CBR201609: Diabetic Testing Supplies

Transcription

1 Stay Tuned for Webinar Audio dial-in: ; PIN: # For technical assistance, send to : Diabetic Testing Supplies 3:00 P.M. ET July 27, 2016

2 : Diabetic Testing Supplies July 27, :00 P.M. ET Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 2

3 The CBR project has made every reasonable effort to ensure the accuracy of the information and web links provided in the CBR materials at the time of publication; however, Medicare policy changes frequently, so the information and links within the material may change without further notice. It is the responsibility of the provider to remain up-to-date with Medicare Program requirements. 3

4 CBR materials are prepared as a service to the public and are not intended to grant rights or impose obligations. The information provided in the CBR material is only intended to be a general summary. It does not supersede or alter the coverage and documentation policies outlined in the Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) for the A/B Medicare Administrative Contractors (MAC) or DME Medicare Administrative Contractors (DME MAC). Please refer any specific questions you may have to the A/B or DME MAC for your region. We encourage providers to review the specific statutes, regulations, and other interpretive material for a full and accurate statement of their contents. 4

5 Webinar Outline 1. Introduction 2. Coverage & Documentation Overview 3. Methods & Results 4. References & Resources 5. Q&A 6. Survey 5

6 Webinar Protocol All attendee lines are muted Submit questions via chat when prompted by speaker Submit questions during the Q&A session at the end of webinar Ask questions pertinent to webinar Contact MAC for specific claims questions 6

7 Webinar Objective Upon completion of this webinar, you should be able to: Demonstrate a general understanding of : Diabetic Testing Supplies (DTS) Comprehend the analytical methods used to develop the report Locate policy references and resources 7

8 Sample CBR Provided for each topic: 8

9 CBR Purpose and Focus Peer comparison, check records against CMS data, review Medicare guidelines Percentage of beneficiaries with a KX modifier and those transitioning between KS and KX modifiers Average number of diabetic supplies per day per beneficiary by HCPCS code & KS/KX modifiers Average mileage between supplier and beneficiary and KL modifier use 12,000 DMEPOS suppliers 9

10 Webinar Materials References and Resources Webinar slides MP4 of webinar Webinar Handout Webinar Q&A Handout 10

11 Acronyms Code DMEPOS DTS DWO HCPCS OIG POD WOPD Description Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Diabetic Testing Supplies Detailed Written Order Healthcare Common Procedurel Coding System Office of Inspector General Proof of Delivery Written Order Prior to Delivery 11

12 Coverage & Documentation Overview Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 12

13 Topic Selection - OIG OIG Findings, In 2011, Medicare inappropriately allowed $6M for DTS claims w/o documented diagnosis $425M in Medicare claims (10% of DTS suppliers) had characteristics of questionable billing Suppliers in 10 geographic areas nationwide responsible for 77% of questionable billing Claims paid for beneficiaries who don t have a diagnosis of diabetes 13

14 Topic Selection - News Sun Sentinel: FBI raids medical-supply company in Boca Raton In 2013, a U.S. Senate Subcommittee on Financial and Contracting Oversight examined a sample of the company s Medicare claims after a whistleblower accused the company of fraud. 14

15 Topic Selection - MACs Medicare Minute: 39% of patients taking insulin test at least once per day 5-6% of patients not taking insulin test at least once per day 15

16 2014 CERT Results Procedure Code Total Dates of Service Total Errors Error Percentage A4253 A % A % A % Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 16

17 Prepayment Review Top Denial Reasons: Medical documentation not received Documentation does not support frequency of testing Documentation does not support beneficiary was evaluated by physician for additional supplies 17

18 Complex Review Results More Denial Reasons: Claims history shows some or all supplies have been paid for that time period Beneficiary log didn t corroborate testing frequency No POD or refill request Invalid/missing detailed written order 18

19 Documentation Compliance Top Denial Reasons: Documentation for supplies billed above normal usage was missing or invalid Untimely medical documentation No DWO, missing description/refill amounts No POD or signature on the POD 19

20 Competitive Bidding Mandated by Congress Intended to improve effectiveness and reduce expenditures for patients and Medicare Contracts awarded on supplier s eligibility, financial stability, and bid price Suppliers accept assignment Suppliers are contracted Only contract suppliers are reimbursed 20

21 Coverage Indicators Beneficiary must have diabetes diagnosis Beneficiary s physician has concluded that the beneficiary (or caregiver) has sufficient training using the particular device prescribed, as evidenced by providing a prescription for the appropriate supplies and frequency of blood glucose testing 21

22 Detailed Written Order (DWO) Beneficiary name Physician s name Start date of order Detailed description of the item(s) Physician s signature with date 22

23 Periodic Basis Dosage or concentration, if applicable Route of administration, if applicable Frequency of use/testing frequency, for test strips and lancets Duration of infusion, if applicable Quantity to be dispensed Number of refills 23

24 Proof of Delivery (POD) Is a supplier standard Must not be signed by anyone with a financial interest in the claim Serves to assist in determining correct coding and billing Must contain legible signature and date Must be kept on file for 7 years 24

25 Documentation Support medical necessity Meet basic coverage criteria Support testing frequency Not be supplier-produced 25

26 Modifiers KX Patient is insulin dependent KS Patient is non-insulin dependent KL Supplies are furnished mail order EY Indicates no DWO GA Indicates an ABN has been signed 26

27 Typical Utilization Beneficiary Type Insulin-treated diabetic Maximum Allowance (Every 3 months) 300 test strips and 300 lancets supporting testing 3 times/day Modifier KX Requirements of coverage have been met Non-insulin treated diabetic 100 test strips and 100 lancets supporting testing 1 time/day KS Glucose monitor supply for diabetic beneficiary not treated with insulin Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 27

28 High Utilization Must meet basic coverage criteria Must have been seen by treating physician within six months prior Must have documentation that patient is actually testing at frequency included in DWO 28

29 Medical Record Support Names, dosages, and timing of medications used to treat diabetes Frequency and severity of symptoms related to hyperglycemia and/or hypoglycemia Review of patient-maintained log of glucose testing values Changes in treatment regimen upon glucose testing results review Laboratory tests indicating level of glycemic control 29

30 Dispensing Refills Dispense maximum of 3-month supply Contact beneficiary/designee no sooner than 14 days prior to shipping date Deliver no sooner than 10 days before current products run out Do not auto-ship No more supplies than needed 30

31 Methods & Results Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 31

32 Report Data Medicare DMEPOS Suppliers By National Provider Identifier (NPI) HCPCS codes A4253 & A4259 Peer groups Used for comparison with individual suppliers 32

33 Peer Groups State: Medicare DMEPOS Suppliers in the Supplier s state HCPCS codes A4253 & A4259 National: All Medicare DMEPOS Suppliers in the nation HCPCS codes A4253 & A

34 Data Source CMS Integrated Data Repository (IDR) Extracted May 9, 2016 DOS: January 1, 2015 December 31,

35 Assumptions and Adjustments Covered Time Capped at 365 Days KS or KX Designation 35

36 Table 1 Table 1: HCPCS Codes, Abbreviated Descriptions, and Items per Unit HCPCS Code Abbreviated Description Items per Unit A4253 Blood Glucose Test Strips 50 A4259 Lancets 100 Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 36

37 Table 2 Table 2: Summary of Your Utilization January 1, 2015 December 31, 2015 HCPCS Code Modifier Allowed Charges Allowed Services Beneficiary Count Beneficiary- Days A4253 KS $1, ,805 A4253 KX $2, ,574 A4259 KS $ ,051 A4259 KX $ Subtotal KS $1, N/A Subtotal KX $2, N/A Total --- $4, N/A 37

38 Understanding Table 2 Table 2: Summary of Your Utilization January 1, 2015 December 31, 2015 HCPCS Code Modifier Allowed Charges Allowed Services Beneficiary Count Beneficiary - Days A4253 KS $1, ,805 A4253 KX $2, ,574 A4259 KS $ ,051 A4259 KX $ Subtotal KS $1, N/A Subtotal KX $2, N/A Total --- $4, N/A 38

39 Comparison Outcomes There are four possible outcomes: 1. Significantly Higher 2. Higher 3. Does Not Exceed 4. N/A 39

40 Percentage of Beneficiaries by Modifier Category Calculated as follows: 40

41 Table 3 Table 3: Percentage of Beneficiaries by Modifier Category January 1, 2015 December 31, 2015 Modifier Category Your Percentage of Beneficiaries Your State s Percentage of Beneficiaries Comparison with Your State s Percentage National Percentage of Beneficiaries Comparison with the National Percentage KS and KX 1% 11% Does Not Exceed 7% Does Not Exceed KX Only 45% 32% Significantly Higher 36% Higher A chi-square was used in this analysis, alpha =

42 Calculating Number of Beneficiaries by Modifier Category Table 2: Summary of Your Utilization January 1, 2015 December 31, 2015 HCPCS Code Modifier Allowed Charges Allowed Services Beneficiary Count Beneficiary- Days A4253 KS $1, ,805 A4253 KX $2, ,574 A4259 KS $ ,051 A4259 KX $ Subtotal KS $1, N/A Subtotal KX $2, N/A Total --- $4, N/A 42

43 Calculating Number of Beneficiaries by Modifier Category (cont.) Percentage of Beneficiaries by Modifier Designation x Total Beneficiary Count KS and KX: (.01 * 67) 1 KX only: (.45 * 67) 30 43

44 Average Allowed Items per Beneficiaryday by HCPCS Code and Modifier Type Calculated as follows: 44

45 Calculating Total Allowed Items A4253: Total Allowed Services X 50 A4259: Total Allowed Services X

46 Calculating Total Number of Beneficiary-Days Days covered by claim line: Through date from date + 1 Summarize by beneficiary: Add days covered Remove overlapping days 46

47 Table 4 Table 4: Average Allowed Items per Beneficiary-Day by HCPCS Code and Modifier Type January 1, 2015 December 31, 2015 HCPCS Code and Modifier Type Your Average Allowed Items per Beneficiary- Day Your State s Average Allowed Items per Beneficiary- Day Comparison with Your State s Percentage National Average Allowed Items per Beneficiary- Day Comparison with the National Percentage A4253KS Does Not Exceed 1.62 Does Not Exceed A4253KX Significantly Higher 3.26 Significantly Higher A4259KS Higher 1.62 Higher A4259KX Significantly Higher 3.19 Higher A t-test was used in this analysis, alpha = Beneficiary-days for line items are capped at a maximum of

48 Calculating Average Allowed Items per Beneficiary-Day by HCPCS Code and Modifier Type Table 2: Summary of Your Utilization January 1, 2015 December 31, 2015 HCPCS Code Modifier Allowed Charges Allowed Services Beneficiary Count Beneficiary- Days A4253 KS $1, ,805 A4253 KX $2, ,574 A4259 KS $ ,051 A4259 KX $ Subtotal KS $1, N/A Subtotal KX $2, N/A Total --- $4, N/A 48

49 Calculating Average Allowed Items per Beneficiary-Day by HCPCS Code and Modifier Type (cont.) Calculated as follows: or 139 X

50 Average Distance from DMEPOS Supplier to Beneficiary Calculated as follows: 50

51 Table 5 Table 5: Average Distance from DMEPOS Supplier to Beneficiary January 1, 2015 December 31, 2015 Your Average Distance from Beneficiary Your State s Average Distance from Beneficiary Comparison with Your State s Percentage National Average Distance from Beneficiary Comparison with the National Percentage Distance in Miles Does Not Exceed Does Not Exceed A t-test was used in this analysis, alpha =

52 References & Resources Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS). Includes codes and descriptors developed, copyrighted and maintained by the American Dental Association (ADA). 52

53 CBR Website About Us CBR Releases Education Recommended Links FAQs CBR Support Contact Us 53

54 Recommended Links General Link: commended-links.html CBR Specific Link: Diabetic Testing Supplies r recommendedlinks.html 54

55 FAQs General FAQs CBR Specific FAQs : Diabetic Testing Supplies faqs.html 55

56 Provider Self-audit Providers and suppliers have an obligation to ensure claims are submitted correctly to Medicare Self-audits allow providers and suppliers to identify coverage and coding errors Refer to the following CBR sections for assistance Documentation and Billing References 56

57 CBR Support Help Desk Monday Friday: 9:00 a.m. to 5:00 p.m. ET Toll Free cbrsupport@eglobaltech.com 57

58 Contacting MACs Providers should contact the Medicare Administrative Contractor (MAC) for assistance with: Claim Information Documentation Requirements Billing and Coding 58

59 NPPES National Plan & Provider Enumeration System Source for mailing address used for the CBR Correct your mailing information at 59

60 Questions & Answers 60

61 We make every effort to address all questions submitted during our webinars. However, we cannot provide responses related to coding issues or to specific claims/scenarios. Since your Medicare Administrative Contractor (MAC) makes the determination to pay or deny a claim based on the CPT codes, medical documentation and description of the circumstances, and we do not have access to this documentation, we cannot respond to these types of questions. Please contact your MAC with questions that we do not address or if you identify any claims discrepancies while reviewing your CBR. The contact information for your MAC is located at 61