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DME Update NYSPMA Clinical Conference
January 17 2019
Paul Kesselman DPM CEO Park DPM Consulting LLC
PICA DME Consultant Chair APMA DME Workgroup (APMA Health Policy)
National DME CAC Rep for APMA Expert Panelist DME Codingline
NYPSMA Insurance Committee Co Chair DME Workgroup [email protected]
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
Thanks
• Exhibitors • APMA Staff- Scott Haag & Jeff Lehrman DPM • Harry Goldsmith DPM • Barry Block DPM Esq. • Dave Freedman DPM • APMA Advisory Work Group • APMA BOT
*What’s New for 2019?
• See the * Slides • * = Very Important New or Updated Info
DME 2019 Agenda • DME MAC Carrier Info and Carrier Changes • Fee Schedule & New Coding Update • Enrollment Issues • CERT &ALJ Issues • MCR Auditing Issues- Target Probe Educate • Most Frequent DME Provided • Custom Therapeutic Shoe Fee Schedule Update • Fabricated Shoe Inserts • MCR Auditing Issues- Target Probe Educate • Mirrored Codes • Responding to DME Audit • Same or Similar • BMAD Data (Courtesy of David Freedman DPM) • HCPCS Code Update • Prior Authorization for DME MCR • CFO P/A and Audits • Review Codingline DME 2018
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
*Price Data Analysis Contractor (PDAC)
• Effective January 15, 2019 Palmetto GBA • Carrier Medical Director Doran Edwards MD • Phone Number Remains: 877-735-1326 • Website www.dmepdac.com transitioned to
Palmetto GBA
*DMEPOS Fees • Slight Increase Despite Deflation Factors • .439 for Orthotics and Prosthetics .556 Sx Dressings • .927 Splints and Casts • Labor Rates • State by State ↑ slight • NYS $23.40 (was 22.74 in 2018) • L7520 Labor/15 minutes for Prosthetics • NYS: $31.77 (Was $30.87 in 2018) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10395.pdf
DME Fee Schedule
• Each State Divided Into Urban and Rural Zones • Competitive Bid Program Undergoing
Renovation • NPWT, TENS, Walkers Designated CB Codes • Manual Walker Codes Exempt from CB for DPMs • CB Now on Temp. Hold
HCPCS Changes
K0903 Changed to A5514
• A5514 Custom Milled Insert for Diabetics Only • A5513 Custom Fabricated Insert for DM Only • A5513 and A5514 Fee Schedule Same • K0903 D/C for DOS Effective Jan 1 2019
*NSC Enrollment Issues • NPI I vs. NPI II for Solo Practitioners? • Three Year Enrollment 2019 = $586 • $569 Per Location 2018 • 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
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
• 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 2018
• Incorrect HCPCS Number • Incorrect Subscriber Number • Incorrect or absent modifier • NPI and CEDI Number not cross linked • Invalid NPI Tax ID Cross Link • Invalid NPI and PTAN Cross Link • Invalid ICD10 • Information not consistent with billing guidelines • Other Invalid ICD10 • Claim Frequency Incorrect (Same claim resubmitted)
Written Proof of Delivery (WPOD)
WPOD Issues
• 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
Supplier Standard Issues on 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
OR
*Medicare Payments for DMEPOS 2019 OIG Plan
• DME MAC Inaccurate Payments for SNF Consolidated Billing DME
• Payments for Medicare Services, Supplies, and DMEPOS Referred or Ordered by Physicians-Compliance (Due 2019)
• Inappropriate Denial of Services and Payment in Medicare Advantage (Due 2020)
*Comprehensive Error Rate Testing (CERT)
Data and Carrier Provided by AdvancedMed
Data for July 1 2016- June 30 2017
2018 Medicare Fee-for-Service Supplemental Improper Payment Data
• 90 Page Report on Incorrect Payment Data • Lots of Data to Review • 35% error rate on DMEPOS (2017 = 46%)
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
© 2018 Copyright, CGS Administrators, LLC
25
CERT Contact Information – CERT Contractor Resources and Contacts
• AdvanceMed Customer Service: 1.443.663.2699 or 1.888.779.7477
• E-mail: [email protected] • 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
© 2018 Copyright, CGS Administrators, LLC 26
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.
© 2018 Copyright, CGS Administrators, LLC 27
2018 Improper Payment Rate
2017: Projected Error: $3.7B /Total Paid $8.2B = 45% error 2018: Projected Error $2.6B/Total Paid $7.3B = 35% error
Figure 3: Improper Payment Rate Error Categories by Percentage of 2018 National Improper Payments by Claim Type
(Adjusted for Impact of A/B Rebilling)
DME: Breakdown: 6.4% insufficient documentation, .2% Medical Necessity; Incorrect Coding .3%, .8% No documentation; 1.3% Other
% of ~ 8 42 8 43
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 Detailed 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 & AFOs.
General Documentation Requirements
• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.”
• It is expected that the patient’s medical records will reflect the need for the care provided.
• The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.
• This documentation must be available upon request and retained in the supplier file for at least seven years.
General Documentation Guidelines Continued
• “If it isn’t documented, it hasn’t been done.” • Reasonable documentation that items or services
are consistent with Medicare coverage is required, upon request, in order to validate:
• The site of service; • The medical necessity and appropriateness of the
equipment, and services provided; and/or • All items furnished have been accurately reported
General Documentation Guidelines Continued
• Must substantiate the medical necessity for the items ordered
• Including but not limited to: • Functional limitations of capabilities and ambulation • Expected functional potential/differences with DMEPOS • Clinical course • Prognosis • Past experience with related items
Physician’s Assessment
• Physical examination with objective statements that are relevant to functional deficits
• Weight and height, including any recent weight loss/gain
• Cardiopulmonary examination
• Musculoskeletal examination
• Arm and leg strength and range of motion
• Neurological examination • Gait • Balance and coordination
Lower Limb Orthoses Documentation
• In addition to the standard documentation requirements (Dispensing Order, Detailed 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 for medical reasons &
• Have the potential to benefit functionally.
Written Proof of Delivery • Proof of delivery record (signed delivery slip) must include:
• Beneficiary’s name
• Delivery address
• Sufficient 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)
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
Figure 13: Universal Errors as a Percentage of DMEPOS Improper Payments Due to Insufficient Documentation
Figure 14: Multiple Universal Errors as a Percentage of DMEPOS Improper Payments Due to Insufficient Documentation
• 4.3%
• 95.6%
CERT Data
Therapeutic Shoes
Diabetic Shoes and Inserts
Error Breakdown
Medical RecordsBillingOrders and NPIEval at Delivery
Diabetic Shoes and Inserts – Medical Records
• No medical documentation received • No face to face encounter within six months prior to shoe
delivery • No statement of certifying physician received • No foot examination received • No indication of certifying physician agreement with foot
exam – Orders and NPI
• No detailed written order received • Detailed written order missing elements or unsigned • NPI on order does not match NPI on claim
© 2018 Copyright, CGS Administrators, LLC 55
CMS Requirements for Detailed Written Orders
• The supplier shall have a detailed written order prior to submitting a claim. If a supplier does not have a faxed, photocopied, electronic or pen and ink dated detailed written order signed by the treating physician/practitioner in their records before they submit a claim to Medicare (i.e., if there is no order or only a verbal order), the claim will be denied. An exception to the requirement for a written order applies in those limited instances in which the prescribing practitioner is also the supplier and is permitted to furnish specific items of DMEPOS and fulfill the role of the supplier in accordance with any applicable laws and policies. In such cases, a separate order is not required, but the medical record must still contain all of the required order elements.
• Source: Chapter 5 Page 4 Medicare Program Integrity Manual
What Must Be In Your Note or Separate Detailed Written Order
• Beneficiary name; • 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; • Date of the order; Physician/practitioner signature • Medical Necessity for All Must Be Clearly Documented
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
© 2018 Copyright, CGS Administrators, LLC 58
Target Probe and Educate
Comparison of Auditing Tactics
Old (Random Pre Pay) • Based on HCPCS or CPT • Random • Luck of the Draw • One Chart/One DOS • Dropped if Successful on ~ 10 • Future Audits Not Implicated • No Mandatory Education • Possible PPA on Specific Code • No Further PPA from Carriers
New (Target Probe Educate) • Based on Multiple Factors • You Are the Target • Based on CBR & Code • Up to 50 per Quarter • Dropped if Successful in 1 qtr • QTRLY Till Successful • Mandatory Education • Pre Payment Audits on All Claims • Referral to CERT RAC OIG
Target Probe Educate
• Overwhelming Audit Demands • Educators Provide Inconsistent Information • Possibly Lead to Universal PPA for All Claims • Free Education from MAC • Optional vs Mandatory • Effective Response to 50 Charts/Quarter?
TPE Issues
• All MAC Offer 1:1 Training • MAC Portal Allow Access to Nurses Notes • Vendors Offer Audit Assistance • Liability Carriers Offer Audit Assistance
TPE 3rd Quarter 2018 LLO DME MAC A
• L1970 L4360 and L4361 • 39% Error Rate (As compared to 90%+) • No Response to ADR • Documentation Does Not Support Coverage
RAC Targeted Issues
• 10% of previous year claims • No more than (8) 45 day periods • AFO/KAFO • DME for Hospice or In Patient • Bone Stim and NPWT • Home Health
ALJ and You • Low Volume Threshold Initiative • MCR Willing to Settle 62% of outstanding amount • <500 Appeals • Each appeal <$9,000 (billed amount) • Appeals Are Across all NPI for All Providers • Many Exclusionary Criteria • What Does This Tell You? • www.cms.gov/Outreach-and-
Education/NPC/National-Provider-Calls-and-Events.html
* Seven Year Trend On A5500 ($M)
2010 2015 2016 2017
• All 121 76.4 71.6 69
• DPM 41 26.4 25.2 24
• Med. Supp. Co. 26.8 14 12.5 12
• Pharmacy 15.2 8.7 7.5 7.2
• C.O. 8.8 5.8 6.1 6
Total Revenue 2010-2017 ↓: 46-48% DPM 47% For Total Paid
*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
Part B BMAD Data
DMEPOS Data for Selected DMEPOS for DPMs & All Suppliers
Courtesy of APMA & David Freedman DPM
Table 14B: 2017 Medicare Part B, Top 300* DME and HCPCS Level II Codes Data for Podiatry Listed by Descending Allowed Charges
*(top 300 ranking based on 2017 allowed charges for podiatry speciatly category)
Chg Allowed % of Submitted Allowed % of
Rank HCPCS APMA Short Descriptor Charges Alw Chg Frequency Frequency Alw Frq
Total Top 300 codes $131,355,483 100.0% 2,652,479 2,220,157 100.0%
1 A5500 Diab shoe for density insert $26,428,829 20.1% 445,246 375,542 16.9%
2 A5513 Multi den insert custom mold $18,997,190 14.5% 527,037 445,060 20.0%
3 A5512 Multi den insert direct form $18,280,958 13.9% 750,684 637,226 28.7%
4 L4360 Pneumat walking boot pre cst $10,726,751 8.2% 47,124 40,877 1.8%
5 L1940 Afo molded to patient plasti $6,773,478 5.2% 14,735 13,559 0.6%
6 L2330 Lacer molded to patient mode $5,009,904 3.8% 14,184 13,063 0.6%
7 L1970 Afo plastic molded w/ankle j $4,774,213 3.6% 8,319 6,770 0.3%
8 L4361 Pneuma/vac walk boot pre ots $4,150,803 3.2% 16,697 15,355 0.7%
9 L4396 Static or dynami afo pre cst $4,136,194 3.1% 30,851 26,254 1.2%
10 L3000 Ft insert ucb berkeley shell $4,018,613 3.1% 50,297 14,690 0.7%
11 L1971 Afo w/ankle joint, prefab $3,715,378 2.8% 9,235 8,468 0.4%
12 L1902 Afo ankle gauntlet pre ots $2,531,242 1.9% 34,451 31,838 1.4%
13 L2820 Soft interface below knee se $1,713,299 1.3% 22,432 20,251 0.9%
14 L5000 Sho insert w arch toe filler $1,506,955 1.1% 3,577 2,934 0.1%
15 L1906 Afo multilig ank sup pre ots $1,366,436 1.0% 13,024 11,988 0.5%
16 A6010 Collagen based wound filler $1,343,767 1.0% 44,843 39,252 1.8%
17 L4386 Non-pneum walk boot pre cst $1,146,838 0.9% 8,529 7,657 0.3%
18 L4397 Static or dynami afo pre ots $1,127,056 0.9% 8,089 7,144 0.3%
19 L1930 Afo plastic $1,106,164 0.8% 5,387 4,824 0.2%
20 L3020 Foot longitud/metatarsal sup $1,083,864 0.8% 12,916 5,906 0.3%
Note L4387 is Not Within the Top 20 for DPM It is @ #33 #9 and 18 are reversed in frequency? Do these trouble you?
*Regional Therapeutic Shoe DPM Statistics 2017
Almost all Regions saw a decrease in claim submission for each HCPCS. Most saw increase in approvals. What Does This Tell You?
1 A5500 Diab shoe for density insert A $7,714,222 109,234 120,937 $64 $1,118 16 18 $1,373 19 22 6,898,181 5,619
1 A5500 Diab shoe for density insert B $6,865,310 97,185 107,014 $64 $1,160 16 18 $1,963 28 31 5,920,474 3,498
1 A5500 Diab shoe for density insert C $6,507,034 92,160 101,245 $64 $540 8 8 $1,340 19 21 12,051,826 4,857
1 A5500 Diab shoe for density insert D $2,990,925 42,351 48,621 $62 $402 6 7 $740 10 12 7,438,841 4,042
29 A5501 Diabetic custom molded shoe A $92,291 452 495 $186 $13 0 0 $16 0 0 6,898,181 5,619
29 A5501 Diabetic custom molded shoe B $34,170 179 258 $132 $6 0 0 $10 0 0 5,920,474 3,498
29 A5501 Diabetic custom molded shoe C $164,160 775 877 $187 $14 0 0 $34 0 0 12,051,826 4,857
29 A5501 Diabetic custom molded shoe D $25,863 127 169 $153 $3 0 0 $6 0 0 7,438,841 4,042
3 A5512 Multi den insert direct form A $5,456,065 189,379 208,008 $26 $791 27 30 $971 34 37 6,898,181 5,619
3 A5512 Multi den insert direct form B $4,668,454 161,959 177,615 $26 $789 27 30 $1,335 46 51 5,920,474 3,498
3 A5512 Multi den insert direct form C $4,331,544 150,311 164,668 $26 $359 12 14 $892 31 34 12,051,826 4,857
3 A5512 Multi den insert direct form D $1,880,159 65,394 74,370 $25 $253 9 10 $465 16 18 7,438,841 4,042
2 A5513 Multi den insert custom mold A $5,294,815 123,391 137,108 $39 $768 18 20 $942 22 24 6,898,181 5,619
2 A5513 Multi den insert custom mold B $5,169,727 120,594 131,496 $39 $873 20 22 $1,478 34 38 5,920,474 3,498
2 A5513 Multi den insert custom mold C $5,112,373 119,037 129,313 $40 $424 10 11 $1,053 25 27 12,051,826 4,857
2 A5513 Multi den insert custom mold D $2,473,016 57,546 64,767 $38 $332 8 9 $612 14 16 7,438,841 4,042
A5500 Statistics
A5500 Approvals: Region A 90% ; 91 Region B; 91% Region C; 87% Region D Almost all Regions saw increases (Region D had a 6% Increase from 2016)
Table 14E: 2017 Medicare Part B, Top 50* DME and HCPCS Level II Codes
Data for Podiatry Listed by Ascending HCPCS by DME Regional Carrier
*(top 50 ranking based on 2017 allowed charges for podiatry speciatly category)
(Beneficiary source: CMS 2016 Medicare Enrollment Statistics (non-HMO). DPM count source: APMA database, August 2018.)
Avg Alwd Chrg Sub Freq Alwd Freq Region
Chrg DME Allowed Submitted Allowed Alwd per 1000 per 1000 per 1000 Alwd Chrg Sub Freq Alwd Freq Part B Region
Rank HCPCS APMA Short Descriptor Region Charges Frequency Frequency Chrg Benes Benes Benes per DPM per DPM per DPM Enrollees DPMs
1 A5500 Diab shoe for density insert A $7,714,222 109,234 120,937 $64 $1,118 16 18 $1,373 19 22 6,898,181 5,619
1 A5500 Diab shoe for density insert B $6,865,310 97,185 107,014 $64 $1,160 16 18 $1,963 28 31 5,920,474 3,498
1 A5500 Diab shoe for density insert C $6,507,034 92,160 101,245 $64 $540 8 8 $1,340 19 21 12,051,826 4,857
1 A5500 Diab shoe for density insert D $2,990,925 42,351 48,621 $62 $402 6 7 $740 10 12 7,438,841 4,042
A5513 Billing
91% DPM Claims Approved 93% Total Supplier Claims Approved
This is an increase for both from 2016
Rank = 44 A5513 Multi den insert custom mold
% of % of Allowed Total Submitted Allowed Total
SPECIALTY Charges Alw Chg Frequency Frequency Alw Frq All Speciaties $51,064,971 100% 1,289,740 1,189,236 100% Podiatry $18,049,931 35% 462,684 420,568 35% Individual Certified Orthotist $6,241,904 12% 156,354 145,035 12% Medical Supply Company Not Included In 51, 52, Or 53 $5,749,140 11% 145,185 134,082 11% Medical Supply Company With Certified Prosthetist-Orthotist $4,359,213 9% 108,833 101,322 9% Individual Certified Prosthetist $3,865,314 8% 96,281 89,755 8% Pharmacy $3,353,095 7% 84,117 78,954 7% Medical Supply Company with Pedorthic Personnel $2,619,789 5% 64,337 60,845 5% Individual Certified Prosthetist-Orthotist $1,350,224 3% 34,069 31,376 3% Medical Supply Company With Certified Orthotist $1,060,931 2% 26,968 24,706 2%
2 A5513 Multi den insert custom mold A $5,294,815 123,391 137,108 $39 $768 18 20 $942 22 24 6,898,181 5,619 2 A5513 Multi den insert custom mold B $5,169,727 120,594 131,496 $39 $873 20 22 $1,478 34 38 5,920,474 3,498 2 A5513 Multi den insert custom mold C $5,112,373 119,037 129,313 $40 $424 10 11 $1,053 25 27 12,051,826 4,857 2 A5513 Multi den insert custom mold D $2,473,016 57,546 64,767 $38 $332 8 9 $612 14 16 7,438,841 4,042
Table 14E: 2017 Medicare Part B, Top 50* DME and HCPCS Level II Codes
Data for Podiatry Listed by Ascending HCPCS by DME Regional Carrier
*(top 50 ranking based on 2017 allowed charges for podiatry speciatly category)
(Beneficiary source: CMS 2016 Medicare Enrollment Statistics (non-HMO). DPM count source: APMA database, August 2018.)
Region A: 90% Region B: 92% Region C: 92% Region D: 89%
A5512 Billing
DPM: 91% of claims approved 92% total approved
A5512 Multi den insert direct form
% of % of Avg Allowed Total Submitted Allowed Total Alwd
SPECIALTY Charges Alw Chg
Frequency Frequency Alw Frq
Chrg
TOTAL $45,012,883 100.0% 1,701,179 1,564,125 100.0% $29
Podiatry $16,336,221 36.3% 624,661 567,043 36.3% $29 Medical Supply Company Not Included In 51, 52, Or 53 $10,392,969 23.1% 389,959 360,836 23.1% $29 Pharmacy $5,866,464 13.0% 219,914 204,921 13.1% $29 Individual Certified Orthotist $2,147,828 4.8% 80,865 74,483 4.8% $29 Medical Supply Company with Pedorthic Personnel $2,040,857 4.5% 75,787 70,766 4.5% $29 Medical Supply Company With Certified Orthotist $1,957,608 4.3% 73,487 67,967 4.3% $29 Medical Supply Company With Certified Prosthetist-Orthotist $1,616,021 3.6% 59,887 56,102 3.6% $29 Pedorthic Personnel $1,086,143 2.4% 39,911 37,726 2.4% $29 Individual Certified Prosthetist $958,622 2.1% 35,978 33,224 2.1% $29
Table 14E: 2017 Medicare Part B, Top 50* DME and HCPCS Level II Codes
Data for Podiatry Listed by Ascending HCPCS by DME Regional Carrier
*(top 50 ranking based on 2017 allowed charges for podiatry speciatly category)
(Beneficiary source: CMS 2016 Medicare Enrollment Statistics (non-HMO). DPM count source: APMA database, August 2018.)
3 A5512 Multi den insert direct form A $5,456,065 189,379 208,008 $26 $791 27 30 $971
3 A5512 Multi den insert direct form B $4,668,454 161,959 177,615 $26 $789 27 30 $1,335
3 A5512 Multi den insert direct form C $4,331,544 150,311 164,668 $26 $359 12 14 $892
3 A5512 Multi den insert direct form D $1,880,159 65,394 74,370 $25 $253 9 10 $465
Avg Alwd Chrg Sub Freq Alwd Freq Chrg DME Allowed Submitted Allowed Alwd per 1000 per 1000 per 1000 Alwd Chrg Rank HCPCS APMA Short Descriptor Region Charges Frequency Frequency Chrg Benes Benes Benes per DPM
Pre Payment Audit Top Reasons for Rejection Nothing Has Changed Since 2018!
• 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”
• Document Issues with Present Footwear • Proper/Incorrect Sizing • Size The Patient (Length and Width) • Medical Necessity for Therapeutic Footwear
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
“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
PDAC Requirements for Therapeutic Shoe Codes
• A5500 Optional for PDAC Approval • A5512: Mandatory PDAC Approval • A5513/A5514: Mandatory if you are not the mfg.
• You Must Ask Your Vendor if the Product has a PDAC
Stamp of Approval and • You Must Know if the Custom Device is • Custom Molded (A5513) or Custom Milled (A5514)
Other Medicare DME Audits
* 4 L4360 Pneumat walking boot pre cst A $1,119,981 4,081 4,623 $242 $162 1 1 $199 1 1 6,898,181 5,619
4 L4360 Pneumat walking boot pre cst B $1,637,505 6,585 7,417 $221 $277 1 1 $468 2 2 5,920,474 3,498
4 L4360 Pneumat walking boot pre cst C $3,484,125 13,456 14,726 $237 $289 1 1 $717 3 3 12,051,826 4,857 4 L4360 Pneumat walking boot pre cst D $735,386 2,572 3,144 $234 $99 0 0 $182 1 1 7,438,841 4,042 8 L4361 Pneuma/vac walk boot pre ots A $2,178,291 7,859 8,650 $252 $316 1 1 $388 1 2 6,898,181 5,619 8 L4361 Pneuma/vac walk boot pre ots B $1,285,445 5,159 5,638 $228 $217 1 1 $367 1 2 5,920,474 3,498 8 L4361 Pneuma/vac walk boot pre ots C $3,522,156 13,508 14,817 $238 $292 1 1 $725 3 3 12,051,826 4,857 8 L4361 Pneuma/vac walk boot pre ots D $2,768,466 9,781 10,796 $256 $372 1 1 $685 2 3 7,438,841 4,042
Table 14E: 2017 Medicare Part B, Top 50* DME and HCPCS Level II Codes Data for Podiatry Listed by Ascending HCPCS by DME Regional Carrier
*(top 50 ranking based on 2017 allowed charges for podiatry speciatly category)
(Beneficiary source: CMS 2016 Medicare Enrollment Statistics (non-HMO). DPM count source: APMA database, August 2018.)
Why are these rank numbers flipped?
Mirrored Codes
• 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
• If a patient has had a “similar” device within a 5 year period, then the “new” or “similar” device will be rejected.
• Provider Portal Issues • LCD Issues • Changes on the Horizon
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
Same or Similar Table
• Crutches & Canes • E0100, E0105, E0110, E0111, E0112, E0113,
E0114, E0116
• Therapeutic Shoes: • A5500 A5501
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 TFA Each Time You Log In • Provides Eligibility, Claims & Payment Info. • Can Submit Appeals With Attachments • Provides Information on Same & Similar
Issues with Provider Portals
• Some NMBI Do Not Work for Same/Similar • Noridian & My CGS Do Not Cross Reference With Each Other
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/same-
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
• As Reported Last Year 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
Custom Foot Orthotics
L30XX to MCR by DPM
10 L3000 Ft insert ucb berkeley shell $4,018,613 50,297 14,690 $274 $124 2 0 $223 3 1
49 L3002 Foot insert plastazote or eq $64,044 1,051 589 $109 $2 0 0 $4 0 0
35 L3010 Foot longitudinal arch suppo $194,258 2,851 1,218 $159 $6 0 0 $11 0 0
20 L3020 Foot longitud/metatarsal sup $1,083,864 12,916 5,906 $184 $33 0 0 $60 1 0
43 L3030 Foot arch support remov prem $101,792 3,856 1,438 $71 $3 0 0 $6 0 0
48 L3040 Ft arch suprt premold longit $66,731 2,930 1,676 $40 $2 0 0 $4 0 0
44 L3060 Foot arch supp longitud/meta $97,164 3,114 1,656 $59 $3 0 0 $5 0 0
Avg Alwd Chrg Sub Freq Alwd Freq
Chrg Allowed Submitted Allowed Alwd per 1000 per 1000 per 1000 Alwd Chrg Sub Freq Alwd Freq
Rank HCPCS APMA Short Descriptor Charges Frequency Frequency Chrg Benes Benes Benes per DPM per DPM per DPM
Despite Warnings DPMs Continue to Bill MCR for L3000-L3060
Medicare KX Rarely Used for CFO Multiple DPM’s Have Paid Back $100K’s
$ Allowed Approved Submitted
10 L3000 Ft insert ucb berkeley shell A $1,614,663 5,720 28,070 10 L3000 Ft insert ucb berkeley shell B $760,412 2,896 8,160 10 L3000 Ft insert ucb berkeley shell C $1,414,296 5,003 10,687 10 L3000 Ft insert ucb berkeley shell D $1,264,758 4,738 9,563 49 L3002 Foot insert plastazote or eq A $15,636 139 590 49 L3002 Foot insert plastazote or eq B $23,047 167 232 49 L3002 Foot insert plastazote or eq C $20,630 157 181 49 L3002 Foot insert plastazote or eq D $10,244 156 274 35 L3010 Foot longitudinal arch suppo A $20,319 126 533 35 L3010 Foot longitudinal arch suppo B $44,083 267 386 35 L3010 Foot longitudinal arch suppo C $81,778 503 733 35 L3010 Foot longitudinal arch suppo D $11,763 148 303 20 L3020 Foot longitud/metatarsal sup A $208,579 1,135 2,738 20 L3020 Foot longitud/metatarsal sup B $190,316 1,042 2,412 20 L3020 Foot longitud/metatarsal sup C $309,931 1,634 3,167 20 L3020 Foot longitud/metatarsal sup D $287,521 1,637 2,689 43 L3030 Foot arch support remov prem A $41,432 580 1,484 43 L3030 Foot arch support remov prem B $32,847 450 560 43 L3030 Foot arch support remov prem C $26,741 372 487 43 L3030 Foot arch support remov prem D $21,398 299 478 48 L3040 Ft arch suprt premold longit A $17,846 425 761 48 L3040 Ft arch suprt premold longit B $11,353 267 358 48 L3040 Ft arch suprt premold longit C $11,220 260 413 48 L3040 Ft arch suprt premold longit D $30,870 729 1,081 44 L3060 Foot arch supp longitud/meta A $21,154 311 964 44 L3060 Foot arch supp longitud/meta B $11,912 176 441 44 L3060 Foot arch supp longitud/meta C $13,645 271 496 44 L3060 Foot arch supp longitud/meta D $45,723 784 1,021
What’s the Big Deal on Billing CFO to MCR?
False Claims Act $5M x 22K/Claim=
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
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?
Tricare Military Health Insurance Fixed
• DPM’s Currently May Rx DME • DPM’s May Dispense On Own Order or From
another HCP (e.g. MD/DO/DPM)
*Tricare
West North
South
West
North=Health Net (www.hnfs.com) North and South Merge to East Contract Awarded to Humana 1-877-TRICARE (1-877-874-2273) South=Humana Military (www.HumanaMilitary.com Claims Processed by WPS 1-800-444-5445
West=UHC Military www.uhcmilitarywest.com West Contract Awarded to Health Net 1-877-988-WEST (1-877-988-9378) PGBA PGBA claims processor www.mytricare.com
Before 1/1/18
Previous to 1/1/18
Non Medicare Dispensing Prior to Surgery
• Check Your LCD • Obtain P/A
Other Interesting DME BMAD
Do They Concern You?
32 L2112 Afo tibial fracture soft A $41,190 87 97 $425 32 L2112 Afo tibial fracture soft B $44,887 94 103 $436 32 L2112 Afo tibial fracture soft C $51,797 110 138 $375 32 L2112 Afo tibial fracture soft D $50,219 100 102 $492 25 L2114 Afo tib fx semi-rigid A $88,831 159 175 $508 25 L2114 Afo tib fx semi-rigid B $48,617 81 89 $546 25 L2114 Afo tib fx semi-rigid C $217,056 412 519 $418 25 L2114 Afo tib fx semi-rigid D $44,369 95 102 $435 24 L2116 Afo tibial fracture rigid A $55,370 80 87 $636 24 L2116 Afo tibial fracture rigid B $32,478 47 47 $691 24 L2116 Afo tibial fracture rigid C $286,113 462 474 $604 24 L2116 Afo tibial fracture rigid D $22,280 46 57 $391
Table 14E: 2017 Medicare Part B, Top 50* DME and HCPCS Level II Codes Data for Podiatry Listed by Ascending HCPCS by DME Regional Carrier
*(top 50 ranking based on 2017 allowed charges for podiatry speciatly category) (Beneficiary source: CMS 2016 Medicare Enrollment Statistics (non-HMO). DPM count source: APMA database, August 2018.)
Avg Chrg DME Allowed Submitted Allowed Alwd Rank HCPCS APMA Short Descriptor Region Charges Frequency Frequency Chrg
$950K X $ False Claim Penalty = Mega $Millions
Thank You
Questions??
