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$Page 1: ABC Approved Audit Help Presentation L5856 05ñ l î ñ l î ì í ó ï _ 2wwr %rfn +hdowk&duh 'rfxphqwdwlrq *xlgholqhv)xqfwlrqdo 0relolw\ /hyho ,i wkh sdwlhqw zdvq¶w dfwlyh sulru$
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| © Otto Bock HealthCare

Audit Help - Essential Elements of Documentation

Required for Medicare Prepayment Audits

Kimberly Hanson, Director of Reimbursement

Mark Edwards, MHPE, CP, Director of Professional Clinical Services

May 2017

Mission Statement

We help people maintain or regain their freedom of movement.


Agenda

1. What is the Widespread Prepayment Review of L5856?

2. What does the Lower Limb Policy say?

o Coverage

o Functional Levels

o Coding

o Medical Necessity

3. Preparing for an Audit – Ottobock‘s Step by Step Guide to know what is required for an approved claim

4. Resources for you

3 | © Otto Bock HealthCare 4

(CGS), LLC, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C announced on May 16th it will initiate starting in June a widespread pre-payment review for all claims that contain HCPCS code L5856.

Service-specific reviews are issued by the DME MAC when there has been an issue identified with a specific type of service, in this case with L5856 claims.

This review was the result of data demonstrating a high claims payment error rate.

Top 3 Error Rates1. Reason for Replacement2. Detailed Written Order Issues3. Proof of Delivery Issues

.

Widespread Prepayment ReviewWhy L5856?

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The DME MAC will receive the claim and issue an Additional Documentation Request (ADR)

• Claims submitted with L5856 will be flagged for additional documentation needed in order to process for payment or denial.

Tip: Have a discussion with your staff and define a process when these letters are received. Do not wait until you get it to prepare.

You MUST submit your documentation within 45 days.

Don’t be afraid to submit your paperwork, plan ahead before you submit and make sure your notes are in order (Self-audit your charts)

Claim Submission with L5856What is the process?


The ADR letters are sent to the address on file with the National Supplier Clearinghouse (PTAN number).

• Check your records to make sure you don’t miss the letters.

Not responding to the letters is an automatic denial. • You will still have your appeal rights, if you didn’t get the letter in time to

respond, note that on your appeal with the ADR as the cover letter.

The ADR letter and the portal at CGS will provide you with the necessary information that they want to review. A typical request would include:

Preliminary Dispensing Order Detailed Written Order Proof of Delivery Physician Records Prosthetist Records Additional Supporting Records – i.e. PT/OT

Claim Submission with L5856Prepayment Review Documentation Request

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A lower limb prosthesis is covered when the patient:

1. Will reach or maintain a defined functional state within a reasonable period of time

2. and Is motivated to ambulate

Functional Level (K-Level) = Medical NecessityA determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities

Potential functional ability is based on the reasonable expectations of the prosthetist, AND treating physician, considering factors including, but not limited to:3. The beneficiary’s past history (including prior prosthetic use if applicable); and 4. The beneficiary’s current condition including the status of the residual limb and

the nature of other medical problems; and 5. The beneficiary’s desire to ambulate

All 5 items on this list must be documented in the Physician’s Medical Record!

Policy Coverage LanguageMedicare Qualifying Criteria that must be documented


Functional Level 3 Has the ability or potential for ambulation with variable cadence

Typical of the community ambulator who has the ability to traverse most environmental barriers; and

May have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion

The records must document:

The beneficiary’s current functional capabilities

His/her expected functional potential, including an explanation for the difference, if that is the case

Bilateral amputees often cannot be strictly bound by functional level classifications, but you must document patient activities in order to justify their motivation to ambulate and their potential

Documentation GuidelinesFunctional Mobility Level

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Documentation GuidelinesFunctional Mobility Level

• If the patient wasn’t active prior to amputation, it is unlikely the patient will be active after the amputation.

• Unless the patient had been ill or experiencing complications that prevented mobility, document that and tell the story of what the patient’s desire are if they were active prior to being ill.

• History of the patient’s activities prior to amputation is a critical part of the documentation or what they have done recently to justify new activitiesprovides a rationale for the prosthetic decision

i.e. therapy (physical and/or psychological), new exercise program, lost weight and now more mobile, positive life-changing event creates desire to be more mobile

• Tip: Be very descriptive when describing activities including how they get there and what the walking surface

• Use the Activity Guide to provide a consistent approach to the documentation.

9 | © Otto Bock HealthCare

Documentation GuidelinesAdditional Supporting Documentation

1. Define a goal for the fitting of the selected device. What is the primary goal of fitting a new device to the patient?

This may be, for instance, reduce falls / risk of falling / risk of injury improve mobility/performance in activities the patient has to perform reduce the re-occurrence of residual limb wounds/irritations reduce asymmetry and compensatory movements to alleviate pain and/or

prevent long-term comorbidities

2. List the unmet safety and/or mobility needs of the patient.

Match the needs of the patient with the functions of the requested device

3. State why a mechanical hydraulic or fluid knee is not sufficient to meet the patient´s safety and/or mobility needs.

Use the proven clinical benefits supported by evidence to strengthen your decision

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Activity ChartExample

Daily Activities Distance Traveled

Can patient do this activity with current prosthesis?

How will patient be able to do it better with the new prosthesis?

Prior to the amputation, patient walked his two dogs 2 times daily for ½ mile. On his route there are cracks in the sidewalk and slope up to ten degrees.

Goal: Realistic 3.5 miles per week

He currently uses a mechanical knee. It is very difficult to do concurrent activities, such as managing the dogs with a mechanical knee prosthesis. As a result he falls several times per year and recently injured his back, incurring $9500 of related medical expenses.

He will be able to walk the dogs more safely with the C-Leg as it has been proven to increase multitasking capacities and cognitive burden while walking with the prosthesis

.

Prior to the amputation, patient went to the gym 3X per week and walked 2 miles on the tread mill. Realistically, he would like to get back up to 1 mile

Goal: 1 mile @ 3X/wk

He attempted to walk on the treadmill with his current knee. He had to walk at a very slow rate completely supporting himself with the bars. He was afraid of falling and this hurt his shoulders.

The C-Leg will give him the necessary stability to walk on the treadmill using the bars similar to an able-bodied person, without fear of falling.


Use as many objective and validated measures as possible to support your clinical judgment & document them

Get in a routine to test your transfemoral patients the same with the same tests in order to draw consistent conclusions on their functional level.

(e.g. AMP and/or timed walk tests to substantiate K-level determinations, TUG/FSST to assess risk of falling, etc.).

We are not endorsing one testing method over another, just consistency

Enter the results of your validated testing and any other information from conducting the tests that may support your claim directly into your medical records.

i.e. Falls, but also almost falls. In which situations/activities, patient feedback on the device if the patient is already using it. If the patient trials the device, document the experience, the differences, the additional functional capabilities compared to their current device and compare test results

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Documentation GuidelinesAdditional Supporting Documentation

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Clinical benefits supported by evidence

improved safety – less stumbles and falls (up to 80%!), improved balance and confidence (Kannenberg et al. 2014, Highsmith 2014, Burnfield et al. 2012, Highsmith et al. 2010,

Blumentritt et al. 2009, Hafner et al. 2009 and 2007, Kahle et al. 2008, Kaufman et al. 2007)

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C-Leg/Compact vs. NMPK´s

improved and faster slope negotiation (Kannenberg et al. 2014, Highsmith et al. 2013, Burnfield

et al. 2012, Hafner et al. 2009 and 2007)

improved and faster negotiation of uneven terrain and obstacles (Kannenberg et

al. 2014, Hafner et al. 2009 and 2007, Kahle et al. 2008, Seymour et al. 2007)

improved stair descent (Kannenberg et al. 2014, Hafner et al. 2009 and 2007, Kahle et al. 2008,

Schmalz et al. 2007 and 2002)

reduced cognitive demand to walk and improved multi-tasking (Morgan et al. 2015,

Kannenberg et al. 2014, Hafner et al. 2009, Williams et al. 2006)

potential to increase overall mobility / K-level (Kannenberg et al. 2014, Hafner et al. 2009,

Kahle et al. 2008)| © Otto Bock HealthCare

When Fitting a C-Leg, the following codes apply to Medicare:

L5856 Microprocessor control feature, swing and stance phase, includes sensors

L5828 Fluid swing and stance phase control

L5845 Stance flexion feature, adjustable

L5848 Fluid stance extension, dampening feature, with or without adjustability

Tip: You must document the reason/benefits for selecting the microprocessor knee joint and all the features that are additionally coded.

What is the benefit to the patient for MP control?

What is the benefit for fluid swing and stance phase control?

What is the benefit of stance flexion feature?

What is the benefit of fluid stance extension dampening feature?

Why doesn’t a mechanical fluid knee meet the unmet needs and goals of the fitting?

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CodingDocument the patient benefit


When creating a new socket, adding a foot, supplying liners, you must document all these events, not just the knee joint

Base Codes for the socket: L5312 (KDA), L5321 (AK), L5331 (Hip), L5341 (Hemi) or replacements L5701 (KDA, AK) or L5702 (Hip)

• Document the need for the new socket i.e ill-fitted, change in physio, weight changes, surgery revision, new patient, etc.

Alignable System L5920: For a complete new prosthesis

For Socket Options; Suction L5652, Total Contact L5650, Flexible Inner Socket L5643, Ultralight L5960

• Document why you created the patient specific socket design – this is your expertise, document the reasons for material and design choices.

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CodingDocument your work and why


Coverage: A determination of the type of foot for the prosthesis will be made by the treating physician And/Or the prosthetist based upon the functional needs of the patient

• Document the functional needs of the patient to the function of the selected foot

There are a variety of choices of feet covered for K3 and above with documented need and medical necessity

L5972 Flexible-keel foot

L5976 Energy storing foot

L5979 Dynamic response foot with multi-axial ankle

L5980 Flex foot system

L5981 Flex-walk system or equal

L5987 Shank foot system with vertical loading pylon

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CodingDon’t forget the foot

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Make sure your notes match those of the referring/ ordering physician

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The physician´s notes are key & knowing what they say!

• Let the physician know the coverage criteria and what needs to be documented in the physician‘s record.

• Obtain a correct prescription/order.

• Obtain copies of the physician´s notes on the criteria in the coverage policy that require the corraboration of the physician and the prosthetist

• Review it and document it in your record that you recieved

• Compare the physician´s notes with yours and try to resolve any inconsistencies and discrepancies.

• If you can explain the discrepancy and document in your note.

• If not, the patient will need to revisit the physician in order to resolve it.


Denial Reason

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Detailed Written Order

Date of Order: This is required date #1

Dispensing order date if item is already delivered

DWO date if prior to delivery (not physician signature date)

Manufacturer, brand name, model#, narrative description and LT/RT for each component

Physician demographics Physician’s hand written signature, date (and time if device

will be delivered same day) This is required date #2

Meets your state’s requirement for orders


Denial Reason

• The following elements must be in the Proof of Delivery*

– Delivery Date This is the only date needed

– Patient’s Name

– Quantity delivered of each item

– Right and/or Left Side for each item

– Detailed description of each item

– Recommend: Brand Name, Model Number, Serial #

– Allowed: Narrative or HCPCS description (long version)

– Signature and Printed Name of patient, or someone designated to sign on patient’s behalf (If designee signs: the designee’s relationship to the patient must be stated)

– Hand-written signature date is not required, but must match Delivery Date

Tip: Double check your computer generated delivery tickets.

Auditors are seeing a 10% denial rate based on lack of information

*Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c04.pdf

Proof of Delivery

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Denial Reason

Replacement is covered if the treating physician orders a replacement of the entire prosthesis or major component (socket, knee, foot, etc.) and the replacement falls under one of the following

Reasons for Replacement (documented on the order or in the referring physician’s notes).

1) There is a change in the physiological condition of the beneficiary; or

2) There is irreparable wear of the prosthesis/component; or

3) The condition of the prosthesis/component requires repairs, and the cost of such repairs [list price of parts + labor] is greater than 60% of the cost

[Medicare allowable] of the replacement prosthesis/component

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Reason for Replacement

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Denial Reason

Correct Prosthesis: The supplier (prosthetist) is responsible to provide the correct prosthesis for the patient.

If an incorrect prosthesis is supplied, the supplier is obligated to make the situation right (take back the incorrect prosthesis, provide the correct one, and adjust the billing). There is no time limit for this.

What about the 5-year Useful Lifetime Rule? This rule does not apply to prosthetics. The Social Security Act was amended in 2001 to exclude Prosthetics from the Useful Lifetime Rule, so amputees could get replacements when needed.

What is a Replacement? A replacement is the provision of an entire identical or nearly identical item. If the prosthesis is different, it is considered a new device and no longer covered under the original order.

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Denial Reason

Documentation

Physician:

New Detailed Written Order (DWO) is required. The reason for replacement must be on the order (DWO) or in the physician’s medical record.

The documentation must met all the current coverage criteria

Prosthetist:

Retain documentation of components being replaced, reason for replacement, and description of labor involved; functional level documentation and detailed justification for each component (socket, knee, ankle, foot, etc.) replaced. Proof of Delivery.

If replacement is for loss, theft, or natural disaster, you must submit police/insurance report, attestation, photograph with claim.

25.05.2017Titel der Präsentation | Max Mustermann, Orthetik | 22


Review the Medical Coverage Policy

Ottobock Partners with you

Tools


Step-by-Step Guide to Successful Billing of L5856

New Ottobock packet specific to L5856 and Medicare, includes:

• Step-by-Step Guide for Success

• Sample ADR Letter

• Medicare Coverage Requirements

• Prosthetist Documentation Guide

• Documentation Checklist – Self-Audit Checklist

• Signature Requirements

• Documentation Requirements for Replacement

• Activity Chart Guide for C-Leg

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Step-by-Step Guide to Successful Billing of L5856

Additional Documents to Share with Your Referring Physicians

• Physician Documentation Guide

• C-Leg Evidence Guide

• Physician Documentation Request Fax

Presentation Title | Name, Division | 25 May 2017 25 | © Otto Bock HealthCare

ResourcesLower Limb Region C Coverage Policy & Article

Local Coverage Determinations (LCDs) & Policy Articles (PAs)

Current LCD and Policy Article

• LCD - L33787: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33787&ContrID=140

• PA - A52496: https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52496&ContrID=140

• Detailed Written Order requirements

• Proof of Delivery requirement

• Reasons for replacement documentation

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Thank you for your attention

Email reimbursement department for assistance:

[email protected]

Questions