Copyright © 2016 AAPC

DME: DO YOU HAVE THE RIGHT DOCUMENTATION?RHONDA ZOLLARS, COC, CPC

DISCLAIMER• ALL MATERIAL IS PUBLIC ACCESSABLE

• ALWAYS VERIFY YOUR STATE LAWS, PAYOR POLICIES,

CONTRACTS,

OBJECTIVES

• UNDERSTAND DMEPOS

• UNDERSTAND THE REQUIREMENTS FOR ORDERING

• UNDERSTAND THE REQUIREMENTS OF MEDICAL

DOCUMENTATION FROM PROVIDER AND DME

COMPANY

• PROOF OF PURCHASE AND DELIVERY

• PDAC SYSTEM

ACRONYMS

• MSA (METROPOLITAN STATISTICAL AREA).

• DMEPOS- DURABLE MEDICAL EQUIPMENT

PROSTHETICS, ORTHOTICS AND SUPPLIES

• CMS- CENTER FOR MEDICARE MEDICAID SERVICES

• DME – DURABLE MEDICAL EQUIPMENT

• PDAC – PRICING, DATA ANALYSIS AND CODING

• WOPD- WRITTEN ORDER PRIOR TO DELIVER

• F2F- FACE TO FACE

ACRONYMS

• CMN – CERTIFICATE OF MEDICAL NECESSITY

• DIF - DME INFORMATION FORM

• POV – POWER OPERATED VEHICLE

• PMD – POWER MOBILITY DEVICES

5

GENERAL PAYMENT RULES

• DMEPOS ARE CATEGORIZED INTO ONE OF THE

FOLLOWING PAYMENT CLASSES:

• INEXPENSIVE OR OTHER ROUTINELY PURCHASED DME;

• ITEMS REQUIRING FREQUENT AND SUBSTANTIAL

SERVICING;

• CERTAIN CUSTOMIZED ITEMS;

• OTHER PROSTHETIC AND ORTHOTIC DEVICES;

• CAPPED RENTAL ITEMS; OR

• OXYGEN AND OXYGEN EQUIPMENT.

PHYSICIAN ORDERS

• THE SUPPLIER FOR ALL DURABLE MEDICAL

EQUIPMENT, PROSTHETIC, AND ORTHOTIC SUPPLIES

(DMEPOS) IS REQUIRED TO KEEP ON FILE A PHYSICIAN

PRESCRIPTION (ORDER).

• A SUPPLIER MUST HAVE AN ORDER FROM THE

TREATING PHYSICIAN BEFORE DISPENSING ANY

DMEPOS ITEM TO A BENEFICIARY.

VERBAL & PRELIMINARY WRITTEN

ORDERS• THIS ORDER MUST INCLUDE:

• A DESCRIPTION OF THE ITEM,

• THE MEMBER'S NAME,

• THE PHYSICIAN'S NAME

• START DATE OF THE ORDER.

• SUPPLIERS MUST MAINTAIN WRITTEN ORDERS UPON REQUEST

FOR REVIEWS

• IF SUPPLIER DOES NOT HAVE WRITTEN ORDER FROM

TREATING PHYSICIAN BEFORE DISPENSING AN ITEM IT IS

UNCOVERED!!

• SUPPLIER MUST OBTAIN A DETAILED WRITTEN ORDER BEFORE

DISPENSING

FACE TO FACE• TREATING PHYSICIAN MUST IN-PERSON EXAM WITH

MEMBER WITH IN 6 MONTHS PRIOR TO WOPD

• EXAM DOCUMENTS THAT THE MEMBER WAS

EVALUATED/TREATED FOR A CONDITION THAT

SUPPORTS NEED FOR DME ITEM

• MUST BE ON OR BEFORE DATE OF WRITTEN ORDER <

6 MONTHS PRIOR

• DATE OF F2F MUST BE ON OR BEFORE DELIVERY

• SIGNED/STAMPED ON OR BEFORE DATE OF DELIVERY

WOPD-WRITTEN ORDER PRIOR

TO DELIVERY• 8 ITEMS MUST BE DOCUMENTED

• MEMBER’S NAME

• PHYSICIAN’S NAME

• DATE OF ORDER AND START DATE OF DME

• DETAILED DESCRIPTION OF ITEM(S)

• PRESCRIBING PHYSICIAN’S NPI

• PHYSICIAN SIGNATURE

• SIGNATURE DATE

• DATE STAMP INDICATING SUPPLIERS DATE OF RECEIPT FOR

WOPD ON OR BEFORE DATE OF DELIVERY

DISPENSING ORDER

• 5 ITEMS REQUIRED

• DESCRIPTION OF ITEM(S)

• MEMBER’S NAME

• TREATING PHYSICIAN’S NAME

• DATE OF ORDER AND START DATE

• PHYSICIAN SIGNATURE (IF WRITTEN

ORDER)

• OR SUPPLIER’S SIGNATURE (IF VERBAL

ORDER)

DETAILED WRITTEN ORDER

• MEMBER’S NAME

• PHYSICIAN NAME

• DATE OF ORDER AND START DATE

(IF DIFFERENT FROM DATE OF

ORDER)

• DETAILED DESCRIPTION OF

ITEM(S)

• PHYSICIAN SIGNATURE AND

SIGNATURE DATE

• ITEMS PROVIDED ON A PERIODIC

BASIS

• ITEM(S) TO BE DISPENSED

• DOSAGE OR CONCENTRATION (IF

APPLICABLE)

• ROUTE OF ADMINISTRATION (IF

APPLICABLE)

• FREQUENCY OF USE

• DURATION OF INFUSION (IF

APPLICABLE)

• QUANTITY TO BE DISPENSED

• NUMBER OF REFILLS (IF

APPLICABLE)

REFILL REQUIREMENTS• ITEMS BOUGHT IN PERSON AT A RETAIL STORE

• SIGNED DELIVERY/SALES RECEIPT

• ITEMS DELIVERED TO MEMBER

• DOCUMENTATION OF A REQUEST FOR REFILLS IS

REQUIRED

• REFILL RECORD MUST INCLUDE

• MEMBERS NAME OR AUTHORIZED REPRESENTATIVE

• DESCRIPTION OF DME ITEM

• DATE OF REFILL

REFILL REQUIREMENTS CONT.

• REFILL RECORD

• CONSUMABLE SUPPLIES

• NUMBER OF EACH ITEM MEMBER HAS REMAINING

• NON-CONSUMABLE SUPPLIES

• FUNCTIONAL CONDITION OF DME ITEMS BEING REFILLED

• CONTACT WAS MADE WITHMEMBER/REPRESENTATIVE

• WITH IN 14 DAYS PRIOR TO DELIVERY/SHIPPING DATE

• ITEM(S) WERE DELIVERED NO SOONER THAN 10 DAYS

• TO THE END OF USAGE

• REQUIRED TO HELP DOCUMENT THE MEDICAL NECESSITY AND OTHER

COVERAGE CRITERIA FOR SELECTED DMEPOS ITEMS

• CMN’S SECTION A AND C

• COMPLETED BY THE SUPPLIER

• CMN’S SECTION B AND D (SERVES AS PROVIDERS WOPD)

• COMPLETED BY THE PHYSICIAN WHO TREATED AND SEEN THE MEMBER

• DIF IS COMPLETED AND SIGNED BY THE SUPPLIER

• DOES NOT REQUIRE A NARRATIVE DESCRIPTION OF EQUIPMENT AND

COST OR A PHYSICIAN SIGNATURE

• MUST BE MAINTAINED BY THE SUPPLIER AND AVAILABLE UPON

REQUEST

CERTIFICATE OF MEDICAL NECESSITY (CMN)

AND DME INFORMATION FORM (DIF)

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ACCEPTABLE CMN’S – ITEMS REQUIRING CMN

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DME MAC FORM CMS FORM ITEMS ADDRESSED

484.03 after 10/1/2015 484.3 484 Oxygen

04.04B 846Pneumatic Compression

Devices

04.04C 847 Osteogenesis Stimulators

06.03B 848Transcutaneous Electrical

Nerve Stimulators (TENS)

07.03A 849 Seat Lift Mechanisms

11.02 854 Section C Continuation Form

ACCEPTABLE DIF’S – FOR ITEMS REQUIRING DIF

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DME MAC FORM CMS FORM ITEMS ADDRESSED

09.03 10125 External Infusion Pumps

10.03 10126Enteral and Parenteral

Nutrition

• VALID CMN IS ONE IN WHICH THE TREATING PHYSICIAN HAS

ATTESTED TO AND SIGNED SUPPORTING THE MEDICAL NEED AND

• THE APPROPRIATE INDIVIDUALS HAVE COMPLETED THE MEDICAL

PORTION OF THE CMN

• VALID DIF IS ONE IN WHICH THE SUPPLIER HAS ATTESTED TO AND

SIGNED SUPPORTING THE MEDICAL NEED

• FAILURE TO HAVE A VALID CMN OR DIF ON FILE OR TO SUBMIT A

VAILD FORM MAKES THE CLAIM INVALID INITIATES OVERPAYMENT

ACTIONS

• NO DOCUMENTATION TO SUPPORT REASONABLE AND NECESSARY

VALID VS INVALID CMN’S OR DIF’S

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SUPPLIER REQUIREMENTS• BEFORE SUBMITTING A CLAIM TO THE DME MAC

• MUST HAVE DISPENSING ORDER

• DETAILED WRITTEN ORDER

• CMN OR DIF (IF APPLICABLE)

• INFORMATION FROM THE TREATING PHYSICIAN

• MEMBERS DIAGNOSIS

• MODIFIERS IF REQUIRED

• ATTESTATION STATEMENTS AS DEFINED IN CERTAIN DME MAC POLICIES

• SHOULD ALSO OBTAIN DOCUMENTATION F2F IF REQUIRED

• IF MEDICAL NECESSITY NOT SUPPORTED SUPPLIER IS LIABLE FOR

DOLLAR AMOUNT UNLESS A PROPERLY EXECUTED ABN HAS BEEN

OBTAINED.

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PROOF OF DELIVERY METHOD 1• DIRECT DELIVERY TO MEMBER BY SUPPLIER

• DATE MEMBER/REPRESENTATIVE SIGNS FOR

SUPPLIES

• IS TO BE THE DATE OF SERVICE

• MEMBERS NAME

• DELIVERY ADDRESS

• DETAILED DESCRIPTION OF DME BEING DELIVERED

• QUANTITY DELIVERED

• DATE OF DELIVERY

• MEMBER/REPRESENTATIVE SIGNATURE

PROOF OF DELIVERY METHOD 2

• DELIVERY VIA SHIPPING OR DELIVERY SERVICE -

• SHIPPING DATE IS TO BE DATE OF SERVICE OF CLAIM

• MEMBERS NAME

• DELIVERY ADDRESS

• PACKAGE ID #/INVOICE # OR ALTERNATIVE METHOD

• MUST LINK DELIVERY DOCUMENTS TO DELIVERY SERVICE

RECORDS

• DETAILED DESCRIPTION OF ITEM(S) DELIVERED

• QUANTITY DELIVERED

• DATE OF DELIVERY & EVIDENCE OF DELIVERY

PROOF OF DELIVERY METHOD 3• DELIVERY TO NURSING FACILITY ON BEHALF OF A

MEMBER

• WHEN A SUPPLIER DELIVERS DIRECTLY TO NURSING

FACILITY

• DOCUMENTATION REQUIREMENTS OF METHOD 1 IS REQUIRED

• WHEN DELIVERY SERVICE OR MAIL ORDER IS USED

• DOUCMENTATION MUST BE SAME AS METHOD 2

• REGARDLESS THE METHOD OF DELIVERY TO THE MEMBER

IN THE NURSING FACILITY

• INFORMATION FROM NURSING FACILITY NEEDS TO SUPPORT THAT THE

ITEMS DELIVERED WERE ACTUALLY PROVIDED TO AND USED BY THE

MEMBER

• THESE MUST BE ALL BE AVAILABLE UPON REQUEST

CONTINUED NEED CONTINUED USE

• RECENT ORDER BY

TREATING PHYSICIAN FOR

REFILLS OR

• RECENT CHANGE IN

PRESCRIPTION OR

• COMPLETED CMN OR DIF

WITH APPROPRIATE LENGTH

OF NEED SPECIFIED OR

• TIMELY DOCUMENTATION IN

MEMBER’S MEDICAL

RECORD SHOWING USAGE

OF THE ITEM

• TIMELY DOCUMENTATION IN

MEMBER’S MEDICAL RECORD

SHOWING USAGE OF THE ITEM,

RELATED OPTIONS/ACCESSORIES OR

SUPPLIES

• SUPPLIER RECORDS DOCUMENTING

THE REQUEST FOR

REFILLS/REPLACEMENT OF SUPPLIES

IN COMPLIANCE WITH THE REFILL

DOCUMENTATION REQUIREMENTS OR

• SUPPLIER RECORDS DOCUMENTING

MEMBERS CONFIRMATION OF

CONTINUED USE OF A RENTAL ITEM

MEDICAL RECORDS• DOCUMENTATION NEEDS TO SUPPORT THAT ALL THE

COVERAGE CRITERIA ARE MET

• MUST REFLECT NEED OF DME ITEM

• PHYSICIAN OFFICE RECORDS

• HOSPITAL RECORDS

• NURSING HOME RECORDS

• HOME HEALTH AGENCY RECORDS

• RECORDS FROM OTHER HEALTHCARE PROVIDERS

• TEST REPORTS

• THESE RECORDS AREN’T ROUTINELY SUBMITTED BUT MUST BE

AVAILABLE UPON REQUEST, ALTHOUGH NOT A REQUIREMENT, IT IS

RECOMMENDED THAT SUPPLIERS OBTAIN AND REVIEW MEDICAL

RECORDS AND MAINTAIN A COPY

MEDICAL NECESSITY EVIDENCE

• REPLACEMENT SUPPLIES FOR THERAPEUTIC USE OF

PURCHASED DMEPOS

• TREATING PHYSICIAN MUST SPECIFY ON THE ORDER/CMN, TYPE

OF SUPPLIES NEEDED AND FREQUENCY

• WITH WHICH THEY MUST BE REPLACED, USED OR CONSUMED

• PRN OR AS NEEDED IS NOT ACCEPTABLE

• MEDICAL NECESSITY DETERMINATIONS MAY ASK SUPPLIER TO

OBTAIN DOCUMENTATION FROM TREATING PHYSICIAN TO

ESTABLISH THE SEVERITY OF PATIENTS CONDITION AND

IMMEDIATE AND LONG TERM NEED OF EQUIPMENT AND

THERAPEUTIC BENEFITS THE PATIENT IS EXPECTED FROM USE

TENS UNITS• ALL TENS (E0720, E0730) AND GARMENTS (E0731)

• F2F

• WRITTEN ORDER PRIOR TO DELIVERY

• ALL TENS SUPPLIES

• DETAILED WRITTEN ORDER

• REFILL REQUIREMENTS

• ALL TENS, GARMENTS, AND SUPPLIES

• MEMBER AUTHORIZATION

• POD

• CONTINUED NEED

• CONTINUED USE

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TENS – MEDICAL RECORDS

• TENS UNIT (E0720, E0730)

• TREATING PHYSICIAN ORDERS DISEASE OR CONDITION

JUSTIFYING NEED OF TENS UNIT

• COVERAGE FOR TREATMENT OF MEMBERS

• WITH CHRONIC, INTRACTABLE PAIN OR

• ACUTE POST-OPERATIVE PAIN

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TENS- ACUTE POST-OP PAIN• LIMITED TO 30 DAYS FROM DAY OF SURGERY

• PAYMENT ONLY MADE AS A RENTAL

• DOCUMENTATION MUST INCLUDE

• DATE OF SURGERY

• NATURE OF SURGERY

• LOCATION AND SEVERITY OF THE PAIN OR

• CHRONIC PAIN OTHER THAN LOW BACK

• CHRONIC LOW BACK PAIN

• MUST MEET ALL THE REQUIREMENTS AS LISTED IN

DOCUMENTATION CHECKLIST

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CONDUCTIVE GARMENTS (E0731)• ONLY COVERED IF ALL OF THE FOLLOWING REQUIREMENTS ARE

MET:

• PRESCRIBED BY TREATING PHYSICIAN FOR USE IN DELIVERING

TENS TREATMENT AND

• MEMBER MEETS ONE OF THE COVERED MEDICAL CONDITIONS

• MEMBER HAS DOCUMENTED MEDICAL CONDITION

• SKIN PROBLEMS THAT PRECLUDE APPLICATION OF ELECTRODES,

ADHESIVE TAPES AND LEAD WIRES; OR

• BENEFICIARY REQUIRES ELECTRICAL STIMULATION BENEATH A CASE TO

TREAT CHRONIC INTRACTABLE PAIN

• COVERED DURING RENTAL PERIOD

• REASONABLE AND NECESSARY FOR MEMBER

29

TENS BILLING REMINDERS• E0731 MUST INCLUDE THE BRAND, NAME AND MODEL NUMBER OF

THE CONDUCTIVE GARMENT

• KX MODIFIER MUST BE ADDED TO CODE IF COVERAGE CRITERIA

HAS BEEN MET

• GA OR GZ MODIFIER IF EXPECTATION OF DENIAL ON VALID ABN

• Q0 MODIFIER MUST BE ADDED TO E0720 AND E0730 IF USED FOR

CLBP

• ICD-10 CODES THAT JUSTIFY NEED FOR TENS WHEN USED IN

CLINICAL TRIAL TO TREAT CLBP

• CLINICAL TRIAL IDENTIFIER NUMBER REQUIRED ON EACH CLAIM

FOR MEMBERS ENROLLED IN CLINICAL TRIAL TREATMENT FOR CLBP

• “CLINICALTRIALS.GOV”

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PATIENT LIFTS• E0636, E1035, E1036

• F2F REQUIREMENTS ON OR BEFORE DATE OF DELIVERY

• WRITTEN ORDER PRIOR TO DELIVERY

• KX MODIFIER MUST BE ADDED

• ALL OTHER EQUIPMENT AND SUPPLIES

• DISPENSING ORDER

• DETAILED WRITTEN ORDER

• BENEFICIARY AUTHORIZATION

• POD AS DISCUSSED EARLIER

• MEDICAL RECORD DOCUMENTATION

BILLING REMINDERS FOR LIFTS• E0636 E1035 E1036

• KX MODIFIER MUST BE ADDED TO THESE CODES

• THE ONLY PRODUCTS THAT CAN BE BILLED WITH THESE ARE

THOSE THAT HAVE A WRITTEN CODING VERIFICATION REVIEW

FROM PDAC CONTRACTOR

• MEDICAL NECESSITY DENIAL EXPECTATION

• GA MODIFIER IF VALID ABN OBTAINED

• GZ MODIFIER IF VALID ABN NOT OBTAINED

• IF UPGRADE IS PROVIDED

• GA, GK, GL AND/OR GZ MODIFIER MUST BE USED TO INDICATE

UPGRADE

• HEAVY DUTY BARIATRIC LIFTS E0630-E0640

DMEPOS COMPETETIVE BIDDING

PROGRAM• STATUTE REQUIRES “SINGLE PAYMENT AMOUNTS”

WHICH REPLACE THE CURRENT MEDICARE DMEPOS

FEE SCHEDULE

• THERE ARE CURRENTLY COMPETITIVE BIDDING

PROGRAMS IN 99 METROPOLITAN STATISTICAL AREAS

(MSAS) THROUGHOUT THE UNITED STATES, INCLUDING

HONOLULU, HAWAII

• JULY 2016 CMS SENT OUT A FACT SHEET REGARDING

PAYMENT CHANGES,

ITEMS INCLUDED IN DMEPOS• OXYGEN, OXYGEN EQUIPMENT, AND

SUPPLIES

• CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) DEVICES AND RESPIRATORY ASSIST DEVICES (RADS) AND RELATED SUPPLIES AND ACCESSORIES

• HOSPITAL BEDS, COMMODE CHAIRS, PATIENT LIFTS, AND SEAT LIFTS

• INFUSION PUMPS

• SUPPORT SURFACES OR PRESSURE REDUCING MATTRESSES AND OVERLAYS

• ENTERAL NUTRIENTS, SUPPLIES, AND EQUIPMENT

• NEBULIZERS AND RELATED SUPPLIES

• NEGATIVE PRESSURE WOUND

THERAPY (NPWT) PUMPS AND

RELATED SUPPLIES AND ACCESSORIES

• STANDARD MOBILITY EQUIPMENT AND

RELATED ACCESSORIES, INCLUDING

WALKERS, STANDARD POWER AND

MANUAL WHEELCHAIRS, SCOOTERS,

AND RELATED ACCESSORIES

• GROUP 2 COMPLEX REHABILITATIVE

POWER WHEELCHAIRS

• TRANSCUTANEOUS ELECTRICAL

NERVE STIMULATION (TENS) DEVICES

AND SUPPLIES

DMEPOS• MANDATED BY CONGRESS THROUGH THE MEDICARE

PRESCRIPTION DRUG, IMPROVEMENT AND MODERIZATION

ACT OF 2003

• COMPETITION AMONG SUPPLIERS

• SUPPLIERS ARE REQUIRED TO SUBMIT A BID FOR SELECTED

PRODUCTS

• DOES NOT APPLY TO ALL PRODUCTS

• BIDS SUBMITTED ELECTRONICALLY

• BASED ON SUPPLIER’S ELIGIBILITY, FINANCIAL STABILITY AND BID

PRICE

PDAC SYSTEM - NORIDIAN MAC

• RECEIVES, EVALUATES AND PROCESSES CODING VERIFICATION

APPLICATIONS FOR DMEPOS

• ESTABLISHES, MAINTAINS AND UPDATES ALL CODING

VERIFICATION DECISIONS ON THE PRODUCT CLASSIFICATION LIST

THAT IS AVAILABLE ON DMECS

• PROVIDES CODING GUIDANCE FOR MANUFACTURERS AND

SUPPLIERS ON THE PROPER USE OF THE HEALTHCARE COMMON

PROCEDURE CODING SYSTEM (HCPCS)

• MAINTAINS AND PUBLISHES THE NDC/HCPCS CROSSWALK AND

OACD PRICING FILES

• CONDUCTS DMEPOS DATA ANALYSIS

• DME PDAC

• NORIDIAN MEDICARE

CPAP RESULTS ON PDAC

RESOURCES• DME FEE SCHEDULE JULY UPDATE

• HTTPS://WWW.CMS.GOV/MEDICARE/MEDICARE-FEE-FOR-

SERVICE-PAYMENT/DMEPOSFEESCHED/DMEPOS-FEE-

SCHEDULE.HTML

• COMPETITIVE BIDDING PROGRAM

• HTTP://WWW.DMECOMPETITIVEBID.COM/PALMETTO/CBIC

.NSF/DOCSCAT/HOME

• CMS DME MANUAL

• HTTPS://WWW.CMS.GOV/CENTER/PROVIDER-

TYPE/DURABLE-MEDICAL-EQUIPMENT-DME-

CENTER.HTML

RESOURCES• NORIDIAN MAC DOCUMENTATION CHECKLIST

• https://med.noridianmedicare.com/web/jddme/policies/docume

ntation-checklists

• MEDICARE PDAC SYSTEM

• MAC’S BY STATES

• PROGRAM INTEGRITY MANUAL CHAPTER 5 DME

• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/pim83c05.pdf.

• CMN AND DIF FORMS AND HOW TO FILL THEM OUT

• https://med.noridianmedicare.com/web/jddme/topics/documen

tation/cmn-dif

47

CEU:

THANK YOU!