CERT Oxygen Errors: The DME CERT Outreach and Education Task Force Responds DME CERT Outreach and Education Task Force National Oxygen Webinar, July 22, 2014 1
Today s Presenters Michael Hanna, CERT Task Force Coordinator Jurisdiction A: Jurisdiction B: Jurisdiction C: Jurisdiction D: Denise Winsock Provider Outreach & Education Consultant Stacie McMichel Provider Outreach & Education Consultant Angie Cooper Provider Outreach & Education Consultant Jody Whitten Provider Outreach & Education Consultant 2
CERT Errors Medical Records 3
Oxygen Common Errors - Medical Documentation No medical records submitted indicating a qualifying arterial blood gas or saturation test conducted within 30 days of the date on the initial CMN No medical records submitted indicating re-evaluation conducted within 90 days of the date on the recertification CMN 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 Missing one of three required oximetry tests performed during exercise 4
Oxygen Policy Requirements Medical Documentation 5
Oxygen Coverage 1. Oxygen is considered for coverage if the following are met: 2. Severe lung disease or hypoxia-related symptoms that will improve with oxygen therapy 3. Beneficiary s blood gas study meets certain criteria 4. Qualifying blood gas study performed by physician or qualified provider of laboratory services 5. Qualifying blood gas performed in one of the following: 1. Within two days of discharge from an inpatient stay 2. Beneficiary in a chronic, stable state 6. Alternative treatment measures considered and deemed clinically ineffective 6
Oxygen Coverage Group I Group I includes any of the following: 1. ABG at or below 55 mm Hg or SAT at or below 88% taken at rest 2. ABG at or below 55 mm Hg or SAT at or below 88% for at least five minutes during sleep (for beneficiaries with ABG at or above 56 mm Hg or SAT at or above 89% while awake) 3. Decrease in ABG more than 10 mm Hg or decrease in SAT more than 5% taken during sleep associated with symptoms or signs reasonably attributed to hypoxemia 7
Oxygen Coverage Group I 4. ABG at or below 55 mm Hg or SAT at or below 88% taken during exercise for beneficiaries who exhibit ABG at or above 56 mm Hg or SAT at or above 89% taken at rest. Three blood gas tests required to complete this exercise test and show improvement in hypoxemia during exercise: i. Test taken on room air while at rest ii. iii. Test taken on room air while exercising Test taken on oxygen while exercising 8
Oxygen Coverage Group II A. ABG of 56-59 mm Hg or SAT at 89% taken during while at rest, during sleep for at least five minutes or during exercise (as noted in the preceding slide), and B. Any of the following: Dependent edema suggesting congestive heart failure, or Pulmonary hypertension or cor pulmonale, or Erythrocythemia with hematocrit greater than 56% 9
Oxygen Coverage Time Frame Initial coverage for Group I beneficiaries is limited to 12 months (or physician-specified length of need, whichever is shorter) Initial coverage for Group II beneficiaries is limited to 3 months (or physician-specified length of need, whichever is shorter) Beneficiaries with ABG at or above 60 ml Hg or SAT at or above 90% are considered Group III and there is no Medicare coverage 10
Oxygen Coverage Recertification Recertification for Group I patients occurs twelve (12) months after initial certification (i.e., with the thirteenth month s claim) Recertification for Group II patient occurs three (3) months after initial certification (i.e., with the fourth month s claim) Beneficiary must be seen and evaluated within 90 days of the recertification for either Group I or Group II beneficiaries and the most recent qualifying test should be reported on the CMN For Group II beneficiaries, a new qualifying test is required between the 61st and 90th day following initial certification 11
Oxygen Coverage - Documents If requested by a Medicare auditing entity, the supplier should provide medical records (primary care physician, hospital inpatient records, IDTF test results, home health chart notes, etc.) that show the beneficiary has Qualifying test results within 30 days of initial date Presence of lung condition or other medical condition that causes hypoxia Notes indicating other treatments that were tried and not effective 12
Oxygen Coverage - Documents The following are some guidelines to remember: Supplier-generated forms are not considered part of the beneficiary s medical record (PIM 5.7 5.9) Templates and forms (i.e., CMNs) are subject to corroboration with information in the medical record (PIM 5.7 5.9) All medical records must be signed by the author (PIM 5.3) If the qualifying test result is on the physician s orders, that same test result must be in the beneficiary s medical record (PIM 5.7 5.9) 13
CERT Errors Physician s Orders 14
Common Errors - Detailed Written Orders No detailed written order submitted or the 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 The length of need or number of refills on the order has expired Orders missing elements such as frequency, dosage, or description of item Detailed written order was not dated by the treating physician or a date stamp was used 15
Oxygen Policy Requirements Physician s Orders 16
Oxygen Coverage Dispensing Orders Equipment 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 detailed written order prior to submitting a claim Note: Exceptions for some HCPCS codes per MM8304. 17
Oxygen 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 (for HCPCS codes affected by ACA 6407) Signature stamps and date stamps are not accepted by Medicare 18
Oxygen Coverage Oxygen HCPCS in ACA 6407 Some oxygen HCPCS codes are found in ACA 6407 and require valid detailed written orders prior to delivery HCPCS Code E0424 E0431 E0433 E0434 E0439 E0441 E0442 E0443 E0444 Description Stationary gaseous oxygen system Portable gaseous oxygen system Portable liquid oxygen system, home liquefier Portable liquid oxygen system Stationary liquid oxygen system Stationary gaseous oxygen contents Stationary liquid oxygen contents Portable gaseous oxygen contents Portable liquid oxygen contents 19
Oxygen Coverage Oxygen HCPCS in ACA 6407 The codes on the preceding slide require a face-to-face examination within six months prior to delivery The codes on the preceding slide require a detailed written order prior to delivery that includes the physician s NPI Refer to Medicare Learning Matters article MM8304 for additional information 20
Oxygen Coverage: Contents If. Your next step F2F and WOPD for oxygen equipment Claims may be submitted for oxygen includes oxygen contents for the initial contents once the stationary equipment set up of home oxygen therapy. meets the 36 month cap. F2F and WOPD for oxygen equipment A new F2F and WOPD is required prior does not include oxygen contents prior to delivery of the contents after the 36 to the initial set up for home oxygen month cap. therapy 21
CERT Errors CMNs 22
Common Errors - Detailed Written Orders/CMNs CMN used as a detailed written order and Section C was not sufficiently detailed Invalid CMN for date of service under review Missing signed recertification CMN Initial CMN invalid/incomplete/not submitted Revised CMN not submitted when the LPM per medical records differ from initial CMN 23
Oxygen Policy Requirements CMNs 24
Oxygen Coverage CMNs CMNs are required per the Oxygen LCD. CMNs must be on form CMS-484 no other type or version of the Oxygen CMN will be accepted. There are three types of CMNs in the Oxygen LCD Initial required when oxygen therapy begins Valid for twelve (12) months for Group I beneficiaries Valid for three (3) months for Group II beneficiaries Revised used to reflect change in supplier, physician, modality, length of need, etc. Recertification required at the end of the initial certifying period to reaffirm the need for oxygen therapy 25
Oxygen Coverage CMNs Suppliers may complete Sections A and C Section A supplier, beneficiary and physician information Section C narrative description of items being ordered Physicians must complete Sections B and D Section B Question set used to show test conditions and test results (may be completed by physician employee) Section D Physician s signature and signature date Please note CMN may serve as the detailed written order if Section C is appropriately completed 26
CERT Errors Continued Use and Continued Need 27
Common Errors - Continued Use and Continued Need No documentation of continued use in the beneficiary s medical record or records from the supplier Illegible records submitted No evidence of continued oversight or medical management No documentation submitted indicating beneficiary is mobile within the home (when portable prescribed) No evidence of re-evaluation before the recertification CMN was signed by the treating physician 28
Oxygen Policy Requirements Continued Use and Continued Need 29
Oxygen Coverage Continued Use Continued Use is the ongoing utilization of supplies or rental item by the beneficiary. Examples of Continued Use: Evidence of portable tank exchange in the supplier s documentation Evidence of supply provisions (i.e., tubing) or concentrator maintenance in supplier documentation Treating physician s chart notes indicating current oxygen therapy utilization 30
Oxygen Coverage Continued Need Continued Need is the proof of medical necessity for oxygen therapy by the beneficiary. Examples of Continued Need: Medical records or chart notes by the treating physician stating ABG or SAT results and continued need for oxygen therapy Medical records or chart notes by the treating physician showing continued need for oxygen therapy prior to the recertification CMN being signed. 31
Questions? 32
Thank you! Thank you for participating in this DME CERT Outreach and Education Task Force Presentation. 33
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 http://www.cms.gov. 34