DME CERT Task Force Webinar December 18, Revised December 6, Copyright.

Transcription

1 DME CERT Task Force Webinar December 18,

2 Michael Hanna, CERT Task Force Coordinator Jurisdiction A: Denise Winsock Provider Outreach & Education Consultant Jurisdiction B: Nina Gregory Provider Outreach & Education Consultant Jurisdiction C: Mia Gott Provider Outreach & Education Consultant Jurisdiction D: Jody Whitten Provider Outreach & Education Consultant 2

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

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

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6 The DME MAC CERT Task Force consists of representatives from each of the DME MACs and is independent from the CMS CERT Team and CERT Contractors, who are responsible for the calculation of the Medicare Fee-for-Service Improper payment rate. The CERT Task Force has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. The CERT Task Force employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at 6

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8 Physician s Name Beneficiary s Name Start Date Description of the Item Physician s Signature 8

9 Why is this dispensing order invalid for a lightweight wheelchair? Dr. Bruce Smith M.D. Dr. Paul Clark M.D. Dr. Julia Pain D.O. Illegible Signature 9

10 No detailed written order submitted or the order is illegible Order missing one or more of the required elements Detailed written order did not include all items ordered The length of need on the order has expired Start date is after the date of service CMN was used as an order and section C was not sufficiently detailed Signature requirements not met: Illegible Signature Signature Stamp used Detailed written order was not dated by the treating physician or a date stamp was used 10

11 Beneficiary s Name Physician s Name Order Date Length of Need/Refills Description of the Items and Quantity Dosage and Frequency Physician s Signature and Date 11

12 Order For Nebulizer and Supplies What is missing? Missing the description of all items ordered Missing the length of need/number of refills for supplies 12

13 Why is this glucose supply order invalid? Unclear frequency of testing 13

14 Remember: Orders will be less clear after faxing. If you can not read it neither can the reviewers! 14

15 A CMN can serve as the order as long as Section C is sufficiently detailed. What is missing from Section C of this Oxygen CMN? E1390 $250.00/month $198.40/month E0431 $250.00/month $31.79/month Dr. James Davis Missing Narrative Description 15

16 Beneficiary s Name Physician s Name NPI Order Date Length of Need/Refills Description of the Items and Quantity NPI is required on all items which require a face to face under the ACA Physician s Signature and Date Dosage and Frequency 16

17 No 7-Element order submitted Order missing one of the 7 elements No confirmation the supplier received a copy of the 7-Element order within 45 days after completion of the Face-to-Face 7-Element order and detailed product description are on the same document 7-Element order is dated prior to the Face-to-Face evaluation 17

18 Valid 7 Element Order Beneficiary s name Description of the item that is ordered Date of the face-to-face examination Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair Length of need Physician s signature Date of physician signature 5/15/12 18

19 Why is this 7 element order invalid? No Date Stamp to Document Receipt No Pertinent Diagnoses/ Conditions 19 No Physician s Signature Date

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21 Continued use describes the ongoing utilization of supplies or a rental item by a beneficiary Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary 21

22 Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary: Timely documentation in the beneficiary s medical record showing usage of the item, related option/accessories and supplies Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements (sufficient to document continued use for the base item, as well) Supplier records documenting beneficiary confirmation of continued use of a rental item 22

23 Initial justification for medical need is established at the time the item(s) is first ordered Beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription 23

24 There must be information in the beneficiary s medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary A recent order by the treating physician for refills A recent change in prescription A properly completed CMN with an appropriate length of need specified Timely documentation in the beneficiary s medical record showing usage of the item 24

25 Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy This applies to both continued use and continued medical need 25

26 Records are not within 12 months of the date of service reviewed Illegible Signature Electronic protocol for electronic signature Signature log for hand written signatures Records submitted do not make reference to the item ordered. 26

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28 Medicare Program Integrity Manual Chapter 5 Section 5.2.5: For DMEPOS items and supplies that are provided on a recurring basis, billing must be based on prospective, not retrospective use. 28

29 Physician writes an order for enteral nutrition that translates into the dispensing of 100 units of nutrient for one month 100 units delivered Date of service = date of delivery 100 units billed Acceptable! 29

30 Physician writes an order for enteral nutrition that translates into the dispensing of 100 units of nutrient for one month 100 units delivered but claim is not billed Supplier determines at the end of the month the beneficiary used 90 units of the 100 delivered (adjusted future shipment accordingly) Claim is submitted after the used amount is determined with a date of service as the date of delivery indicating 90 units Not acceptable! 30

31 Medicare Program Integrity Manual Chapter 5 Section 5.2.6: Suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis: Ensure the refilled item remains reasonable and necessary Existing supplies are approaching exhaustion Confirm any changes/modifications to the order Contact must take place no sooner than 14 calendar days prior to the delivery/shipping date. Supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product regardless of which delivery method is utilized 31

32 Consumable: Yes or No questions only regarding whether a refill is needed/wanted Documentation only providing information regarding the amount of supplies being requested Documentation only stating less than the threshold is remaining Non-consumable Need for refill not justified *Identical refill language for each beneficiary raises question on whether an individual assessment was conducted 32

33 Submit individualized and detailed records that quantify or assess the functional status of remaining supplies Actual count is recommended but not necessary however evidence of an individual assessment is required *Auditor must be able to determine quantity or functional status was assessed and approaching exhaustion or nonfunctional on the delivery date 33

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35 Supplier Standard 12 Required for all items provided Verifies beneficiary received item Must be available upon request Assists in coding verification and billing information If the service provided does not have appropriate proof of delivery from the DME supplier, the claim in question will be denied and/or overpayment will be requested Maintain for seven years 35

36 Signed delivery slip must include: Beneficiary s name Delivery address Sufficiently detailed description to identify the item(s) Quantity delivered Date delivered Beneficiary (or designee) signature and date of signature Date of signature must be date beneficiary or designee received item Date of service must be date of delivery 36

37 Proof of delivery can be signed by: Beneficiary Beneficiary s designee Relationship to beneficiary must be noted on delivery slip Proof of delivery cannot be signed by: Suppliers Employees of suppliers Anyone with financial interest in delivery of item 37

38 Jane Dodo 38

39 Proof of delivery requirements: Beneficiary s name Delivery address Delivery service s package ID number (or any alternative method that links the supplier s delivery documents with the delivery service s records) Detailed description of the item(s) delivered Quantity delivered Date delivered Evidence of delivery 39

40 Suppliers may use return postage-paid invoice from the beneficiary/designee This type of delivery record must contain the information outlined on the previous slide Date of service must be shipping date 40

41 This example is valid as the order number is on the UPS tracking information and on the packing slip. The items shipped can be verified from all documents related to the shipment. 41

42 Delivery to a nursing facility on behalf of the beneficiary Direct deliveries, follow Method 1 delivery requirements Delivery service/mail, follow Method 2 delivery requirements Facility records must show beneficiary actually received and used the items delivered Must be available on request 42

43 This valid example includes documents presented through Slide 48. There is evidence of a consistent number across the documents and proof the enteral nutrition was held for the Medicare beneficiary in question 43

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49 Items may be delivered to a hospital or nursing facility for fitting or training up to 2 days prior to anticipated discharge Date of service must be date of discharge Items may be delivered to beneficiary s home in anticipation of discharge approximately 2 days prior to discharge Date of service must be date of discharge 49

50 Direct delivery invoice missing date signed Date of service on the claim does not match date of direct delivery or ship date Items dispensed to the home two days prior to discharge do not list discharge date as date of service on the claim No proof items delivered to a nursing home was received by the beneficiary 50

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53 To Ask a Verbal Question: Raise your hand The Green Arrow means your hand is not raised (Click to raise your hand) The Red Arrow means your hand is raised (Click to lower your hand)

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