Billing and Receiving Reimbursement for DME in Orthopaedics

1. Billing and Receiving Reimbursement for DME in Orthopaedics Lynn M. Anderanin, CPC,CPMA, CPC-I,CPPM, COSC 1

2. Agenda • Current CMS information • Current OIG Work Plan for DME • Documentation guidelines • Assigning the HCPCS code • Determining the charge • Insurance compliance • Inventory management • Replacements and returns • Resources 2

3. Stark Law • Prohibits healthcare providers from referring to or providing certain services in facilities they operate/own. • Exceptions: canes, crutches, walkers, and orthotics (L codes) • Wheelchairs and scooters are not permitted 3

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5. Article Changes November, 2017 • Documentation must be maintained in the supplier's files for seven (7) years from DOS 5

6. 2018 OIG Work Plan • https://oig.hhs.gov/reports-and- publications/workplan/active-item-table.asp 6

7. 2018 OIG Work Plan • Since 2014, claims for three off-the-shelf orthotic devices (L0648, L0650, and L1833) have grown by 97 percent and allowed charges have grown by 116 percent, reaching $349 million in 2016. • A Medicare Administrative Contractor (MAC) has identified improper payment rates as high as 79 percent for L0648, 88 percent for L0650, and 91 percent for L1833 within its jurisdiction. 7

8. 2018 OIG Work Plan • A top concern of the MAC is a lack of documentation of medical necessity in patients' medical records. • Specifically, they will evaluate the extent to which Medicare beneficiaries are being supplied these orthotic devices without an encounter with the referring physician within 12 months prior to their orthotic claim. 8

9. CMS Program Integrity Manual Chapter 5 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/pim8 3c05.pdf ‒ DME Documentation requirements –Physician order –Signed medical necessity statement –Chart documentation requirements –Proof of Delivery 9

10. ORDERS  Ordering/referring physician must be a Medicare enrolled physician  Must be identified on claim 1/6/14  Chiropractor not eligible  Name must match what stored in PECOS • Denied CO-16 claim lacks information o N264 missing/incomplete/invalid ordering provider name o N575 mismatch between submitted ordering/referring provider name & records  Include NPI and match what stored in PECOS • Denied CO-16 claim lacks information o N265 missing/incomplete/invalid ordering provider name o N276 mismatch between submitted ordering/referring provider name & records 10

11. DETAILED WRITTEN ORDERS  Detailed written order  Written=original, fax or electronic  Must be signed and dated by ordering physician before item billed  Name of the beneficiary  Diagnosis  Detailed description of all items provided including quantity and frequency of use when applicable  Length of need for accessories/supplies  Legible physician signature and signature date  If for an item already dispensed, must clearly indicate the start date 11

12. Medical Necessity Statement • Must be signed by the ordering physician before dispensing or billing the item “I certify that the above prescribed items, its setup and related patient education are medically indicated in my opinion both reasonable and necessary to the accepted standards of medicine of this patient’s condition” 12