CERT PAP Errors: The DME CERT Outreach and Education Task Force Responds

Transcription

1 CERT PAP Errors: The DME CERT Outreach and Education Task Force Responds DME CERT Outreach and Education Task Force National PAP Webinar, December 17, 2014

2 PAP CERT Errors Medical Records: Face-to-Face Exam 3

3 PAP Common Errors - Medical Records: Face-to-Face No signature (handwritten or electronic) on the medical records Missing or illegible signature and no attestation statement provided No medical records submitted No notation of clinical disease management in the medical record No record of a face to face visit indicating the need for a sleep test No record of a face to face visit prior to the sleep study Conflicting information within the face to face visit examination 4

4 PAP Policy Requirements Medical Records: Face-to-Face Exam 5

5 PAP Initial Coverage A positive airway pressure device (PAP) is considered for coverage if the following are met: 1. The Medicare beneficiary has a face to face clinical evaluation prior to the sleep test to assess the beneficiary for obstructive sleep apnea 2. Beneficiary has a Medicare covered sleep study that meets 1. AHI or RDI > 15 events per hours with a minimum of 30 events 2. AHI or RDI > 5 and < 14 events per hour with a minimum of 10 events and documentation of: 1. Excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke 3. Beneficiary and/or caregiver has received instruction from the supplier on use and care of the equipment and related accessories 6

6 Face-to-Face Clinical Evaluation Detailed, narrative notes of the face-to-face in the beneficiary s chart History should include: Signs and symptoms of sleep disordered breathing Duration of symptoms Validated sleep hygiene inventory (i.e., Epworth) Physical exam should include: Focused cardiopulmonary and upper airway system evaluation Neck circumference Body Mass Index (BMI) 7

7 PAP CERT Errors Medical Records: Sleep Test 8

8 PAP Common Errors - Medical Records: Sleep Test No signature (handwritten or electronic) on the sleep test Missing or illegible signature and no attestation statement provided No sleep test submitted Sleep test results did not meet Medicare requirements No sleep test interpretation (only raw data provided) No indication interpreting physician holds appropriate credentials 9

9 PAP Policy Requirements Medical Records: Sleep Test 10

10 Facility-Based Sleep Study A Type I sleep test takes place in a facility or sleep center that qualifies as a Medicare provider This polysomnogram includes continuous and simultaneous monitoring and recording of physiological and pathophysiologial parameters of sleep with physician review, interpretation and report Includes sleep staging (EEG, EOG, EMG, and ECG) Includes airflow, respiratory effort and oxygen saturation by oximetry Can be performed as a whole night study for diagnosis purposes or splitnight study to diagnose and initially evaluate treatment 11

11 Home Sleep Study (HST) An unattended HST may be performed to measure the AHI and RDI for Medicare coverage consideration The HST must be ordered by the treating physician The portable monitoring device must meet the criteria defined in the LCD (Type II, III, or in limited circumstances IV Device) The entity conducting the HST may not be a DME supplier Instruction must be provided to the beneficiary by the entity conducting the HST Face-to-face demonstration Video or telephonic instruction with 24 hour availability of qualified personnel to troubleshoot The DME supplier is prohibited from participating in any HST activities (e.g., delivery or pickup of the HST device) 12

12 Interpreting Sleep Tests For PAP devices with initial date of service on or after January 1, 2010, all sleep tests must be interpreted by a physician who holds either: 1. Current certification in Sleep Medicine by the ABSM; or, 2. Current subspecialty certification in Sleep Medicine by a member board of the ABMS; or, 3. Completed residency or fellowship training by ABMS with all requirements for subspecialty certification until next eligible exam is offered; or, 4. Active staff membership of a sleep center or laboratory accredited by AASM, ACHC, or JCAHO 13

13 CERT Errors Physician s Orders 14

14 Common Errors - Detailed Written Orders No detailed written order submitted Detailed written order is illegible Orders written or signed and dated after submission of the Medicare claim Detailed written order did not include all items ordered or did not match item delivered/billed to the Medicare program Detailed written order was not dated by the treating physician or a date stamp was used NPI was not present on the detailed written orders 15

15 PAP Policy Requirements - Physician s Orders 16

16 PAP Coverage Detailed Written Orders Detailed written orders must include: Beneficiary s name Physician s name Detailed description of the items being ordered Physician signature Physician date Physician NPI (as HCPCS codes E0601 and E0470 are included in Section 6407 of the Affordable Care Act) Signature stamps and date stamps are not accepted by Medicare 17

17 PAP Coverage Dispensing Orders Supply items and accessories may be delivered to the beneficiary based on dispensing orders if those orders include: The beneficiary s name Prescribing physician s name Date of the order and the start date of the order (if the start date is different than the order date) Physician signature (for written orders) or supplier signature (for verbal orders) The supplier must obtain a valid detailed written order prior to submitting a claim to the Medicare program 18

18 CERT Errors Continued Use and Continued Need 19

19 Common Errors - Continued Use and Continued Need No documentation of PAP compliance/usage by the beneficiary No documentation of a re-evaluation with the treating physician No documentation the beneficiary or caregiver completed a course of instruction on the use and care of the equipment No refill requests or documented need for new accessory items 20

20 PAP Policy Requirements Continued Use and Continued Need 21

21 PAP Requirements Beyond First Three Months Documentation of clinical benefit of PAP use demonstrated by: Face-to-face re-evaluation with the treating physician and documentation of OSA symptom improvement Between 31st and 91st day of beginning PAP therapy Objective evidence of adherence to use of the PAP device, reviewed by treating physician Adherence = usage > 4 hours 70% of last 30 nights Adherence measured with direct download or visual inspection of usage data 22

22 PAP Coverage Continued Need Continued need is the proof of medical necessity for PAP therapy by the beneficiary (as outlined on the previous slide) Continued need examples include: Medical records or chart notes by the treating physician stating beneficiary continues to use and benefit from PAP therapy Physician s orders for accessories (some states require an annual order) 23

23 PAP Coverage Continued Use Continued use is the ongoing utilization of supplies by the beneficiary. PAP supplies are considered non-consumable Continued use examples include: Evidence of beneficiary request for new mask as current mask broken or seal no longer works Evidence of beneficiary request for new tubing as tubing is cracking and dirty 24

24 Questions? 25

25 Thank you! Thank you for participating in this DME CERT Outreach and Education Task Force presentation. 26

26 Disclaimer The DME CERT Outreach and Education Task Force consists of representatives from each of the DME MACs and is independent from the CMS CERT Team and CERT Contractors, who are responsible for the calculation of the Medicare Fee-for-Service Improper payment rate. The DME CERT Outreach and Education Task Force has produced this material as an informational reference for providers furnishing services in our contract jurisdictions. The DME CERT Outreach and Education Task Force employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) website at 27