2.Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered by the Division of Health Care Financing and Policy (DHCFP) and Nevada Check Up (NCU) for eligible recipients. CMS published specific “conditions for payment” for power mobility devices (PMDs), such as power wheelchairs and power-operated vehicles or scooters. Applications are available at the American Dental Association web site, http://www.ADA.org. This article discusses these issues further. Suppliers need to recognize that receiving Medicare payment depends on their obtaining and retaining sufficient documentation to establish the medical necessity of claimed items and services. Medicare will review the information to make sure that you’re eligible and meet all requirements for the item. This includes items such as CPT codes, CDT codes, ICD-10 and other UB-04 codes. The Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.3, “Third-Party Additional Documentation Request” states: The treating physician, another clinician, provider, or supplier should submit the requested. [11]. Suppliers also need to be cognizant of the current political environment regarding health care reform. [23]. CPT is a trademark of the AMA. The U.S. Department of Justice, on behalf of CMS, then filed an appeal and asked the Court of Appeals for the Fourth Circuit to reverse the district court’s decision. The ADA does not directly or indirectly practice medicine or dispense dental services. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. OIG Semi-Annual Report, April 1, 2008 – Sept. 30, 2008, issued Dec. 3, 2008, available at www.oig.hhs.gov/publicatoins/doc/semiannual/2008/semiannual_fall2008. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) There must be information in the patient’s medical record that supports the medical necessity for the claimed items and substantiates the answers of the CMN (if applicable). You acknowledge that the AMA holds all copyright, trademark, and other rights in CPT. LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT"). Applications are available at the AMA Web site, http://www.ama-assn.org/ama. 3. II. Home health recertification documentation. The appeals court reaffirmed the position previously expressed by the HHS Medicare Appeals Council that power wheelchairs and other DME furnished to beneficiaries and supported solely by a CMN, without supporting medical documentation, may be determined not medically reasonable and necessary and, therefore, not covered by Medicare.[15]. The judge concluded the Medicare program “cannot require that DME suppliers…obtain Medicare beneficiaries’ medical records and make a judgment as to whether the equipment is medically necessary and reasonable.”[9]. Further, upon request, a supplier must “submit additional documentation to CMS or its agents to support and/or substantiate the medical necessity of the power mobility device.”[18]. Two separate ALJ decisions were subsequently issued reversing both carrier overpayment assessments. [1]. Please click here to see all U.S. Government Rights Provisions. © 2021 Noridian Healthcare Solutions, LLC Terms & Privacy. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. Based on its legal conclusion, the Court enjoined Medicare’s recovery of the two overpayments. if(pathArray[4]){document.getElementById("usprov").href="/web/"+pathArray[4]+"/help/us-government-rights";} Documentation is required for every treatment day and every therapy service. The CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. 2. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. 6 Definitions of blue words are on pages 18–19. Without understanding and following documentation requirements, You’re putting your office at risk to fail an audit. See Gulfcoast Medical Supply, Inc. v. Secretary, Department of Health and Human Services, 468 F.3d 1347 (11 Cir. Occupational License(s) HME License(s) Oxygen Permit(s) / Retailer and Wholesalers License / Permit . Suppliers are reminded to review the Local Coverage Determination (LCD) and Policy Article for specific documentation guidelines. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. AFTER: A separate statement is not needed. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable … [21]. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. The ADA is a third-party beneficiary to this Agreement. End Users do not act for or on behalf of the CMS. It is mandatory to procure user consent prior to running these cookies on your website. This website uses cookies to improve your experience while you navigate through the website. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. 5911 Kingstowne Village Parkway Three courts of appeals have now affirmed the principle that supporting medical documentation, in addition to a CMN, may be required to establish Medicare coverage.[23]. Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. AMA Disclaimer of Warranties and Liabilities This documentation must be retained by the supplier and furnished to CMS or a contractor upon request. var pathArray = url.split( '/' ); Effective June 5, 2006, the following requirements were imposed: The regulations state that a supplier “may not dispense a PMD to a beneficiary until the PMD prescription and the supporting documentation have been received the physician or treating practitioner who performed the face-to-face examination of the beneficiary.”[17]. ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. Enforcement of Medicare’s documentation requirements has become more stringent, and it’s affecting healthcare professionals and patients. Applicable Regulations § 2600.141(a)(1) - A resident shall have a medical evaluation by a physician, physician's assistant or certified registered nurse practitioner documented on a form specified by the Department, within 60 days prior to admission or within 30 days after admission. View documentation checklists created to help suppliers ensure all applicable documentation is readily available as part of Medicare claims payment and processing activities. AHA copyrighted materials including the UB-04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. Cal. 4. No fee schedules, basic unit, relative values or related listings are included in CDT. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. The OIG issued a report in August 2008 regarding an audit of CMS’ medical review of DME claims paid by Medicare in fiscal year 2006. The U.S. Supreme Court’s denial of review in the Maximum Comfort case resolves the legal debate about whether a CMN may be the sole basis for determining Medicare coverage and payment of expensive DME. “CMS Enhances Program Intgrity Efforts To Fight Fraud, Waste and Abuse in Medicare,” Oct. 6, 2008,available at http://www.cms.hhs.gov/apps/media,press/release.asp?Counter=3291&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. ... in collaboration with the Jurisdiction C Durable Medicare Equipment Medicare Administrative Contractor (DME MAC), is providing information concerning required documentation for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). quantity; • On a regular basis (even if there is no change in the order/prescription) only if it is so specified in … In other words, almost 30 percent of the DME claims reviewed were erroneously paid by the Medicare program. The information in the medical records should include the patient’s diagnosis and other pertinent information, including duration of the condition, clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and past experience with related items. [25]. The use of the information system establishes user's consent to any and all monitoring and recording of their activities. The Court also noted that appeals courts in two other circuits had decided in a similar fashion that the statute does not preclude the Medicare program from requiring additional documentation, beyond the CMN, to establish the medical necessity of claimed DME. • Physician/practitioner exam per current DME Manual’s requirements. Suite 300 Samoa, Guam, N. Mariana Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY. These cookies do not store any personal information. You also have the option to opt-out of these cookies. 5, §5.7, Feb 3, 2008; effective March 1, 2008, available at www.cms.hhs.gov/manuals. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. Durable Medical Equipment billing continues to scrutinized by Medicare and other Commercial Carriers, so everyone needs to understand DME Documentation Requirements. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. BEFORE: Physicians needed to include a separate statement about how much longer home health services would be needed as part of the home health recertification. For DME to be covered by Medicare, the medical records must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items claimed. Standard Documentation Checklists. Joint DME MAC Publication. CMS DISCLAIMER. 7.0 Medical Treatment Billing and Payment Requirements for Electronically Submitted ….. “CMS” means the Centers for Medicare and Medicaid Services of the U.S. …. Without supporting medical records, suppliers run the risk of having their claims for payment denied or delayed pending the submission of additional documentation. To obtain comprehensive knowledge about the UB-04 codes, the Official UB-04 Data Specification Manual is available for purchase at http://www.ahaonlinestore.org. Determine if the clients receive power wheelchairs as prescribed. Social Security Act §1862(a)(1)(A). 2004). Alexandria, VA 22315. To license the electronic data file of UB-04 Data Specifications, contact AHA at (312) 893-6816. Understanding Documentation Requirements: •Goal: o Gain a better understanding of the documentation requirements for the Medicare Therapeutic Shoe Program. The Council also has applied the positions set forth in its Maximum Comfort decision in other cases. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose. All rights reserved. It should be noted that without meeting the payer requirements, the claim will be denied. Providers should submit adequate documentation to ensure that claims are supported as billed. The Council also determined that the supplier had sufficient notice that the items would not be covered without additional medical documentation and, therefore, was liable for the overpayment assessments.[7]. $50 Million Anti-Kickback and Stark Law Settlement, OIG 2019 Report on Fraud Actions and Recoveries. Health Lawyers Weekly, Vol. This site uses cookies and other tracking technologies to assist with navigation and your ability to provide feedback, analyze your use of our products and services, assist with our promotional and marketing efforts, and provide content from third parties. www.aappm.org According to the Council, no legal support exists for the supplier’s proposition “that the primary purpose of the CMN is to eliminate the need for any supporting medical documentation to establish medical necessity.”[6]. Beneficiary Authorization - A request for payment signed by the beneficiary must be filed on or with each claim for charge basis reimbursement except in certain situations.. VI, Issue 39, Oct. 10, 2008.Other equipment to receive heightened review include continuous positive airway pressure devices(CPAP), oxygen equipment, glucose monitors, and test strips. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. [22]. However, because the … The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. On November 12, 2008, Senator Max Baucus, Chairman of the Senate Finance Committee, issued a “health care reform blueprint” that includes five principles for “preventing [health care] fraud, waste, and abuse before they happen, and aggressively detecting them when prevention fails.”[25]. These checklists include the documentation required for payment and retention of that payment in the event of a review by entities looking at documentation today and in the future. else{document.getElementById("usprov").href="/web/"+"jeb"+"/help/us-government-rights";}, ACA: Face-to-Face and Detailed Written Order, Advance Beneficiary Notice of Noncoverage (ABN), Oral Anticancer Drugs and Oral Antiemetic Drugs, Transcutaneous Electrical Nerve Stimulators (TENS), Non-Medical Record Review Notifications and Results, Supplemental Medical Review Contractor (SMRC), Unified Program Integrity Contractor (UPIC), Provider Outreach and Education Advisory Group (POE AG), Common Electronic Data Interchange (CEDI), CR9968 CURES Act Fee Schedule Adjustments, Healthcare Integrated General Ledger Accounting System (HIGLAS), General Documentation Requirements Checklist - Printable Version, Power Wheelchair: Group 1 and 2 No Power Option and Custom, Power Wheelchair: Group 2 Single/Multiple Power Options, Power Wheelchair: Group 3 Single/Multiple Power Options, Power Wheelchair: Group 3 No Power Options, Respiratory Assist Devices - E0470 and E0471, click here to see all U.S. Government Rights Provisions. The Medicare Appeals Council concluded that the supplier had claimed Medicare payment with only a CMN as support, so the equipment was not covered by Medicare. The responsibility for the content of this file/product is with Noridian Healthcare Solutions or the CMS and no endorsement by the AMA is intended or implied. 7500 Security Boulevard, Baltimore, MD 21244 opens in new window opens in new window opens in new window This category only includes cookies that ensures basic functionalities and security features of the website. Based on its review of a sample of DME claims, the OIG estimated that the Medicare payment error rate was 28.9 percent. LICENSE FOR USE OF PHYSICIANS’ CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT”) End User Point and Click Amendment: CPT codes, descriptions and other data only are copyright 2020 American Medical Association. 1. 100-08,Chap. If the entry immediately above or below the entry is dated, MR may reasonably assume the date of the entry in question. Medicare such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required. This system is provided for Government authorized use only. This license will terminate upon notice to you if you violate the terms of this license. Coincidentally, on the same day, the Centers for Medicare & Medicaid Services (CMS) announced that it was “enhanc[ing] program integrity efforts to fight fraud, waste and abuse in Medicare.”[1]. Dissatisfied with the ALJ decisions, CMS asked the U.S. Department of Health and Human Services’ (HHS) Medicare Appeals Council to undertake an “own motion” review. You may also contact AHA at ub04@healthforum.com. 2007). Visit our sister company Compliance Resource Center for custom tools and services, designed to meet your compliance program needs. the bill, then a header … Unauthorized or improper use of this system is prohibited and may result in disciplinary action and/or civil and criminal penalties. On January 1, 2020, new rules took effect governing written orders for all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). In 1996, CMS revised the regulations governing Medicare coverage and payment for DME. If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. This field is for validation purposes and should be left unchanged. Medicare Program Integrity Manual, Pub. var url = document.URL; A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. Rejection of the appeal means that documentation of medical necessity, in addition to a certificate of medical necessity (CMN), may be required to substantiate a supplier’s claim for Medicare coverage and payment. ; Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) All items billed to Medicare require a prescription from the treating practitioner as a condition of payment. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Medicare documentation requirements for home enteral therapy A written confirmation of a verbal order is required for home enteral therapy. General Documentation Requirements Checklist - Printable Version [PDF], Last Updated Tue, 05 Jan 2021 16:04:53 +0000. This booklet explains Original Medicare coverage of DME and what you might need to pay. The Medicare Program Integrity Manual was revised, effective March 1, 2008, and now provides: The HHS Office of Inspector General (OIG) has identified ongoing problems with Medicare payment of DME claims. • Medical documentation supporting the need. PLEASE CHECK AND SUBMIT COPIES OF THE FOLLOWING . CMS Disclaimer To ensure that correct payment is made for items and services provided to Medicare beneficiaries, the need for detailed medical documentation is paramount. Reimbursement may be made for expenses incurred by a patient for the rental or purchase of durable medical equipment (DME) for use in his/her home. 2014-12-01. Medical Records Documentation Title. A physician or treating practitioner must conduct a face-to-face examination of the beneficiary for the purpose of determining the medical necessity of a PMD as part of the overall treatment plan. Paid for by the Department of Health & Human Services. The legal principles involved in this case were reviewed at numerous levels prior to the Supreme Court’s denial of the appeal. CDT is a trademark of the ADA. These materials contain Current Dental Terminology, (CDT), copyright © 2020 American Dental Association (ADA). *DME must be for use in patient's residence other than a health care institution. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare and Medicaid Services (CMS). • If requesting for a member under 21 years old must address growth potential of item(s) requested. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. The carrier then extrapolated its sample findings to the universe of the supplier’s claims, assessing an overpayment of $548,555 in the first audit and an overpayment of $237,229 in the second audit. Therefore, Maximum Comfort remained liable for the assessed overpayments. Paper Claim: Submit a copy of the completed CMN or DIF with the paper claim. But opting out of some of these cookies may have an effect on your browsing experience. General Documentation Requirements Checklist - Printable Version [PDF] CPT codes, descriptions and other data only are copyright 2002-2020 American Medical Association (AMA). General Documentation Requirements apply to all DMEPOS categories.