APMA DME Update NYSPMA Clinical Conference January 23 2020

Paul Kesselman DPM CEO Park DPM Consulting LLC

Partner PARE Compliance PICA DME Consultant

Chair APMA DME Workgroup (APMA Health Policy) National DME CAC Rep for APMA

Member All Four Jurisdictional Councils Codingline Expert Panelist

NYPSMA Insurance Committee Peer & IME Reviewer for Insurance Carriers, NYSWC, NYSNF

parkdpm@hotmail.com 516 632 9944

Disclaimer The contents of this lecture are solely the opinion of

Dr. Kesselman. They are not to be interpreted as legal opinion nor the policy of any third party payer, APMA or any Sponsors of

this presentation. CMS and third-party payment policies are subject to change and individual interpretation by each carrier. One should always check with your carrier and/or health care

attorney for corroboration and further information. Any reproduction in any format without the express written

permission of Dr. Kesselman is prohibited. All materials provided are copyright protected and any use

without prior written permission of Dr. Kesselman or his sponsors are prohibited by law.

Conflicts of Interest

• Multiple DME Manufacturers • CEO Park DPM • Partner PARE Compliance

Thanks • Exhibitors • APMA Staff • Dave Freedman DPM • APMA DME Advisory Work Group • APMA BOT

DME 2020 Agenda • Fee Schedule & New Coding Update • Enrollment Issues • TPE CERT, RAC & ALJ Issues • MCR Auditing Issues- Target Probe Educate • Therapeutic Shoe Update • Mirrored Codes • Competitive Bidding • Responding to DME Audit • Same or Similar • BMAD Data (Courtesy of David Freedman DPM) • Prior Authorization for DME MCR • CFO P/A and Non-Medicare DME Issues

What’s New for 2020?

• Audits: TPE CERT RAC ZPIC • Same or Similar Denials • Increased Enrollment Delays • Increase Enrollment Fee

DME MAC & Important Info • JA Noridian 866-419-9458 • JD Noridian 1-877-320-0390 • www.noridianmedicare.com • Noridian Medicare Portal • www.noridianmedicareportal.com • JB IVR: 877.299.7900

Customer Service: 866.590.6727 • JC IVR: 866.238.9650

Customer Service: 866.270.4909 • Portal: MYCGS.com

• Subscribe to the List Serve of Your MAC

• Familiarize Yourself with LCD Changes

• Removed ICD10 from LCD and Placed Them Into PA or SIA

DME MAC Critical Information

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Price Data Analysis Contractor (PDAC)

• Palmetto GBA • Carrier Medical Director Doran Edwards MD • Phone Number 877-735-1326 • Website www.dmepdac.com • Therapeutic Shoe Validation Changes (Stay Tuned).

PDAC Requirements & DPM

• A5500 Optional for PDAC Approval – Changes ?? • A5512: Mandatory PDAC Approval • A5513/A5514: Mandatory if you are not the mfg. • L1906, A6021-6024 (Collagen Dressing) • Ask Your Vendor if the Product has a PDAC Validation • You Must Know if the Custom Device is • Custom Molded (A5513) or Custom Milled (A5514) • https://www4.palmettogba.com/pdac_dmecs/

2020 DMEPOS Fees • CPI First Apply Deflation Factors: • .431 for O&P .547 for Sx. Dressings .912 Splints and Casts - • 1.6% Increase from 2019; • Labor Rates L4205 • State by State ↑ slight • NYS $25.41 (was 23.40 in 2019) • L7520 Labor/15 minutes for Prosthetics • NYS: $32.28 (Was $31.77 in 2019)

https://www.cms.gov/files/document/mm11570

“Therapeutic Shoe Program Fees” HCPCS 2013 2014 2015 2016 2017 2018 2019 A5500 68.84 69.53 70.57 70.29 70.78 71.56 73.21 A5501 206.49 208.55 211.68 210.83 212.31 214.65 219.59 A5512 28.08 28.36 28.79 28.67 28.97 29.19 29.86 A5513 41.91 42.33 42.96 42.79 43.01 43.56 44.56 A5514 (Was K0903) 44.56

HCPCS Changes

HCPCS Changes

• No HCPCS Changes Effecting DPM for 2020

NSC Enrollment Issues • NPI I vs. NPI II for Solo Practitioners? • Three Year Enrollment 2020 = $595 • $586 Per Location 2019 • Fees Paid Through PECOS System • Electronic Or Paper = Web PECOS or 855S** • Reactivation and Disenrollment • EFT Mandatory • Inspection Issues (ADA Requirements, Multiple Locations, Timing of

Inspection, etc.) • Use The Most Current NSC 855S • Competitive Bidding and NSC Enrollment Issues

Rogue (Threatening) Inspector Issues

• “Threatening to shut you down” • Asking to review charts • Asking for any more than signage and sample inventory and

Copy of Supplier Standards, or other NSC related materials- • Get the name of the inspector and badge number • Document exactly what they want/need • Make copies of their ID Cards • Call Your ADC Carrier and APMA Health Policy

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Other NSC Issues • ↑ Penalties to 10 Years for Failure to Comply • Currently 1 Year for Failure to Report New/Existing Location • Currently 2 Year Ban for Failure to Be Available for Inspection • Potential to Share & Impose Bans on Other CMS Enrollment

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Non-Enrolled DMEPOS Suppliers • Cannot Submit Claims for Payment • No PTAN to Cross Walk to NPI/Tax ID • CMS1490 for Beneficiary • Patient Responsibility Rejections (PR96) • Requires Specific ABN • Patient May or May Not Receive Payment • Beneficiary May File (1) 1490 PER Lifetime

CMS 1490 Patient Submission of DME Claims from Non-Enrolled Supplier

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012949.html

Common Electronic Data Interchange (CEDI)

Help Desk: 866-311-9184 ngs.cedihelpdesk@anthem.com.

Common Electronic Data Interchange

• Trading Partner Annual Recertification is Mandatory

• Filters all Electronic DME Claims

• Front End Audits

• Routes Claims to Proper DME MAC

• Matches CEDI Number to: NPI, TAX ID & NSC Number

Top CEDI Errors for November 2019 • Incorrect HCPCS Number/Modifier Comb • Incorrect Subscriber Number • Incorrect NPI/Trading Partner • NPI an Tax ID are not linked • NPI and PTAN not cross linked • Information not consistent with billing guidelines • Modifiers Duplicated • This HCPCS Code does not allow for spanned dates • Units cannot be more than 1 • Date(s) of service are in the future • Other Invalid ICD10 • Claim Frequency Incorrect (Same claim resubmitted)

Written Proof of Delivery (WPOD)

WPOD Issues • Every DME Device You Dispense • Patient (or Patient Rep) Signature • Layperson or HCPCS Description of Item(s) • Date of Receipt (May be Dated by Office Rep) • Location of Delivery (Your Office Address) • Patient Receipt of Complaint Protocol • Patient Receipt of Supplier Standards • Proof You Provided Warranty Information

Including the Supplier Standard Issues or Incorporate onto the WPOD

The products and/or services provided to you by supplier legal business name or DBA are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g., honoring warranties and hours of operation). The full text of these standards can be obtained from the U.S. Government Printing Office website

Supply an actual copy of the Current Supplier Standards & state it on the WPOD

OR

Written Proof of Delivery • Proof of delivery record (signed delivery slip) must include:

• Beneficiary’s name

• Delivery address

• Description to identify item(s) delivered

• Detailed, narrative description or brand name, make, and model number

• Quantity delivered

• Date delivered (date of service billed to the Medicare program)

• Beneficiary signature (or designee signature)

“MY CGS Connect” For Suppliers in JC • Concierge Level of Voluntary Pre-Payment Review • Submit All Your Documentation Prior to Claim Submission • Auditor will Advise if Your Claim is Up to Par • Does Not Guarantee You will pass TPE or Post Payment Audit • TPE or Post Payment Audits Conducted By Different Auditor • Therapeutic Shoe Codes Top Codes Voluntary Selected

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OIG: Medicare Payments for DMEPOS Due 2020 • DME MAC ASP as Compared to Other Payers

• SNF Consolidated Billing DME

• Payments for Medicare Services, Supplies, and DMEPOS Referred or Ordered by Physicians-Compliance (Due 2019)

• (Still not released). • Inappropriate Denial of Services and Payment in Medicare

Advantage (Due 2020)

• Inappropriate payment E/M Services to DPM During RFC or other CPT codes

Target Probe and Educate (TPE) • Pre-Payment Audits • Conducted Only by DME MAC • 100% Pass Rate in First Round - • BYE For Remainder of Year

• Overall TPE: • 6-10% Pass on First Round • 45% Move from Round 2-3 • Most Errors- • Missing/Wrong Modifiers, SWO, Med. Necessity Issues

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TPE Auditors

• Voluntary- Beware If the gov’t says they’re here to help you • TPE Auditors Have Been Known To Be VERY Wrong

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TPE

• Statistical Analysis Between Suppliers Is Difficult to Assess • Doesn’t Cross Between Rounds or Codes • Round 3 Suppliers Skew the % for earlier rounds • Non-Specific As to Type of Supplier

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Top TPE Denials of Shoes

• Lack of 2⁰ Foot Findings by DM managing MD/DO or those of DPM Not Attested to by Cert. MD/DO.

Solution: Have your exam initialed and dated by Cert MD and Submit Entire Exam to DME MAC.

• No Evidence of Exam by MD/DO Documenting the Management of DM within 6 months Solution: Obtain an exam from the MD/DO of your patient within 6 months of shoe delivery.

• Cert Physician is not managing DM Solution: Be sure the “Certifying Physician’s” notes document mgmt of DM

• Medical Records Contain No Foot Exam

Solution: Perform an exam which documents 1/6 qualifying Condition

• No Supplier Foot Exam Prior to Dispensing Solution: Your medical exam is your supplier exam. PQRS Measure 127 stipulating size/width DWO,etc.

• Supplier Dispensing Documentation did not include an objective fitting Exam.

Solution: Document at the time of delivery the fit of the shoes and inserts with the patient wearing the

• Problems with Signature in the medical records Solution: Be sure all documents conform with “CMS Signature Requirements”

• No Cert Physician Statement

Solution: Be sure the MD/DO signed &dated it within 3months of shoe dispensing and dated same date or date subsequent to their medical records

Perform a “Fitting Exam” Prior to Dispensing

• Document Issues with Present Devices (if used) • Proper/Incorrect Sizing • Size The Patient (Length and Width), Document Impression • Medical Necessity for Therapeutic Footwear, AFO, etc.

Dispensing Note and Proof of Delivery

• Shoe/Inserts/AFO etc. Fit well in length & width. This fit was observed with patient wearing the shoe(s), insert(s), etc. The device(s) is/are in good working order. There was no rubbing, there is ample room at the toe(s).

• Patient’s Name and Date of Service • Describe Product Dispensed (e.g. size, width, model, serial number,

etc.) • Product Description Should Match HCPCS. • Patient Can Apply & Remove Device (w or w/o assistance) – If

W/Assistance by Whom (e.g. HHA, spouse, etc.) • Current Supplier Standards, Warranty and Written Instructions Were

Provided • Signature & Date

Post Payment DME Review

• Supplemental Medical Review Contractor (SMRC) • https://med.noridianmedicare.com/web/smrc • Ask for Required Elements in LCD • 45 Day Window to Respond to ADR • Paper, Fax, ESMD, Encrypted Electronic or CD/DVD

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ZPIC or UPIC Post Payment Audits • Zone Program Integrity Contractor or UPIC Unified Program Integrity Contractor • Identify cases of suspected fraud, investigate them, and take action to ensure any

inappropriate Medicare payments are recouped. • Fraud: • Billing for services not furnished • Billing that appears to be deliberate for duplicate payment • Altering claims or medical records to obtain a higher payment amount • Soliciting, offering, or receiving a kickback or rebate for patient referrals • Billing non-covered or non-chargeable services as covered • UPIC actions to detect and deter fraud and abuse may include: • Investigating potential fraud and abuse, including interviews and onsite visits • Perform medical review, as appropriate • Perform data analysis • Identify the need for administrative actions, such as payment suspensions and prepayment,

or auto-denial edits • Referring cases to law enforcement for consideration and initiation of civil or criminal

prosecution.

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Anatomy of a Post DME Payment Audit

• 25+ Charts Selected for Review From One Supplier • DOS: ~ 3 Years Ago • 21+ Initially Rejected by SMRC & Payment Requested • Appealed- • 17 Charts Rejected on ZPIC Review • 4 Charts Payment Upheld • 17 Charts Onto ALJ • Interest and Penalties Accrue During Appeal

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What Are The Issues? • Lack of Medical Necessity • Same Or Similar Type Issues with Myriad of Device Changes

without clear rationalization • WPOD • Orders are either absent, unclear, confusing • Custom Fitting Wasn’t Clear

• Is this your practice?

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Comprehensive Error Rate Testing (CERT) Data and Carrier Provided by AdvancedMed Data for July 1 2018- June 30 2019

CERT DATA Rates

• Decreased from 46% 2017 to 31% in 2019 • Reduction in the CERT Error Rate: • Suppliers Have Improved Their Documentation • MAC & ZPIC Have Improved Their Auditing Process • CERT Has Improved Its Audit & Examination Process

CERT Documentation Requests • AdvanceMed is the CERT contractor • Documentation may be submitted the following ways

• Via Postal Mail to: CERT Documentation Center 1510 East Parham Road Henrico, Virginia 23228

• Via Fax to: 1-804-261-8100 or 1-443-663-2698 • Use the barcoded cover sheet as the only coversheet. • Do not add your own cover sheet—this slows down the receipt and identification process • Send a separate fax transmission for each individual claim.

• Via Electronic Submission of Medical Documentation (esMD): • Include a CID# or Claim number and the barcoded cover sheet in your file transmission. • Information on esMD can be found at https://www.cms.gov/esMD

© 2019 Copyright, CGS Administrators, LLC 41

CERT Contact Information • CERT Contractor Resources and Contacts

• AdvanceMed Customer Service: 1.443.663.2699 or 1.888.779.7477 • E-mail: certmail@admedcorp.com • Website: https://certprovider.admedcorp.com

• DME MAC CERT Resource Locations • JA: https://med.noridianmedicare.com/web/jadme/cert-

reviews/cert • JB: https://www.cgsmedicare.com/jb/claims/cert/index.html • JC: https://www.cgsmedicare.com/jc/claims/cert/index.html • JD: https://med.noridianmedicare.com/web/jddme/cert-

reviews/cert © 2019 Copyright, CGS Administrators, LLC 42

Appeal Rights from CERT Audits

• If the CERT contractor finds errors with the claim in question, the supplier will receive an Overpayment Demand Letter and a revised Medicare Remittance Advice.

• If the supplier does not agree with the outcome of the CERT review, they should file an appeal to the Redeterminations department of their DME MAC within 120 days of the date on the demand letter or Medicare Remittance Advice

• If a Redetermination is filed to the appropriate DME MAC within 30 days of the letter/MRA, all recoupment activities will cease until the redetermination decision is made.

© 2019 Copyright, CGS Administrators, LLC 43

2018: DPM CERT DMEPOS Error rate was 82%

2018

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73

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Cert Error Rate for Orthotics (AFO KAFO Spinal)

• Missing clinical documentation supporting the medical necessity of the custom fabricated AFO

vs. prefabricated orthosis. • Missing clinical documentation to support the orthosis is needed for beneficiary with weakness

and deformity of the foot and ankle and requires orthosis for stabilization and has the potential to benefit functionally.

• The Standard Written Order was not provided, missing sufficient detail, or missing the physician signature.

• Missing the documentation that supports the modification performed to prefabricated item by an individual with expertise.

• Missing Proof of Delivery for the item billed, POD did not include sufficient detail, or POD missing beneficiary/designee’s signature.

• Missing a detailed description of the substantial modification necessary at the time of fitting the orthosis to the beneficiary in order to provide an individualized fit beyond minimal self-adjustment.

• High Error Rates Continue for all Suppliers. • High CERT Errors for Shoes, AFO, Surgical Dressings and Orthopedic Footwear.

Lower Limb Orthoses Documentation • In addition to the standard documentation requirements (Dispensing

Order, Standard Written Order, and Proof of Delivery) review the LCD coverage criteria for specific information required in medical records.

• Example: Ankle-foot orthoses (AFO) described by codes L1900, L1902-

L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

• Require stabilization in which planes (>1), which deformity needs

stabilization and why

• The need for each HCPCS Code needs to be documented in the note

• Have the potential to benefit functionally.

If You Do Get Audited • Respond Promptly • Know Your Rights • If you know you are right and the auditor is wrong on a

specific point provide the written proof and its source • Appeal and Appeal

Standard Written Order Has Replaced Detailed Written Order

• Beneficiary name on MBI; • Order Date (DOS of your note) • A description of the item to include all items, options or additional

features that are separately billed or require an upgraded code; • The description can be either a general description (e.g., AFO), a brand

name, a HCPCS code, or a HCPCS code narrative; • All options or accessories that will be separately; • All supplies that will be separately billed (List each separately), • Frequency of use, if applicable; • Quantity to be dispensed; • Treating Practitioners Name or NPI • Practitioner’s Signature • Medical Necessity for All Must Be Clearly Documented

New Advisory from CMS on “Standard Written Order”

CMS Requirements for Standard Written Orders

• The supplier shall have a standard written order for the DMEPOS prior to submission of the DMEPOS claim.

• In those limited instances in which the treating practitioner

is also the supplier and is permitted to furnish specific items of DMEPOS and fulfill the role of supplier in accordance with any applicable laws and policies, a separate SWO is not required. However, the medical record must still contain all the required SWO elements.

• Source: Chapter 5 Page 4 Medicare Program Integrity Manual

Diabetic Shoes and Inserts • Evaluation at Delivery

• No evaluation at delivery information received • No objective statements of fit by supplier • No indication of evaluation by supplier • Delivery documentation not signed by beneficiary

• Billing • Billing prior to date of service • Billing prior to delivery

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RAC: Performant Recovery

https://perfomantrac.com 1 866 201 0580

RAC Targeted Issues

• 10% of previous year claims • No more than (8) 45 day periods • AFO/KAFO and Therapeutic Shoes • DME for Hospice or In Patient • Bone Stim and NPWT • Home Health

Administrative Law Judge Appeals

• >3 Year Wait • Low Volume Threshold Initiative • MCR Willing to Settle 62% of outstanding amount • <500 Appeals • Each appeal <$9,000 (billed amount) • Appeals Are Across all NPI for All Providers • Many Exclusionary Criteria • What Does This Tell You? • www.cms.gov/Outreach-and-Education/NPC/National-Provider-

Calls-and-Events.html

Part B BMAD Data

DMEPOS Data for Selected DMEPOS for DPMs & All Suppliers Courtesy of APMA & David Freedman DPM

Eight Year Trend On A5500 ($M) 2010 2015 2016 2017 2018

• All 121 76.4 71.6 69 66

• DPM 41 26.4 25.2 24 23

• Med. Supp. Co. 26.8 14 12.5 12 11.7

• Pharmacy 15.2 8.7 7.5 7.2 6.4

• C.O. 8.8 5.8 6.1 6 5.6

Total Revenue 2010-2018 ↓: 56% DPM

DPM Participation T Shoes

• 2018 42% Yes 57% No • 2017 48% Yes 52% No • 2016 52% Yes 48% No

• Source: Barry Block PM News Polls

Top 15 DPM DME for 2018

1 A5500 Diab shoe for density insert $23,287,911 16.7% 356,919 326,315 10.1% $71 100.0%

2 A5512 Multi den insert direct form $15,201,380 10.9% 569,294 521,962 16.1% $29 100.0%

3 A5513 Multi den insert custom mold $12,949,755 9.3% 325,117 298,659 9.2% $43 100.0%

4 A6010 Collagen based wound filler $10,857,615 7.8% 343,145 311,873 9.6% $35 100.0%

5 L4361 Pneuma/vac walk boot pre ots $10,185,089 7.3% 43,356 37,604 1.2% $271 100.0%

6 L1940 Afo molded to patient plasti $6,966,016 5.0% 15,942 13,919 0.4% $500 100.0%

7 L4360 Pneumat walking boot pre cst $6,160,090 4.4% 27,386 23,331 0.7% $264 99.8%

8 L2330 Lacer molded to patient mode $5,965,958 4.3% 17,028 15,254 0.5% $391 100.0%

9 L3000 Ft insert ucb berkeley shell $5,544,195 4.0% 60,030 19,776 0.6% $280 99.1%

10 L1970 Afo plastic molded w/ankle j $4,492,884 3.2% 7,513 6,292 0.2% $714 100.0%

11 L1971 Afo w/ankle joint, prefab $3,534,745 2.5% 9,295 7,938 0.2% $445 100.0%

12 L4396 Static or dynami afo pre cst $2,809,627 2.0% 21,084 17,554 0.5% $160 100.0%

13 L1902 Afo ankle gauntlet pre ots $2,782,977 2.0% 41,192 34,493 1.1% $81 100.0%

14 L4397 Static or dynami afo pre ots $2,746,705 2.0% 19,600 17,149 0.5% $160 100.0%

15 A6021 Collagen dressing <=16 sq in $2,158,413 1.5% 100,544 91,606 2.8% $24 100.0%

Top DPM DME 16-30 for 2018

16 L2820 Soft interface below knee se $1,841,575 1.3% 24,590 21,436 0.7% $86 100.0%

17 L5000 Sho insert w arch toe filler $1,702,239 1.2% 3,624 3,215 0.1% $529 100.0%

18 L1906 Afo multilig ank sup pre ots $1,170,522 0.8% 12,361 10,041 0.3% $117 99.9%

19 A6023 Collagen dressing >48 sq in $1,132,208 0.8% 5,655 5,286 0.2% $214 100.0%

20 L1930 Afo plastic $1,106,755 0.8% 5,352 4,670 0.1% $237 99.7%

21 L1907 Afo supramalleolar custom $1,057,401 0.8% 2,224 1,977 0.1% $535 100.0%

22 L3020 Foot longitud/metatarsal sup $988,035 0.7% 10,026 5,344 0.2% $185 99.4%

23 A6212 Foam drg <=16 sq in w/border $961,576 0.7% 100,382 88,521 2.7% $11 100.0%

24 K0005 Ultralightweight wheelchair $870,175 0.6% 523 428 0.0% $2,033 100.0%

25 L2280 Molded inner boot $654,044 0.5% 1,706 1,383 0.0% $473 100.0%

26 L4386 Non-pneum walk boot pre cst $640,781 0.5% 5,019 4,248 0.1% $151 99.9%

27 A6222 Gauze <=16 in no w/sal w/o b $506,732 0.4% 229,804 211,404 6.5% $2 100.0%

28 L0650 Lso sc r ant/pos pnl pre ots $497,255 0.4% 668 430 0.0% $1,156 100.0%

29 L4387 Non-pneum walk boot pre ots $463,052 0.3% 3,625 3,150 0.1% $147 100.0%

30 L1960 Afo pos solid ank plastic mo $426,406 0.3% 964 750 0.0% $569 100.0%

Top 50 DME ALL Providers for 2018 #3 Code

Top 50 DME ALL Providers for 2018 #4 Code

Table 14F: 2018 Medicare Part B, A5500 by Supplier Type

Therapeutic Shoes for DPM By Regional Carrier 2018

Table 14F:A5501 by Supplier Type # 42 for DPM

Collagen Dressings for DPM By Region 2018

# 4 for DPM

A5512 Heat Molded Insert Data By Specialty

#2 for DPM

A5513 Data By Supplier Type

# 3 for DPM

Data for DPM Orthopedic Footwear Codes

Most Common HCPCS Code Trends 2017 to 2018 for DPMs HCPCS 2017 Freq 2018 Freq 2017 $M 2018 $M

A5500 1 1 26.4 23.28

A5512 3 2 18.3 15.2

A5513 2 3 19 12.95

L4360 4 7 10.7 6.1

L4361 8 5 4.1 10.1

L1970 7 10 4.7 4.5

L3000 10 9 4.4 5.5

L3020 20 22 1.08 .98

L5000 14 17 1.5 1.7

L4386 17 26 1.1 0.64

L4387 33 29 Not in top 30 .463

Underutilized by DPMs?

86 L5020 Tibial tubercle height w/ toe filler $34,644 0.0% 19 14 0.0% $2,475 100.0%

198 L5010 Mold socket ankle height w/ toe filler $4,659 0.0% 4 4 0.0% $1,165 100.0%

17 L5000 Shoe insert w arch toe filler $1,702,239 1.2% 3,624 3,215 0.1% $529 100.0%

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Tibial Fracture AFO Still in Top 50 for DPM

45 L2116 Afo tibial fracture rigid $201,350 0.1% 430 374 0.0% $538 100.0%

35 L2114 Afo tib fx semi-rigid $346,995 0.2% 893 634 0.0% $547 100.0%

48 L2112 Afo tibial fracture soft $170,829 0.1% 411 351 0.0% $487 100.0%

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What’s the Big Deal on Billing CFO to MCR?

False Claims Act $22K/Claim x 28,000 claims=$616M (Potential for CFO)

FCA Health Care $2.6B &70% of Health Care FCA

were Qui tams

Other Frequently Audited HCPCS

Cam Boot or Night Splint DPM

14 L4397 Static or dynami afo pre ots $2,746,705 2.0% 19,600 17,149 0.5% $160 100.0%

12 L4396 Static or dynami afo pre cst $2,809,627 2.0% 21,084 17,554 0.5% $160 100.0%

29 L4387 Non-pneum walk boot pre ots $463,052 0.3% 3,625 3,150 0.1% $147 100.0%

26 L4386 Non-pneum walk boot pre cst $640,781 0.5% 5,019 4,248 0.1% $151 99.9%

169 L4370 Pneum full leg splnt pre ots $7,367 0.0% 56 43 0.0% $171 100.0%

5 L4361 Pneuma/vac walk boot pre ots $10,185,089 7.3% 43,356 37,604 1.2% $271 100.0%

7 L4360 Pneumat walking boot pre cst $6,160,090 4.4% 27,386 23,331 0.7% $264 99.8%

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Popular Mirrored Codes for DPM’s

• L4360 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

• L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item, Off-The Shelf

• L4386 Walking boot, non pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

• L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item, Off-The Shelf

• L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

• L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for

positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

Mirror Code Fee Differentials?

• When? • Are There Any Examples? • Split Code Policies?

Workflow for Pre-Fabricated Devices

Same or Similar

Same or Similar Table AFO

L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631

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100

101

Same or Similar and L5000? • Does Not Apply Based On Time • Medical Notes Must Document Issues With: • Device or Patient Which Mandate Replacement • Payments are held due to a TPE or – • Recoupment Due to Post Payment Audit

Provider Portals Noridian JA: https://med.noridianmedicare.com/web/jadme/topics/nmp Noridian JD: https://med.noridianmedicare.com/web/jddme/topics/nmp CGS Region B: https://www.cgsmedicare.com/jb/mycgs/index.html CGS Region C https://www.cgsmedicare.com/jc/mycgs/index.html

Provider Portals • Enrollment Governed by CMS Regulations • Multiple Hurdles to Overcome • Requires MFA Each Time You Log In • Provides Eligibility, Claims & Payment Info. • Can Submit Appeals With Attachments • Provides Information on Same & Similar

Issues with Provider Portals

• Noridian & My CGS Do Not Cross Reference • My CGS Requirement of 90 Day Recertification Renewal • Passwords Need Frequent Changing • Passwords With MY CGS Are Problematic and Confusing • Secure Your Password Hint Questions • Must Log On At Least Once every 14 days

Same or Similar • April 2019 • Operation Brace Yourself $1B in Medicare Fraud

• Impact on Same Or Similar • Impact on Supplier Enrollment, Policy Changes

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Responding to an Audit or Same & Similar Rejection • Include Copy of Cover Letter • LCD & Supplier Manual: Highlight & Reprint Those Sections • Number Your Chart Notes and Provide a Table of Contents • Bold Print Pertinent Sections of Your Notes Which-- • Address What the Previous Device Was Used For • Address What the New Replacement Device is For • Tell why the old (previous device) is not useful for the new Dx. • Show Where the Detailed Written Order is Located • Show Where the Written Proof of Delivery is Located • Show Where Other Pertinent Information Is Located

Same or Similar Chart Note • 1.3.19 • “Patient received a pneumatic cam walker (L4361) from Dr.

John Smith on 2/2/17 for a left foot 5th metatarsal fracture. The patient now has an MRI confirmed Posterior Tibial Tendonosis of the left foot resulting in a multiplane deformity of the subtalar & Talo Navicular joints which are both painful and require stabilization. The patient now requires a custom fabricated AFO (L1970) to stabilize this joint for >6 months. Due to his atrophic skin and ischemia he also requires a soft tissue interface (L2820) and …..

Same or Similar Resources

• https://www.apma.org/News/NewsDetail.cfm?ItemNumber=32546&

• https://med.noridianmedicare.com/web/jadme/topics/s

ame-or-similar

MCR DMEPOS Pre-Authorization Effecting DPMs

• L5010 Partial foot, molded socket, ankle height, with toe filler. • L5020 Partial foot, molded socket, tibial tubercle height, with toe filler • Still Minimal Effect on DPM

Private Insurance DMEPOS Issues

• Pre-Authorization • Pre-Determination of Benefits • Each Carrier is Different • Specific Policies Within a Carrier May Differ • Examples: VSNY FIDA vs VSNY MCR Part C

Emblem Health • Long List AFOs, TENS, etc. requiring P/A • Examples: L1906, L1970, L4396

• Source: https://www.emblemhealth.com/Providers/Claims-

Corner/Utilization-Review/DME-Will-Require-Prior-Approval?utm_source=blast&utm_campaign=december_provider_newsreminders_1217&utm_medium=email

1199 • Custom Foot Orthotics Once Per 365 YTD • No P/A • L3020 Pays Higher Than L3000 • A5500 Pays Once Per Calendar Year • Less Policy Restrictions than MCR

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Custom Foot Orthotics

Medicare Dispensing Prior to Surgery

• Only if Medically Necessary • POS = 12 • If In-Patient Must Be <48 Hours Prior to D/C

Local Issues

Custom Foot Orthotics

DME & Medicare Advantage Plans Contractual Issues

• Prior Authorization • Outsourcing Requirements • Fee Schedules at or Below Your Wholesale Costs • POS Issues • ABN Restrictions

117

CFO Coverage Issues

• Varies from State to State, Carrier to Carrier &……..

• Policy to Policy • BC Amerigroup, Health First, Fidelis • MCD Managed Care • Subject to NYS MCD Coverage • Most Have Converted To Fax Patient Notes • Conservative Care ≥ 6 months • Care May Be OTS, Patient Directed

L3000 Audits Non MCD Non MCR • Nationwide Audits Continue • $2.2M • $120K • $90K • $87K • $100K • $750K • Are You Next?

Issues at Stake for CFO • Wrong HCPCS • Billing CFO on Casting DOS • Billed with Wrong or Multiple Impression Codes • Absence or Missing WPOD • Impression/Dispensing Note Inaccurate/Missing • Billed on IOV • No Conservative Care Documented • Overutilization • Extrapolated Data

L3000

• What Does Your Lab Order Say? • What Do Your Office Notes Say? • What Does the Dispensing Note Say? • What Does Your Lab Invoice Say?

Non-Medicare Dispensing Prior to Surgery

• Check Your LCD • Obtain P/A

• No Prior Authorization for DME • Pre-Payment Review $500 • Prescriber & Supplier Documentation: • Lack of Medical Necessity • Illegible and Template Like • Poor Diagnosis • WPOD Poor or Non-Existent • HCPCS Code of Rx ≠ Supplier • HCPCS Code ≠ Description • Paid at WC Fee Schedule • Don’t Have to Accept N/F to see N/F

Patients • Patients May Self Submit Claims • Most Pre-Payment Audits Denied

• Custom DME Requires P/A • >$500 Requires P/A • Illegal to Charge WC Patients

if You are Not WCB Rated & Service is Covered by NYSWCB

• Most Pre-Payment Audits – Denials-

• Denials same reason as NF

NYS NO Fault NYS Workers Compensation

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Thank You

Questions??