on.its.website.especially.for.coding,.coverage.and.payment.issues.related.to.DMEPOS,.http://www.cms.gov/center/dme.asp..You.may.also.get.more. information.by.calling.800.MEDICARE.(800.633.4227).

Section II—Sites of service—home, LTACH and SNF

Jurisdiction A: Connecticut,.Delaware,.Maine,.Massachusetts,.New.Hampshire,. New.Jersey,.New.York,.Pennsylvania,.Rhode.Island,.Vermont.and.Washington,.DC. NHIC, Corp. National Heritage Insurance Company

75.Sgt..William.Terry.Drive Hingham,.MA.02043 DME.Customer.Service.(IVR):.866.419.9458 DME.Customer.Service:.866.590.6731 http://www.medicarenhic.com Medical.Director:.Dr..Paul.Hughes Jurisdiction B: Illinois,.Indiana,.Kentucky,.Michigan,.Minnesota,. Ohio.and.Wisconsin.

National Government Services, Inc. 8115.Knue.Road Indianapolis,.IN.46250 DME.Customer.Service.(IVR):.877.299.7900 DME.Customer.Service:.866.590.6727 http://www.ngsmedicare.com/ngsmedicare/HomePage.aspx Medical.Director:.Dr..Stacey.Brennan Jurisdiction C: Alabama,.Arkansas,.Colorado,.Florida,.Georgia,.Louisiana,. Mississippi,.New.Mexico,.North.Carolina,.Oklahoma,.Puerto.Rico,.South.Carolina,. Tennessee,.Texas,.U.S..Virgin.Islands,.Virginia.and.West.Virginia

Cigna Government Services CGS Administrators, LLC 2.Vantage.Way Nashville,.TN.37202.. DME.Customer.Service.(IVR):.866.238.9650 DME.Customer.Service:.866.270.4909 http://www.cgsmedicare.com Medical.Director:.Dr..Robert.Hoover Jurisdiction D: Alaska,.Arizona,.California,.Hawaii,.Idaho,.Iowa,.Kansas,.Missouri,. Montana,.Nebraska,.Nevada,.North.Dakota,.Oregon,.South.Dakota,.Utah,. Washington,.Wyoming,.American.Samoa,.Guam.and.N..Mariana.Islands. Noridian Administrative Services, LLC.

900.42nd.Street.South Fargo,.ND.58103-2146 DME.Customer.Service.(IVR):.877.320.0390.or.dme@noridian.com DME.Contact.Center:.866.243.7272 http://www.noridianmedicare.com Medical.Director:.Dr..Richard.Whitten

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Medicare pricing, data analysis and coding (DME PDAC) Who administers the program?

•. Noridian.Administrative.Services,.LLC.(NAS).is.the.insurance.company.located. in.Fargo,.North.Dakota.who.contracts.with.CMS.to.serve.as.the.Pricing,. Data.Analysis.and.Coding.(PDAC).Contractor..It.performs.the.activities. that.Palmetto.GBA.Statistical.Analysis.DME.Regional.Carrier.(SADMERC). performed.prior.to.August.2008.. •. Website.is.http://www.dmepdac.com. What are the functions of the PDAC?

•. Provides.data.analysis.support.to.the.DME.Program.Safeguard.. Contractors.(PSCs). •. Guides.manufacturers.and.suppliers.on.the.proper.use.of.the.HCPCS. through.product.reviews.and.decisions.. •. Conducts.national.pricing.functions.for.DMEPOS.services.. •. Assists.CMS.with.DMEPOS.fee.schedules.

How does the DMEC program on the PDAC website help manufacturers and suppliers? The.PDAC.supplies.a.web-based.application.that.provides.HCPCS.coding. assistance.and.national.pricing.information.via.searches.for.HCPCS.Level.II. codes.and.modifiers,.DMEPOS.and.CMS.national.fee.schedules.on.its.website.. There.are.four.interactive.components.that.work.together.to.provide.HCPCS.. coding.information: •. Search.by.HCPCS.information •. Search.by.modifier. •. Search.by.fee.schedule. •. Search.by.DMEPOS.product.classification.list. Available resources The.PDAC.website.includes.resources.to.assist.manufacturers,.distributors.and. suppliers.in.coding.DMEPOS.products.and.provides.information.on.HCPCS. changes..This.includes.advisory.articles,.previously.published.by.the.Statistical. Analysis.DME.Regional.Carrier.(SADMERC),.and.those.published.by.the.PDAC.. In.addition,.they.provide.related.DME.and.HCPCS.websites.and.information. about.the.Comprehensive.Error.Rate.Testing.program.to.help.prevent.coding. errors..All.PDAC.questions.should.be.directed.to:.

PDAC Contact Center. http://www.dmepdac.com Toll.free:.877.735.1326... Direct:.701.433.3077... Fax:.866.209.1236... Hours:.8:30.a.m..to.4.p.m..CT Mailing.address:.Pricing,.Data.Analysis.and.Coding,.. PO.Box.6757,.Fargo,.ND.58108-6757. Courier.address:.Pricing,.Data.Analysis.and.Coding,. . 900.42nd.Street,.South.Fargo,.ND.58108-6757 What is the HCPCS review or coding verification process?. HCPCS.review.or.coding.verification.process.is.the.process.that.allows. manufacturers,.distributors.and.other.parties.to.request.a.coding.decision. on.a.DMEPOS.item..A.Coding.Verification.Request.form.and.supporting. documentation.is.submitted.to.the.PDAC.staff.for.review.and.a.decision.. Manufacturers.use.this.process.to.verify.that.their.particular.DMEPOS.product. falls.into.a.particular.HCPCS.code..The.process.takes.usually.90.days.and.the. PDAC.will.issue.a.coding.verification.letter.to.the.manufacturer.stating.that.its. product.falls.into.a.particular.HCPCS.code..The.PDAC.will.then.list.it.with.the. DMEC.program.

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Coverage in the home care setting Coverage.for.DMEPOS.is.either.governed.by.a.national.coverage.determination. (NCD),.which.would.apply.in.all.states,.or.by.local.coverage.determinations.(LCD).. The.national.coverage.determinations.can.be.found.on.the.CMS.website.(http:// www.cms.gov/medicare-coverage-database)..The.local.coverage.determinations.can. be.found.on.each.one.of.the.DME.MAC.websites.listed.above.and.in.the.Appendix. section.of.this.manual..More.information.about.ventilators.will.be.found.in.Section. III.of.this.manual. A.national.coverage.determination.(NCD).does.exist.for.ventilators.and.thus.applies. to.all.states.. Ventilators:.Covered.for.treatment.of.neuromuscular.diseases,.thoracic.restrictive. diseases.and.chronic.respiratory.failure.consequent.to.chronic.obstructive.pulmonary. disease..Includes.both.positive.and.negative.pressure.types..(See.§240.5.of.the.. NCD.Manual.)

Payment in the home care setting

Medicare.payment.for.DME,.prosthetics.and.orthotics.(P&O),.parenteral.and.enteral. nutrition.(PEN),.surgical.dressings.and.therapeutic.shoes.and.inserts.is.equal.to.80%. of.the.lower.of.either.the.actual.charge.for.the.item.or.the.fee.schedule.amount. calculated.for.the.item,.less.any.unmet.deductible..The.beneficiary.is.responsible. for.20%.of.the.lower.of.either.the.actual.charge.for.the.item.or.the.fee.schedule. amount.calculated.for.the.item,.plus.any.unmet.deductible.. We.have.included.specific.payment.information.regarding.ventilators.and.accessories. in.Section.III.of.this.manual.

2. Site of service: Long-term acute care (LTAC)

Medical.Assistance.Administration.(MAA).approved.LTAC.facilities.provide.inpatient. intensive.long-term.acute.care.services.to.eligible.Medical.Assistance.clients.who. require.the.following.Level.1.or.Level.2.services..

Long-term acute care facility structure

•.Level 1 services:.Long-term.acute.care.(LTAC).services.provided.to.clients. who.require.more.than.eight.hours.of.direct.skilled.nursing.care.per.day... Level.1.services.include.one.or.both.of.the.following: -. Active.ventilator.weaning.care.and.any.specialized.therapy.services,.such.as. physical,.occupational.and.speech.therapies -. Complex.medical.care.that.may.include: +. Care.for.complex.draining.wounds +. Care.for.central.lines +. Multiple.medications.(intravenous) +. Frequent.assessments.and.close.monitoring +. Third.degree.burns.that.may.involve.grafts.and/or.frequent.transfusions +. Specialized.therapy.services,.such.as.physical,.occupational.and.. speech.therapies

•.Level 2 services:.Long-term.acute.care.(LTAC).services.provided.to.clients.who. require.four.to.eight.hours.of.direct.skilled.nursing.care.per.day..Level.2.services. include.at.least.two.of.the.following: -. Ventilator.care.for.clients.who.are.stable,.dependent.on.a.ventilator.and.have. complex.medical.needs -. Care.for.clients.who.have:.tracheostomies,.complex.airway.management.and. medical.needs,.and.the.potential.for.decannulation -. Specialized.therapy.services,.such.as.physical,.occupational.and.. speech.therapies

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8 LTAC PPS *MAA.pays.the.LTAC.facility.the.LTAC.fixed.per.diem.rate.in.effect.at.the.time.the. LTAC.services.are.provided,.minus.the.sum.of: •. Client.liability,.whether.or.not.collected.by.the.provider •. Any.amount.of.coverage.from.third.parties,.whether.or.not.collected.by.the. provider,.including,.but.not.limited.to,.coverage.from:. -. Insurers.and.indemnitors -. Other.federal.or.state.medical.care.programs -. Payments.made.to.the.provider.on.behalf.of.the.client.by.individuals.or. organizations.not.liable.for.the.client’s.financial.obligations -. Any.other.contractual.or.legal.entitlement.of.the.client,.including,.but.. not.limited.to: +. Crime.victims’.compensation +. Workers’.compensation +. Individual.or.group.insurance +. Court-ordered.dependent.support.arrangements +. The.tort.liability.of.any.third.party *Note:.MAA.may.make.annual.rate.increases.to.the.LTAC.fixed.per.diem.rate.by. using.the.same.inflation.factor.and.date.of.rate.increase.that.MAA.uses.for.acute. care.hospital.diagnostic-related.group.(DRG).rates.

3. Site of service: Long-term acute care (LTAC)

Skilled nursing facilities structure

•. Skilled.care.is.healthcare.given.when.skilled.nursing.or.rehabilitation.is.needed. to.treat,.manage,.observe.and.evaluate.care..Examples.of.skilled.care.include:. intravenous.injections.and.physical.therapy. •. It.is.care.given.in.a.skilled.nursing.facility.(SNF).by.professional.staff.. -. Non-professional.staff.is.not.considered.skilled.care. •. Usually.people.do.not.stay.in.a.SNF.until.they.are.completely.recovered..Medicare. covers.certain.skilled.care.services.that.are.needed.daily.on.a.short-term.basis.. (up.to.100.days). •. Skilled.care.requires.the.involvement.of.skilled.nursing.or.rehabilitative.staff.so.. to.be.certain.it.is.given.safely.and.effectively..Skilled.nursing.and.rehabilitation. staff.includes: -. Registered.nurses. -. Licensed.practical.and.vocational.nurses -. Physical.and.occupational.therapists -. Speech-language.pathologists.. -. Audiologists

Per diem PPS, CB and RUG categories

The.Balanced.Budget.Act.of.1997.mandated.the.implementation.of.a.per.diem. prospective.payment.system.(PPS).for.SNFs.covering.all.costs.(routine,.ancillary. and.capital).related.to.the.services.furnished.to.beneficiaries.under.Part.A.of.the. Medicare.program..Major.elements.of.the.system.include: Rates:.Federal.rates.were.set.using.allowable.costs.from.FY.1995.cost.reports.. The.rates.also.include.an.estimate.of.the.cost.of.services.which,.prior.to.July.1,. 1998,.had.been.paid.under.Part.B.but.furnished.to.SNF.residents.during.a.Part. A.covered.stay..FY.1995.costs.were.updated.to.FY.1998.by.a.SNF.market.basket. minus.one.percentage.point.for.each.of.fiscal.years.1996,.1997.and.1998..Providers. that.received.new.provider.exemptions.in.FY.1995.were.excluded.from.the. database..Routine.cost.limit.exceptions.payments.were.also.excluded..The.data.was. aggregated.nationally.by.urban.and.rural.area.to.determine.standardized.federal.per. diem.rates.to.which.case.mix.and.wage.adjustments.applied. Case.mix.adjustment:.Per.diem.payments.for.each.admission.are.case-mix.adjusted. using.a.resident.classification.system.(Resource.Utilization.Groups.III.or.RUG).based. on.data.from.resident.assessments.(Minimum.Data.Sets.or.MDS.2.0).and.relative. weights.developed.from.staff.time.data.

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Geographic.adjustment:.The.labor.portion.of.the.federal.rates.is.adjusted.for. geographic.variation.in.wages.using.the.hospital.wage.index. Annual.updates:.Payment.rates.are.increased.each.Federal.fiscal.year.using.a.SNF. market.basket.index. Also.enacted.in.the.Balanced.Budget.Act.of.1997.(BBA),.Public.Law.105-33,. Section.4432(b),.is.a.Consolidated.Billing.(CB).requirement.for.SNFs..Under.the.CB. requirement,.an.SNF.itself.must.submit.all.Medicare.claims.for.the.services.that.its. residents.receive.(except.for.specifically.excluded.services.listed.below). Conceptually,.SNF.CB.resembles.the.bundling.requirement.for.inpatient.hospital. services.that.has.been.in.effect.since.the.early.1980s,.assigning.to.the.facility.itself. the.Medicare.billing.responsibility.for.virtually.the.entire.package.of.services.that.a. facility.resident.receives,.except.for.certain.services.that.are.specifically.excluded. CB.eliminates.the.potential.for.duplicative.billings.for.the.same.service.to.the.Part. A.fiscal.intermediary.by.the.SNF.and.the.Part.B.carrier.by.an.outside.supplier..It. also.enhances.the.SNF’s.capacity.to.meet.its.existing.responsibility.to.oversee.and. coordinate.the.total.package.of.care.that.each.of.its.residents.receives.

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Section III—Coverage, coding and payment for LTV series ventilators

10

Process for utilizing the LTV series ventilators

Create.with.your.customer,.the.process.for.determining.that.the.LTV.ventilator.is.the. best.choice.for.a.particular.patient: 1..Develop.relationships.with.the.physician,.case.manager,.the.DME.provider.and.if. possible.and.of.great.importance,.a.caregiver.to.the.patient. a.. Generally,.steps.1.and.2.occur.concurrently..As.the.ventilator.is.being. presented.to.the.physician.and./or.RT,.the.relationship/s.necessary.to.be. successful.begin... b.. Remember.to.network.with.the.case.manager.and.the.patient’s.caregiver.(this. will.be.the.parent.when.dealing.with.a.child)..These.individuals.will.be.strong. advocates.for.the.LTV.ventilator.and.make.powerful.arguments.to.the.payer.in. favor.of.the.LTV.ventilator. i.. Instances.exist.where.payers.agreed.to.pay.or.provide.increased. reimbursement.simply.because.the.parent.was.relentless.in.their.pursuit.to. obtain.the.best.product/value.for.their.child.. 2..Have.the.patient.placed.on.the.LTV.ventilator.while.in.a.subacute.care/step.down. unit.to.demonstrate.the.benefits.and.to.have.the.patient.and.family.acclimate. to.the.ventilator..Have.them.“get.a.feel”.for.the.value.of.the.ventilator.and.thus. create.a.strong.desire.. 3..Now.it.is.time.to.have.all.of.the.parties.involved.“buy-in”.to.the.LTV.ventilator.as. the.ventilator.of.choice..The.goal.is.for.all.parties.to.recite.the.ventilator’s.benefits. for.this.particular.patient.. a..Success.in.demonstrating.the.features.and.benefits.to.the.patient,.caregiver.. and.providers.will.be.directly.proportional.to.the.amount.of.time.spent. familiarizing.them.with.the.ventilator.and.its.capabilities..It.can.be.said.that.. the.LTV.ventilator.is.only.as.good.as.the.weakest.person.on.the.night.shift,.. so.time.invested.in.training.staff.and.caregivers.on.the.ventilator.will.be.time. well-spent.. i.. If.nurses.and.RTs.do.not.feel.comfortable.using.the.ventilator,.the. discomfort.becomes.the.reason.for.its.lack.of.success,.not.the.lack.of. familiarity.on.the.part.of.the.staff. b..Remember,.once.a.patient.is.discharged.on.another.ventilator,.it.is.a.lost. opportunity.and.one.not.likely.to.be.regained;.therefore,.getting.to.the.patient. prior.to.their.discharge.from.an.institutional.setting.is.a.critical.step..There. are.a.number.of.tools.available.to.support.the.benefits.of.the.LTV.ventilator. and.assist.in.convincing.the.physician,.case.manager.and.caregiver.of.the.LTV. ventilator’s.capabilities. i.. These.tools.include.reprints.of.clinical.articles,.reference.lists,.in-service. videos,.media.kits,.etc.,.but.none.of.these.replace.the.direct.interaction.with. these.influencers. ii..If.these.individuals.are.not.convinced.that.the.LTV.ventilator.is.the.ventilator. of.choice,.chances.of.success.in.selling.the.LTV.ventilator.will.be.diminished.. 4..Once.a.commitment.for.the.LTV.ventilator.is.obtained,.the.next.step.is.to. establish.medical.necessity.by.having/coaching.the.physician.on.the.medical. necessity.for.the.prescription.and.answering.any.foreseen.issues.with. reimbursement..The.physician.needs.to.write.a.Certificate.of.Medical.Necessity,. which.should.include.information.as.outlined.on.the.following.page: a..The.patient’s.medical.history.and.respiratory.ailment. b..A.synopsis.of.the.most.recent.episode..This.is.typically.the.reason.why.they.. are.now.in.the.hospital.

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E0450 Volume Control ventilator, without Pressure Support mode, may include Pressure Control mode, used with invasive interface (e.g., tracheostomy tube)

E0461 Volume Control ventilator, without Pressure Support mode, may include Pressure Control mode, used with noninvasive interface (e.g., mask)

E0463 Pressure Support ventilator with Volume Control mode, may include Pressure Control mode, used with invasive interface (e.g., tracheostomy tube)

A9279 Monitoring feature/device, standalone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

E0464 Pressure Support ventilator with Volume Control mode, may include Pressure Control mode, used with noninvasive interface (e.g., mask)

c..Why.they.need.Pressure.Support,.Pressure.Control.and.Flow.Triggering. d..Describe.the.alternatives.or.“consequences”.if.they.don’t.receive.the.benefit/s. from.the.listed.feature/s.above..These.consequences.may.include: i.. A.longer.and.more.costly.hospital.stay ii..A.longer.weaning.time iii..Risk.of.a.repeated.acute.episode.of.a.respiratory.illness.resulting.in.an. emergency.room.visit.and.possible.re-admission.into.the.hospital. 5..Determine.the.appropriate.reimbursement.code.to.be.used.BEFORE.the.patient.. is.discharged. 6..Be.prepared.to.answer.several.questions.and.overcome.any.resistance.to.why.the. patient.needs.the.LTV.ventilator.

1. Site of service: Home—the payment process

Establishing medical necessity.

Answer.the.question,.“Why.does.the.patient.require.a.ventilator?”.Describe.the. medical.purpose.for.ventilatory.support,.such.as.respiratory.insufficiency/failure.. due.to.[name.the.disease/s]..Physiologic.parameters.play.a.role.in.medical.necessity.. (e.g.,.ABGs.demonstrating.before.and.after.results.from.being.placed.on.the. ventilator,.SpO2.readings,.NIF,.etc.).

Ventilator coverage example

Positive.and.negative.pressure.ventilators.are.generally.covered.for.treatment.of. neuromuscular.diseases,.thoracic.restrictive.diseases.and.chronic.respiratory.failure. associated.with.chronic.obstructive.pulmonary.disease.

Ventilator coding and payment information Coding: Payment: The.following.information.is.designed.to.provide.guidance.on.determining.the. most.appropriate.code/s.to.use,.provide.some.guidelines.to.assist.in.preparing. reimbursement.submissions.and.put.forth.some.examples.on.a.state-by-state.basis. whereby.submissions.have.been.completed. •. Medicare -. For.the.most.current.Medicare.fee.schedules,.please.use.the.HCPCS.code. search.at:.http://www.dmepdac.com. •. Medicaid. -. Representative.State.Medicaid.fee.schedules.can.be.found.on.the.below. table/s..Every.effort.was.given.to.achieve.accuracy.in.reporting.this.information. as.of.September.2011. .

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12

State E0450 E0461 E0463 E0464 Notes

Alabama $649.07 $801.64 $1,125.10 Not list

Alaska $781.48 $1,002.05 $1,408.30 $1,408.30 Prior authorization required

Arizona $29.72/day $29.72/day $43.79/day $43.79/day Prior authorization required:

602.417.4400

California $649.07 $649.07 $1,125.10 $1,125.10 Prior authorization required

Colorado $608.08 $774.29 $1,374.39 $1374.39 Prior authorization required:

Form 10013

Florida $756.60 N/A $756.60 $756.60 Medical necessity

Georgia $763.62 Not covered $1,125.10 $1,125.10 Prior authorization required

Illinois $855.81 $394.33 $855.81 $855.81 Prior authorization required

Indiana $770.77 $809.15 $1,135.65 $1,135.65

Kentucky $913.17 Not covered $1,265.74 $1,265.74 Prior authorization required

Louisiana Manually priced - MSRP - 18% OR provider invoice submitted amount Not covered Manually priced - MSRP - 18% OR provider invoice submitted amount Manually priced - MSRP - 18% OR provider invoice submitted amount

Prior authorization required

Maine $792.25 $791.46 $1,253.94 $1,253.94 Out of state providers require prior

authorization Massachusetts $1,002.25 (rental 1st 6 mos)

$851.91 (7 mos & beyond)

$1,002.25 (rental 1st 6 mos) $851.91 (7 mos & beyond)

$1,255.19 (rental 1st 6 mos) $1,476.70 (7 mos & beyond)

$1,255.19 (rental 1st 6 mos) $1,476.70 (7 mos & beyond)

Michigan $843.04 $708.01 $843.04 Manually priced Yes, web-forms

Minnesota $1,001.25 $1,001.25 $1,475.22 $1,475.22

Covered for rental only; they never cap; prior authorization required if both stationary and portable are ordered

Mississippi $680.85 $680.85 $1,180.18 $1,180.18 Prior authorization required

Missouri $825.00 and $412.50 for

backup vent Not covered

First vent: $1,406.38 Second vent: $703.19

Not an approved code in the State of MO

Prior authorization required at http:// www.dss.mo.gov/mhd/cs/dmeprecert/ pages/dmeprecert.htm

Nebraska $917.44 $1,087.30 $1,466.93 $1,466.93

Ohio $760.00 Not covered $900.00 Not Covered

Pennsylvania $778.32 $801.64 $1,181.36 Not Covered

South Dakota $859.84 $1,001.25 $1,475.22 $1,475.22

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State E0450 E0461 E0463 E0464 Notes

Texas $949.79 Not covered $949.79 $1,476.70 Prior authorization required

Vermont $8794.5 Manually priced Manually priced Not covered E0461 requires prior authorization

Virginia $13,015.34 $13,015.34 $1,284.9 $1,284.9

Washington $851.91 $851.91 $1,476.7 $1,476.7

E0463/E0464 prior authorization required; will pay $425.95 for 2nd back-up ventilator

Wisconsin $7,123.03 Not covered $8,226.45 $8,226.45 Yes, prior authorization required after

60 days w/ E0450

Medicaid reimbursement by state (continued)

Frequently asked questions

Why does the LTV ventilator cost more than a conventional ventilator? •. The.LTV.ventilator.employs.the.latest.technology.in.a.form.and.function.that. results.in.higher.manufacturing.cost.. •. There.was.also.a.substantial.investment.in.developing.this.technology.and.the. benefits.derived.from.this.equipment.are.three-fold: -. It.can.assist.in.reducing.the.overall.cost.of.caring.for.the.patient.since.they.can. be.discharged.sooner.than.previously.possible. -. Depending.on.the.patient’s.condition,.the.LTV.ventilator’s.features.. (e.g.,.Pressure.Support).may.reduce.the.time.to.wean.a.patient.from.a. ventilator,.resulting.in.an.overall.reduction.in.costs. -. The.LTV.ventilator’s.size.and.weight.has.been.said.to.increase.a.patient’s.quality. of.life.since.the.patient.and.their.family.members.are.more.mobile.

Which ventilator gets prescribed for what medical necessity? •. If.the.medical.necessity.is.for.Pressure.Support:.. -. The.LTV.ventilator.is.currently.one.of.two.commercially.available.ventilators.with. 510(k).clearance.for.the.home.that.offers.Pressure.Support.with.Variable.Rise. Time.and.Variable.Termination.Criteria..(The.other.is.the.TBird.Legacy... The.I-Vent.offers.Variable.Rise.Time,.but.does.not.offer.Variable.. Termination.Criteria). -. All.of.these.ventilators.are.priced.in.the.same.range..The.PLV.and.LP.series. ventilators.do.not.offer.Pressure.Support. •. If.the.medical.necessity.is.for.Pressure.Control.and.Pressure.Support:.. -. The.LTV.950.and.1150.ventilators.offer.Pressure.Control.and.Pressure.Support. with.Variable.Rise.Time.and.Variable.Termination.Criteria. -. The.T.Bird.Legacy.does.not.offer.Pressure.Control.and.the.Achieva.does.not. offer.Pressure.Control.with.Pressure.Support.(SIMV).. -. The.I-Vent.offers.Pressure.Support.with.Pressure.Control,.but.does.not.provide. Variable.Termination.Criteria.. -. All.of.these.ventilators.are.priced.competitively.among.each.other. -. The.PLV.and.LP.series.ventilators.do.not.offer.Pressure.Control.or.. Pressure.Support.

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14 •. If.the.medical.necessity.is.for.Flow.Triggering: -. All.of.the.LTV.ventilators.offer.flow.triggering,.except.the.LTV.800. -. The.T-Bird.Legacy.and.I-Vent.also.offer.flow.triggering. -. The.Achieva.only.offers.flow.triggering.when.attached.to.a.high-pressure. external.gas.source,.which.is.typically.not.found.in.the.home. -. The.PLV.and.LP.series.ventilators.do.not.offer.flow.triggering.

What if the physician order is for a Volume ventilator (E0450 or E0461) and all the HME provider has in stock or carries in inventory are Pressure Support (E0463 or E0464) ventilators?

•. Bill.using.the.upgrade.provision.with.appropriate.modifiers... •. Payment.will.be.granted.for.the.reasonable.and.necessary.therapy/Volume. ventilator.(E0450.or.E0461).that.the.physician.prescribed.. •. In.addition,.be.certain.to.escalate.some.example.claims.through.your.MAC’s. customer.service.process,.as.this.will.identify.the.need.for.any.code.and/or. fee.schedule.rate.change/s.necessary Background Suppliers.may.use.advanced.beneficiary.notices.(ABNs).when.providing. upgrades..CMS.defines.an.upgrade.as.an.item.that.is.more.expensive.because. the.item.contains.more.components.or.features,.or.is.greater.in.quantity.than. what.the.physician.ordered..Items.that.are.simply.more.expensive,.or.of.“higher. quality”.than.standard.items,.do.not.qualify.as.an.upgrade. Upgrades.must.be.within.the.range.of.services.that.are.appropriate.for.the. beneficiary’s.medical.condition..ABNs.may.not.be.used.to.substitute.an.item.or. service.that.does.not.meet.the.intended.medical.purpose.of.the.item.originally. ordered.by.the.physician. An.ABN.is.not.required.if.the.supplier.chooses.to.provide.a.free.upgrade.to. the.beneficiary..When.providing.a.free.upgrade,.suppliers.should.not.have.the. beneficiary.sign.an.ABN,.because.the.beneficiary.will.not.be.charged.more.than.. the.normal.deductible.and.copayment.for.the.non-upgraded.item.

Claims for upgrades

Two.lines.should.be.listed.on.each.claim.for.an.upgrade..Suppliers.will.need. to.bill.their.submitted.charges.for.the.upgraded.item.on.Line.1.and.the.full. amount.for.the.physician.order.on.Line.2..Both.line.items.are.to.appear.on.a. single.claim.

Claims for free upgrades

When.providing.a.free.upgrade.to.a.beneficiary,.suppliers.should.report.the. appropriate.HCPCS.code.for.the.non-upgraded.item.that.the.physician.ordered.. A.“GL”.modifier.is.attached.to.the.HCPCS.code.for.the.physician-ordered.item. to.indicate.it.is.an.upgraded.item.at.no.additional.charge..Suppliers.may.only. charge.for.the.non-upgraded.item.on.the.claim.form..In.this.situation,.the. supplier.does.not.bill.the.HCPCS.code.that.describes.the.item.being.provided. In.box.19.of.the.claim.form,.or.as.an.attachment.to.the.claim,.the.supplier. must.specify.the.make.and.model.of.the.upgraded.item.that.was.provided. and.describe.why.this.item.is.an.upgrade..If.filing.claims.electronically,. this.information.may.be.entered.in.the.NTE.segment/line.note.on.the.837. electronic.format. DME upgrades

ABN and claims modifiers

ABN required Required modifier/s DMAC payment Beneficiary pays for upgrade 3. Supplier provides

upgrade for supplier convenience: a. Supplier provides upgrade free of charge to beneficiary No GL R&N item only (GL line) No

GL is added to HCPCS code for item that meets Medicare coverage requirements and demonstrated that this is an upgraded item at no additional charge.

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2. Site of service: LTAC—the payment process

LTAC.fixed.per.diem.rate.is.the.daily.rate.Medical.Assistance.Administration. (MAA).reimburses.for.LTAC.room.and.board.and.selected.services..Refer.to. prior.authorization.information.for.more.details.about.selected.services. Payment rate •. Payments.to.LTACs.under.the.LTAC.PPS.is.based.on.a.single.standard.Federal. rate.for.both.the.inpatient.operating.and.capital-related.costs,.but.not. certain.pass-through.costs.. •. The.LTAC.payment.is.determined.by.CMS.starting.with.the.standard.Federal. rate,.which.is.the.standard.Federal.rate.for.the.previous.LTAC.PPS.rate. year,.updated.by.the.increase.factor,.and.adjusted.for.outlier.payments.and. budget.neutrality... •. The.standard.Federal.rate.is.multiplied.by.the.applicable.Medicare.severity. for.long-term.care.diagnostic.related.group.(MS-LTC-DRG).relative.weight.to. determine.the.Federal.prospective.payment.that.is.paid.for.each.discharge. .-. Referred.to.as.the.unadjusted.LTCH-PPS.payment.. .-. This.amount.is.then.subject.to.the.case-level.adjustments.and.facility-level. adjustments.for.each.discharge.. •. Under.the.LTAC.PPS,.patients.are.classified.into.distinct.diagnostic.groups. based.on.clinical.characteristics.and.expected.resource.needs..The.patient. classification.system.groupings.under.the.LTAC.PPS.are.called.long-term.care. diagnosis-related.groups.(LTC-DRGs). .-. The.LTC-DRGs.are.the.same.DRGs.used.under.the.hospital.inpatient. prospective.payment.system.(IPPS),.but.they.have.been.weighted.to.reflect. the.resources.required.to.treat.the.type.of.medically.complex.patients’. characteristic.of.LTACs.. -. Relative.weights.for.the.LTC-DRGs.reflect.resource.utilization.for.each. diagnosis.and.account.for.the.variation.in.cost.per.discharge. .•.Under.the.LTAC.PPS,.the.LTC-DRG.relative.weights.are.updated.annually.for. each.Federal.fiscal.year.(October.1.through.September.30).using.the.most. recently.available.LTAC.claims.data...

Long-term acute care ventilator facility EXAMPLE

LTC – DRG 207

Title Resp system diagnosis w/ vent support - 96+ hours

Relative weight 2.1381 Average length of stay 34.6 Threshold: Short stay outlier 28.8 LTAC cases 13,299 LTCH-PPS payment $79,268 Note:

• The “unadjusted LTCH-PPS payment” is $79,268.

• This calculation was derived by multiplying the FY2009 standard Federal rate times the FY2008 relative weight: $39,114 x 2.0266 for this example.

• Numbers were extrapolated from Table 3 in the May 9, 2008 LTCH-PPS final rule.

•. Beginning.in.FY.2008,.CMS.adopted.the.refined.severity-adjusted.DRGs. that.were.also.adopted.under.the.IPPS,.that.is,.the.Medicare-Severity-LTC-DRGs.(MS-LTC-DRGs),.which.continue.to.be.weighted.to.account.for.the. difference.in.resource.use.by.LTAC.patients.

3. Site of service: SNF—the payment process

Resource Utilization Group (RUG): A ventilator patient example The.case-mix.adjusted.rates.for.each.of.the.RUG.groups.can.be.found.in.the. final.rule.for.the.SNF.PPS..They.are: •. SE3:.$374.(urban);.$364.(rural) •. SE2:.$318.(urban);.$310.(rural) •. SE1:.$283.(urban);.$277.(rural). These.do.not.include.the.AIDS.adjustment.or.the.geographic.adjustment..The. labor.portion.of.the.rule.is.then.adjusted.for.geographic.variation.using.the. hospital.wage.index..Those.rates.are.in.the.final.rule....

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16 Category: Extensive.services:.Services.that.last.14.days:.IV.feeding.or.medications,.suctioning,. tracheostomy.care,.ventilator./.respirator..(If.MDS.meets.this.criteria,.but.ADL.<.7,. then.the.MDS.automatically.classifies.under.Special.Care.*).. ADL.=.7.-.18.. End.splits:.Extensive.services.count:.IV.feedings,.IV.medications,.special.care,. clinically.complex,.impaired.cognition. RUG.category:.SE3,.SE2,.SE1

Moving on to Medicaid: A ventilator patient example

Post.100.days.of.the.patient.receiving.Part.A.Medicare.benefits,.coverage.. stops.unless.another.SNF.event.is.identified..Ventilator.patients.who.stay.on.. go.to.Medicaid.services.and.are.now.considered.non-covered.by.Medicare.. and.are.outpatients. Medicaid.payments.vary.from.state-to-state..For.example,.PA.and.TN.pay.a.bundled. PPS/RUG.format,.so.ventilator.payment.continues.to.be.part.of.that.bundle..The. SNF.bills.and.the.HME.provider.rents.to.the.SNF.as.during.the.Medicare.stay..Some. states.use.the.DME.HCPCS.fee.schedule.payment.for.ventilators..Remember,.in. order.to.bill.Level.II.HCPCS,.a.supplier.number.is.required.

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Section IV—Coding verification competitive products

Coding verification for Pressure Support ventilators

Manufacturer Product name *HCPCS code/s

CareFusion (also under the name of Pulmonetic Systems, Inc.

and Viasys Healthcare Respiratory Technologies Group)

ReVel™ ventilator LTV 1200 ventilator LTV 1150 ventilator LTV 1100 ventilator LTV 900 ventilator LTV 950 ventilator LTV 1000 ventilator TBird® Legacy

E0463 (invasive) or E0464 (noninvasive)

Covidien (also under the name of Nellcor Puritan Bennett—

a Tyco Healthcare Company)

Puritan Bennett 540 Achieva PS Achieva PSO2 E0463 or E0464 E0463 E0463

GE Healthcare (also under the name of Versamed, Inc.) IVent 101 expert model

IVent 101 performance model IVent 101 signature model IVent 201-IC IVent 201-IC/AB E0463 or E0464 E0463 or E0464 E0463 or E0464 E0463 E0463

Newport Medical Instruments Newport HT70 family of ventilators

Newport HT70M family of ventilators Newport HT50-H ventilator

Newport HT50-H1 ventilator

E0463 (invasive) or E0464 (noninvasive)

Philips Respironics Trilogy 200 ventilator

Trilogy 100 ventilator PLV continuum ventilator

E0463+, A9279 or E0464+ E0463 or E0464

E0463 or E0464

CareFusion LTV 800 laptop ventilator E0450 (invasive) or E0461 (noninvasive)

Covidien LP10 volume ventilator E0450

Philips/Respironics LifeCare PLV-100

portable volume ventilator

E0450

*Codes *Descriptors

E0450 Volume Control ventilator, without Pressure Support mode, may include Pressure Control mode, used with invasive interface (e.g., tracheostomy tube)

E0461 Volume Control ventilator, without Pressure Support mode, may include Pressure Control mode, used with noninvasive interface (e.g., mask)

E0463 Pressure Support ventilator with Volume Control mode, may include Pressure Control mode, used with invasive interface (e.g., tracheostomy tube)

A9279 Monitoring feature/device, standalone or integrated, any type, includes all accessories, components and electronics, not otherwise classified

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Section V—Accessory coding and payment

How are accessories to ventilators coded and paid?

The.ventilator.codes.we.have.been.discussing.address.positive.and.negative.pressure.ventilators.used.with.invasive.or.noninvasive.interfaces..Medicare.categorizes.ventilators. as.items.requiring.frequent.and.substantial.servicing..For.items.that.fall.in.the.payment.category.of.frequent.and.substantial.service,.rental.payments.include.payment.for. supplies.and.accessories.unless.specifically.noted.otherwise..Humidifiers.are.considered.accessories.and.cannot.be.billed.separately..Additional.payment.is.not.made.for. repair,.maintenance.or.replacement.of.equipment.that.requires.frequent.and.substantial.service..It.is.the.supplier’s.responsibility.to.make.certain.there.is.an.emergency.plan. in.place.to.address.mechanical.failure.of.the.equipment. 18 Accessories.to.ventilators.may.consist.of.the.following.items: •. Humidifiers •. Filters •. Batteries,.battery.cables,.battery.charger •. Breathing.circuits Other: •. LTM.(Lap.Top.Monitor.graphics.package).is.coded.under.A9279.. -. Monitoring.feature/device,.standalone.or.integrated,.any.type,.includes.all. accessories,.components.and.electronics,.not.otherwise.classified.

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Glossary of Medicare terms

(CMS) Centers for Medicare and Medicaid Services:.The.federal.agency.that.runs. the.Medicare.program..In.addition,.CMS.works.with.the.States.to.run.the.Medicaid. program..CMS.works.to.make.sure.the.beneficiaries.in.these.programs.are.able.to.get. high.quality.healthcare.

(DRG) Diagnosis Related Group:.A.classification.system.that.categorizes.hospital. patients.into.clinically.coherent.and.homogenous.groups.with.respect.to.resource.use. (i.e.,.similar.treatments.and.statistically.similar.lengths.of.stay.for.patients.with.related. medical.conditions)..Classification.of.patients.is.based.on.the.International.Classification. of.Diseases,.the.presence.of.a.surgical.procedure,.patient.age,.presence.or.absence.of. significant.co-morbidities.or.complications.and.other.relevant.criteria.

(HCPCS) Healthcare Common Procedural Coding System:.A.medical.code.set.that. identifies.healthcare.procedures,.equipment.and.supplies.for.claim.submission.purposes... It.has.been.selected.for.use.in.the.HIPAA.transactions..HCPCS.Level.I.contain.numeric.. CPT.codes,.which.are.maintained.by.the.AMA..HCPCS.Level.II.contains.alphanumeric. codes.used.to.identify.various.items.and.services.that.are.not.included.in.the.CPT.medical. code.set..

(LTAC) Long term acute care:.Inpatient.intensive.long-term.acute.care.services.provided. in.MAA-approved.LTAC.facilities.to.eligible.Medical.Assistance.clients.who.require.Level.. 1.or.Level.2.services.

LTAC fixed per diem rate:.The.daily.rate.MAA.reimburses.for.LTAC.room.and.board. and.selected.services.

Market basket:.Described.as.a.fixed-weight.index.because.it.answers.the.question.of. how.much.more.or.less.it.would.cost,.at.a.later.time,.to.purchase.the.same.mix.of.goods. and.services.that.was.purchased.in.a.base.period..As.such,.it.measures.“pure”.price. changes.only..A.market.basket.is.constructed.in.three.steps..The.sum.of.the.products.for. all.cost.categories.yields.the.composite.index.level.in.the.market.basket.in.a.given.year. Medicaid:.The.state.and.federally.funded.Title.XIX.program.under.which.medical.care.is. provided.to.persons.eligible.for.the.categorically.needy.program.or.medically.needy.program. Medicare:.The.federal.government.health.insurance.program.for.certain.aged. or.disabled.clients.under.Titles.II.and.XVIII.of.the.Social.Security.Act..Medicare.. •.“Part.A”.covers.the.Medicare.inpatient.hospital,.post-hospital.skilled.nursing.facility.care,. home.health.services.and.hospice.care. •.“Part.B”.is.the.supplementary.medical.insurance.benefit.(SMIB).covering.the.Medicare. doctor’s.services,.outpatient.hospital.care,.outpatient.physical.therapy.and.speech. pathology.services,.home.healthcare.and.other.health.services.and.supplies.not.covered. under.Part.A.of.Medicare.

Medically necessary:.A.term.for.describing.[a].requested.service.that.is.reasonably. calculated.to.prevent,.diagnose,.correct,.cure,.alleviate.or.prevent.worsening.of.conditions. in.the.client.that.endanger.life,.or.cause.suffering.or.pain,.or.result.in.an.illness.or.infirmity,. or.threaten.to.cause.or.aggravate.a.handicap,.or.cause.physical.deformity.or.malfunction.. There.is.no.other.equally.effective,.more.conservative.or.substantially.less.costly.course.of. treatment.available.or.suitable.for.the.client.requesting.the.service..For.some.purposes,. “course.of.treatment”.may.include.mere.observation.or,.where.appropriate,.no.treatment. at.all.

Non-covered service or charge:.A.service.or.charge.that.is.not.covered.by.the.Medical. Assistance.Administration,.including,.but.not.limited.to,.such.services.or.charges.as.a. private.room,.circumcision.and.video.recording.of.the.procedure.

Pricing, data analysis and coding (PDAC): Provides.support.to.the.DME.Program. Safeguard.Contractors.(PSCs).along.with.guiding.manufacturers.and.suppliers.on.the. proper.use.of.HCPCS.

Ratio of costs-to-charges (RCC):.The.methodology.used.to.pay.hospitals.for.services. exempt.from.the.DRG.payment.method..It.also.refers.to.the.factor.applied.to.a.hospital’s. allowed.charges.for.medically.necessary.services.to.determine.payment.to.the.hospital.for. these.DRG-exempt.services.

Reasonable cost:.Fiscal.Intermediaries.and.carriers.use.CMS.guidelines.to.determine. reasonable.costs.incurred.by.individual.providers.in.furnishing.covered.services.to.enrollees.. Reasonable.cost.is.based.on.the.actual.cost.of.providing.such.services,.including.direct. and.indirect.cost.of.providers.and.excluding.any.costs.that.are.unnecessary.in.the.efficient. delivery.of.services.covered.by.the.program.

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Abbreviations and acronyms

20 ABN—Advance.Beneficiary.Notice. ADMC—Advance.Determination.of.Medicare.Coverage. ALJ—Administrative.Law.Judge. BBA—Balanced.Budget.Act. CMN—Certificate.of.Medical.Necessity. CMR—Comprehensive.Medical.Review. CMS—Centers.for.Medicare.and.Medicaid.Services. COB—Coordination.of.Benefit COPD—Chronic.Obstructive.Pulmonary.Disease. CWF—Common.Working.File. DHHS—Department.of.Health.and.Human.Services. DME—Durable.Medical.Equipment. DMEPOS—Durable.Medical.Equipment,.Prosthetics,.Orthotics.and.Supplies. DRG—Diagnosis.Related.Groups. DX—Diagnosis. ECF—Extended.Care.Facility. EOMB—Explanation.of.Medicare.Benefits. ERN—Electronic.Remittance.Notice. FDA—Food.and.Drug.Administration. HCPCS—Healthcare.Common.Procedure.Coding.System. HHA—Home.Health.Agency. HHS—Health.and.Human.Services. HICN—Health.Insurance.Claim.Number. HIPAA—Health.Insurance.Portability.and.Accountability.Act. HMO—Health.Maintenance.organization. ICD-9-CM—International.Classification.of.Diseases,. Clinical.Modification,.9th.Revision. ICF—Intermediate.Care.Facility. ICN—Internal.Claim.Number. ICU—Intensive.Care.Unit. IRP—Inexpensive.or.Routinely.Purchased. LMRP—Local.Medical.Review.Policies. MAA—Medical.Assistance.Administration MCM—Medicare.Carriers.Manual. MedPAC—Medicare.Payment.Advisory.Commission. MSN—Medicare.Summary.Notice. MSP—Medicare.Secondary.Payer. NF—Nursing.Facility. NH—Nursing.Home. NON-PAR—Non-Participating.Provider NOS—Not.Otherwise.Specified. NSC—National.Supplier.Clearinghouse. NSF—National.Standard.Format. OBRA—Omnibus.Budget.Reconciliation.Act. OIG—Office.of.the.Inspector.General. OPPS—Outpatient.Prospective.Payment.System. PA—Prior.Authorization. PAR—Participating.Provider. PIN—Provider.Identification.Number. RA—Remittance.Advice. Rx—Prescription. PDAC—Statistical.Analysis.Durable.Medical.Equipment.Regional.Carrier. SNF—Skilled.Nursing.Facility. UPIN—Unique.Provider.Identification.Number.

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Helpful Reimbursement Websites

Region A MAC: National Heritage

http://www.medicarenhic.com/dme/index.shtml

Region B MAC: AdminaStar Federal

http://www.ngsmedicare.com/ngsmedicare/HomePage.aspx

Region C MAC: Cigna Medicare

http://www.cignagovernmentservices.com/jc/index.html

Region D MAC: Noridian Administrative Services

https://www.noridianmedicare.com/dme/index.html

CMS Durable Medical Equipment Center

http://www.cms.hhs.gov/center/dme.asp

State Medicaid webpage links

http://64.82.65.67/medicaid/states.html

DMEPOS Quality Standards

http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/04_New_Quality_ Standards.asp

Approved Accreditation Agency Contact List

http://www.cms.hhs.gov/CompetitiveAcqforDMEPOS/

Competitive Bidding Implementation Contractor (CBIC)

http://www.dmecompetitivebid.com/palmetto/cbic.nsf/DocsCat/Home

DMEPOS competitive bidding overview

http://www.cms.hhs.gov/DMEPOSCompetitiveBid/

Durable Medical Equipment Code System (DMECS)

https://www.dmepdac.com/

DMEPOS fee schedule

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Figure

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