Last issue (Issue 11.5-September/October 2016), we began this article on DME; this is the second and final installment.
I am including the Table (Table C) referenced in the first part to show the Cross-Walk. You will notice that HCPCS code L0631 cross-walked to L0648 and L0631.
- Therefore, the code that was being billed, L0631, became the code for the back brace orthotic that required "fitting to a specific patient by an individual with expertise."
- Code L0648 became the new code for a back brace OTS that requires "minimal self-adjustment."
In the ZPIC audit referred to part I, one deficiency cited by ZPIC auditors was the incorrect use of the L0631 code. The documentation submitted by the practice did not contain the required wording to indicate that the brace was "fitted and adjusted" to the patient as they continued to incorrectly use the code that they had been billing for these braces prior to 01/01/2014, which were intended to represent prefabricated Off-the-Shelf back braces that required only "minimal self-adjustment by the patient."
The back braces billed after January 1, 2014, however, were taken from inventory
on hand at the practice and the labels still had the L0631 code on them.
This fact contributed to the incorrect assignment of code L0631 after that
date for a code that now required fitting and adjustment to the patient.
Now, mind you, if you look up the allowable for both L0631 and L0648 (in
my locale, at least), they are the same! Therefore, using an incorrect code
did not cost the federal government financially. However, the practice referred
to in this article filed a Redetermination and was not successful in getting
this point of confusion across, and as a result, Health Integrity determined
the appeal unfavorable.
There were other items, however, that impacted the Redetermination decision. After you have a chance to look at the table below, I will point out very important details that you must have in your documentation to successfully withstand an audit.
What is required to document in the Medical Record for these items in
order to prevent denial due to Medical Necessity?
Failure to follow LCD guidelines can indicate the reason for denial and
recoupment.
The tips below may help to ensure that you prevent an unfavorable audit result
for your practice/clinic.
1. Read and understand all specific LCD requirements. When
they mention certain required items, they mean it. The LCD for each MAC Carrier
can be found on their respective websites and on the CMS website. Here is an
example of what it looks like when accessed on the CGS DME Carrier's website
at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33790&ContrID=140.
Local Coverage Determination (LCD):
Spinal Orthoses: TLSO and LSO (L33790)
LCD #L33790 has an original effective date for services on or after 10/01/2015
and a revision effective date for services performed on or after 07/01/2016.
2. Follow the coverage guidelines for establishing medical necessity
and make sure that the same wording is used in the documentation and required
forms when appropriate for each specific patient. Sharing this information
with your providers can help them understand what needs to be included in
the medical record for sufficient documentation.
Each LCD begins with the statement concerning General Coverage Guidance that
provides the basis for proper payment by the Medicare Administrative Contractor
(MAC) for your region.
It states:
For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of malformed
body member, and 3) meet all other applicable Medicare statutory and regulatory
requirements. For items addressed in this local coverage determination, the
criteria for "reasonable and necessary," is based on the Social Security Act
§ 1862(a) (1) (A) provisions, are defined by the following coverage indications,
limitations, and/or medical necessity.
3. Follow the specific guidelines in the documentation for the item(s)
covered in the LCD such as the following for spinal orthoses:
For spinal orthoses definitions of Off-The-Shelf (OTS), custom fitted and custom fabricated, see the related policy Article Coding Guidelines section.
A spinal orthosis (L0450-L0651) is covered when it is ordered for one of
the following indications:
-
To reduce pain by restricting mobility of the trunk; or
-
To facilitate healing following an injury to the spine or related soft
tissues; or
-
To facilitate healing following a surgical procedure on the spine or
related soft tissue; or
-
To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the
item will be denied as not medically necessary.
Note: Again, they are very serious when they make the above statement, and
in an audit situation, will repeat these statements back to you over and over.
Some physicians do not realize that when they sign the Medicare contract (or
any private carrier contract), they are attesting that they know the pertinent
coverage guidelines for services being billed and will follow them. They
may not understand the complexities that the billing specialists and/or the
coders have to understand and take into consideration (i.e., NCCI edits, the
quarterly changes that are made by insurance carriers, specific insurance
contract coverage guidelines and accepted codes) in order to obtain accurate
reimbursement.
I refer to these coverage requirements as the "magic words" to include in
the clinical documentation for the ordering of items and/or testing in the
physician's narrative.
4. Read and be very familiar with the CPT©, HCPCS, and ICD-10-CM
codes that you are billing on the federal claim form. For the codes
mentioned in the crosswalk as the most frequently used codes for back braces,
let's look at the specific code descriptions:
L0631 - Lumbar-sacral Orthosis, Sagittal Control, with Rigid Anterior and Posterior Panels Posterior Extends From Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, or Otherwise Customized To Fit a Specific Patient by an Individual with Expertise.
L0648 - Lumbar-sacral Orthosis, Sagittal Control with Rigid Anterior and
Posterior Panels, Posterior Extends from Sacrococcygeal Junction to T-9 Vertebra,
Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs,
Includes Straps, Closures, May Include Packing, Shoulder Straps, Pendulous
Abdomen Design, Prefabricated, Off-The-Shelf. (Note: this brace requires
"minimal self-adjustment.")
5. Know and share with your physicians and clinicians the specific
medical record and form requirements such as the following taken from this
LCD for Spinal Orthoses:
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 beneficiary's medical records will
reflect the need for the care provides...
Prescription (Order) Requirements: General - All items billed to Medicare
require a prescription. An order for each item billed must be signed and
dated by the treating physician, kept on file by the supplier, and made available
upon request. Items dispensed and/or billed that do not meet these prescription
requirements and those below must be submitted with an EY modifier added to
each affected HCPCS code.
(Note: When the LCD states "signed and dated by the treating physician,"
they are very serious about this clause. If it is not both signed and dated,
it will not be given credit as a medically necessary order upon audit.)
Dispensing Order(s): Equipment and supplies may be delivered upon receipt
of a dispensing order except for those items that require a written order
prior to delivery. A dispensing order may be verbal or written. The supplier
must keep a record of the dispensing order on file.
It must contain:
-
Description of the item
-
Beneficiary's name
-
Prescribing Physician's name
-
Date of the order and the start date (if the start date is different
from the date of the order)
-
Physician signature (if a written order) or supplier signature (if verbal
order)
For the date of the order described above, use the date the supplier is contacted
by the physician (for verbal orders) or the date entered by the physician
(for written dispensing orders). The dispensing order must be available upon
request. For items that are provided based on a dispensing order, the supplier
must obtain a detailed written order before submitting a claim.
Detailed Written Orders (DWO): A detailed written order is required before
billing. Someone other than the ordering physician may produce the DWO. However,
the order physician must review the content and sign and date the document.
It must contain:
-
Beneficiary's name
-
Physician's name
-
Date of the order and the start date, if start date is different from
the date of the order
-
Detailed description of the item(s) (see below for specific requirements
for selected item(s))
-
Physician signature and date
For items provided on a periodic basis, including drugs, the written
order must include:
-
Item(s) to be dispensed
-
Dosage or concentration, if applicable
-
Route of administration
-
Frequency of use
-
Duration of infusion, if applicable
-
Quantity to be dispensed
-
Number of refills, if applicable
Frequency of use information on orders must contain detailed instructions
for use and specific amounts to be dispensed. Reimbursement shall be based
on the specific utilization amount only. Orders that only state "PRN" or
"as needed" utilization estimates for replacement frequency, use, or consumption
are not acceptable.
The detailed description in the written order may be either a narrative description
or a brand name/model number.
Signature and date stamps are not allowed. Signatures must comply with the
CMS signature requirements outlined in the Program Integrity Manual (PMI)
3.3.2.4.
The DWO must be available upon request. A prescription is not considered
as part of the medical record. Medical information intended to demonstrate
compliance with coverage criteria may be included on the prescription but
must be corroborated by information contained in the medical record. (PIM
5.2.3).
Medical Record Information: General (PIM 5.7-5.9)
The Coverage Indications, Limitations and/or Medical Necessity section of
this LCD contains numerous reasonable and necessary (R&N) requirements. The
Non-Medical Necessity Coverage and Payment Rules section of the related Policy
Article contains numerous non-reasonable and necessary, benefit category and
statutory requirements that must be met in order for payment to be justified.
Suppliers are reminded that:
-
Supplier-produced records, even if signed by the ordering physician,
and attestation letters (e.g. letters of medical necessity) are deemed not
to be part of a medical record for Medicare payment purposes.
-
Templates and forms, including CMS Certificates of Medical Necessity
(CMN), are subject to corroboration with information in the medical record.
Information contained directly in the contemporaneous medical record is the
source required to justify payment except as noted elsewhere for prescriptions
and CMNs. The medical record is not limited to physician's office records
but may include records from hospitals, nursing facilities, home health agencies,
other healthcare professionals, etc. (not all-inclusive). Records from suppliers
or healthcare professionals with a financial interest in the claim outcome
are not considered sufficient by themselves for the purpose of determining
that an item is reasonable and necessary.
Proof of Delivery (PIM 4.26, 5.8): Proof of delivery (POD) is a supplier
standard and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
(DMEPOS) suppliers are required to maintain POD documentation in their files.
For medical review purposes, POD serves to assist in determining correct coding
and billing information for claims submitted for Medicare reimbursement.
Regardless of the method of delivery, the contractor must be able to determine
from delivery documentation that the supplier properly coded the item(s),
that the item(s) delivered are the same item(s) submitted for Medicare reimbursement
and that the item(s) are intended for, and received by, a specific Medicare
beneficiary.
Suppliers, their employees, or anyone else having a financial interest in
the delivery of the item are prohibited from signing and accepting an item
on behalf of a beneficiary (i.e. acting as a designee on behalf of the beneficiary).
The signature and date the beneficiary or designee accepted delivery must
be legible.
The LCD continues by giving very specific instructions and requirements for
each method of delivery.
6. Have written policies and procedures in place in order to ensure that
all processes are followed to ensure that each of these requirements are met
and continuously monitored for appropriate documentation, requirements of
the LCD, and for properly signed and dated documents.
Staff training and re-training on the procedures can potentially save your
physicians thousands of dollars if these records are audited.
In the issue of the January 2014 changes in the Spinal Orthoses codes, Medicare explains in the LCD that there is no physical difference between the two braces. The only difference is what is performed upon delivery.
Therefore, because the small group practice mentioned earlier continued to
use L0631 as a prefabricated OTS back brace which required minimal self-adjustment
for the patient and, due to the fact that the code description had changed
(not the brace, just the description), they had to repair hundreds of thousands
of dollars!
7. Finally, upon request of records from a ZPIC contractor, it is
extremely important that you contact an expert to direct you in the appropriate
steps to take before sending out the records. You need to be aware
of any supporting documentation that you can submit that could help your case.
If in doubt, it is wise to ask for some assistance because it you receive
an unfavorable decision, the process of appeal can be costly and lengthy.
Also remember to check private carrier coverage requirements, some of which
are less stringent than Medicare-while others follow Medicare guidelines.
Maxine Collins, MBA, CPA, CMC, CMOM, CMIS
Director of Compliance, Audit and Education
And
Shirley Kretz, COO, CMOM,
CoreMD Partners, LLC.