DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012

NC Department of Health and Human Services medicaidnorthcarolinamedicaidnorthcarolina

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DURABLE MEDICAL EQUIPMENTDURABLE MEDICAL EQUIPMENTORTHOTICS & PROSTHETICS ORTHOTICS & PROSTHETICS

WEBINARSWEBINARSMAY 2012MAY 2012

Presented by:Presented by:Debbie Leblanc and Yesenia OsorioDebbie Leblanc and Yesenia Osorio

HP Enterprise ServicesHP Enterprise Services

medicaidnorthcarolinamedicaidnorthcarolina

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INTRODUCTIONS• HP Enterprise Services

• Division of Medical Assistance (DMA)


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AGENDA• Program Integrity• EPSDT• N. C. Health Choice• Community Care of North Carolina/Carolina Access• Policy Updates• Prior Approval• Billing Tips• Q & A


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DMAPROGRAM INTEGRITY


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Program (PI) Integrity Unit• Federally mandated

• Prevent, identify, and combat fraud, waste, and abuse within the

Medicaid Program

• Ensure Medicaid recipients receive quality care and do not abuse their benefits

• Take administrative actions when aberrancies are identified


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Program (PI) Integrity Unit It is the mission of Program Integrity to ensure

compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid

appropriately by implementing tort recoveries, pursuing recoupments, and identifying

avenues for cost avoidance.


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Program (PI) Integrity AuthorityFederal

• Code of Federal Regulations (Title 42

Public Health)

• Social Security ActAmendments

• Affordable Care Act

State • General Statues

• State Plan

• State ClinicalPolicies and Bulletin Articles


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Program Integrity Sections • Provider Medical

Review

• Home Care Review Section

• Behavioral Health Review Section

• Third-Party Recovery Section

• Special Projects

Section

• Quality Assurance Section


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IBM Fraud and Abuse Management System (FAMS)

• Data mining software using behavior models to detect common fraud and abuse schemes– Models configured to North Carolina Medicaid using

input from DMA staff

• Algorithms and models used across Healthcare Industry (both public and private payers) as well as cell phone companies, property and casualty insurers, and more


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DME Model• Model: Measurement of provider behavior

– Used to analyze provider as a whole

• DMA Program Integrity, DMA Clinical Policy, and IBM worked together to develop criteria– Example: Number of diapers per patient per month

• PI Data analytics team performed analysis to identify suspicious behavior for further review


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Examples of Initial Findings• Billing for up to 480 nutritional kits per patient, per

month

• Various sizes of diapers for same patient, same date of service

• Two year old receiving enough thickener for 2 gallons of fluid per day


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EPSDT


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EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT

(EPSDT)

MEDICAID FOR CHILDREN Contacts: Director

c/o Assistant Director for Clinical Policy and ProgramsDivision of Medical Assistance2501 Mail Service CenterRaleigh, NC 27699-2501Fax: 919-715-7659


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EPSDT WebsitesBasic Medicaid & N.C. Health Choice Billing Guide

http://www.ncdhhs.gov/dma/basicmed/index.htm

Health Check Billing Guidehttp://www.ncdhhs.gov/dma/healthcheck/index.htm#guide

EPSDT Provider Pagehttp://www.ncdhhs.gov/dma/provider/epsdthealthcheck.htm


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N. C. HEALTH CHOICE


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N. C. Health Choice (NCHC) Claims• Run-out period with BCBSNC was February 29, 2012

for dates of service through September 30, 2011

• Dates of service prior to October 1, 2011 contact DMA Claims Analysis unit at 919-855-4045

Basic Medicaid Billing Guide – Section 3


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Health Choice Eligibility Criteria• Children ages 6-18 (last day of month they turn 19) • No EPSDT• Does not qualify for Medicaid, Medicare, or other

federal government sponsored health insurance• NC resident• Has paid enrollment fee (if applicable)• Within 101% - 200% of the Federal Poverty Level• Co pays do not apply for DME or O&P



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Health Choice Identification Card



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Health Choice Secondary InsurancePursuant to N.C. GEN. STAT. §108A –

70.18(8): Health Choice does not allow secondary insurance. It is the recipient’s duty

to notify the Department of Social Services (DSS) prior to approval, and/or within 10 days of receipt of the other health insurance. The DSS, upon receipt of notice, shall disenroll

the child from the Program.



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Health Choice Resources• Clinical Coverage Policies

http://www.ncdhhs.gov/dma/hcmp/index.htm

• What’s New in DMAhttp://www.ncdhhs.gov/dma/provider/index.htm

• NC Healthy Start Foundationwww.NCHealthyStart.org

• Fee Scheduleshttp://www.ncdhhs.gov/dma/fee/index.htm

• Children with Special Health Care Needs Help Line1-800-737-3028


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Medicaid ID Card

ISSUE DATE MARCH 1, 2012

DHHS Customer Service Center at 1-800-662-7030.


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Federal Regulations• Medicaid is the “payer of last resort”

• If the Medicaid-allowed amount is more than third-party payment, Medicaid will pay the difference up to the Medicaid-allowed amount

• If insurance payment is more than Medicaid-allowed amount Medicaid will not pay any additional amount

• Does not apply to NCHC


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Noncompliance Denials• Medicaid does not pay for services denied by private

health plans due to noncompliance with the private health plan’s requirements

• Compliance with the plan’s requirements is the responsibility of the provider and the patient

• It is the recipient’s responsibility to inform the County DSS of any third-party insurance as well as any changes in insurance coverage.


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CCNC/CA


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CCNC Structure• Statewide program of 14 regional networks

– Non-profits that operate in partnership with hospitals, health depts., DSS, PCPs and others

– Include more than 3000 physicians– Physician led by clinical director

http://www.ncdhhs.gov/dma/ca/ccncproviderinfo.htm



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Process for Giving a CCNC/CA Referral

• For Carolina ACCESS enrollees, the PCP’s NPI number must be provided to the specialist or other health service provider as the authorization number

• Please use the NPI that the PCP reported to DMA for

the Medicaid Provider Number (MPN) used to link Carolina ACCESS recipients to their practice



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CCNC/CA Override Requests• Only for extenuating circumstances• Only considered within 6 months• Carolina Access Override Request Form

http://www.ncdhhs.gov/dma/provider/forms.htm• DME Override Requests are forwarded to DMA for

evaluation



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POLICY


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Policy Guidelines• Refer to Clinical Coverage Policy:

– 5A, Durable Medical Equipment refer to website http://www.ncdhhs.gov/dma/mp/dmepdf.pdf

– 5B, Orthotics and Prosthetics refer to website http://www.ncdhhs.gov/dma/mp/5B.pdf


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General DME Policy Updates• Changes retroactive to October 1, 2011• HCPCS Code list, item description and lifetime

expectancy or quantity limitations – Attachment A of policy

• Effective May 11, 2012, please note the additions to the following sections of the Medical Coverage Policy #5, Durable Medical Equipment have been posted for 15 day public comment; section 5.3.6 Rental Wheelchairs, section 5.6 Delivery of Service and

section 7.2 Record Keeping.


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Roche ACCU-CHEK Diabetic Supplies Under the DME and Pharmacy Programs

• Effective November 15, 2011, Roche Diagnostics Corporation Diabetes Care is N.C. Medicaid's designated preferred manufacturer for blood glucose monitors, diabetic test strips, control solutions, lancets, and lancing devices. These products are covered under the Durable Medical Equipment and Outpatient Pharmacy Programs and will be reimbursed under the pharmacy point-of-sale system with a prescription.

• Prior authorization will be allowed for insulin-pump dependent recipients who cannot use Roche products. Pharmacy and DME providers need to ensure that invoices are easily retrievable in case documentation is needed to support the billing of these products. This could be requested to support the quantities being invoiced to Roche for the rebates due back to N.C. Medicaid and N.C. Health Choice.

• Effective November 15, 2011, there are no designated preferred manufacturers of insulin syringes.

• For additional information, providers may call ACCU-CHEK Customer Care, 1-877-906-8969 or DMA Clinical Policies and Programs at 919-855-4310 (DME) or 919-855-4300 (Pharmacy).


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Diabetic Supplies• Roche ACCU-CHEK Diabetic Supplies Program Extension.• Prodigy diabetic supplies coverage extended until July 31,

2012.• Roche and Prodigy diabetic supplies will be covered until July

31, 2012.• Overrides will not be required. This applies to the durable

medical equipment (DME) and pharmacy point-of-sale claims processing systems.

• Effective August 1, 2012 only ACCU- CHEK diabetic supplies will be covered.


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Prior Authorization Instructions for Insulin Pump Users

With an effective date based on date of service of January 15, 2012 prior authorization will be required for insulin-pump dependent recipients who cannot use Roche products due to a dedicated glucometer communicating with their insulin pump. In these instances the provider must be a durable medical equipment (DME) provider or a pharmacy/DME provider. Claims with a prior authorization on file will need to be submitted with a NU and U9 modifier. Claims for test strips not supplied by Roche that do not have a Prior authorization on file for A4253 NU, U9 will be denied for lack of authorization. The U9 modifier will indicate that test strips not supplied by Roche have been authorized for payment. Prior authorization requests should be submitted to HPES at the following addresses:

N.C. MedicaidP.O. Box 31188

Raleigh, NC 27622

N.C. Health ChoiceP.O. Box 322490

Raleigh, NC 27622


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Prior Authorization Instructions for Insulin Pump UsersBilling Instructions for Submitting Diabetic Supplies under Pharmacy Point-of-Sale System Claims for diabetic test strips, control solution, lancets and lancing devices submitted at point-of-sale must be billed using the NDC. Test strips must be billed in multiples of 50 and lancets must be billed in multiples of 100 except for the ACCU-CHEK Compact Test Strips, 51 count package size and the ACCU-CHEK Multiclix Lancets, 102 count package size. In order to accommodate the unbreakable package sizes under the pharmacy point-of-sale system, the ACCU-CHEK Compact Test Strips (NDC 50924-0988-50) can be billed up to 204 test strips per month for recipients 21 years of age and older and up to 306 test strips per month for recipients under 21 years of age will be allowed. At this time, test strip quantities over 204 per month must be requested through the DME program; however, point-of-sale system changes are underway to accommodate the higher quantity limits for pediatric recipients. Additional information will be provided when this system change has been completed. The same rules apply for the ACCU-CHEK Multiclix Lancets (NDC 50924-0450-01). For Medicaid billing, 1 lancing device = 1 unit. Rates apply to these diabetic supplies; therefore, no copayments and no dispensing fees apply.


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Pediatric Specialty Beds• New addition to hospital beds• Examples are SleepSafe or Pedicraft bed• Special safety features• Designed for children with physical/cognitive

disabilities• Prior Approval (PA) required

Clinical Coverage Policy 5A - Section 5.3.1


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Wheelchairs• PA is required for all wheelchairs• Basic criteria must be met• In addition, more justification for other wheelchairs• Standard criteria change

– Home evaluation required– Adequate access between rooms– Maneuvering space and services

• All Wheelchairs are to be used in the home



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Ultra Light Weight Wheelchair• Recipient in wheelchair minimum of 6 hours• MUST have clinical wheelchair evaluation from a

Physical or Occupational Therapist (PT/OT)• Description of recipient’s medical condition, mobility

limitations, and other physical /functional limitations• PT/OT shall have no financial relationship with

supplier• Manufacturer Suggested Retail Price (MSRP) quote

for PA required for wheelchair and accessories



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High-Strength Lightweight Wheelchair

• Basic manual wheelchair coverage criteria• Recipient in wheelchair minimum of 6 hours a day



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Adult Manual Wheelchair• Basic Manual Wheelchair coverage criteria• Coverage criteria for tilt in space option• Letter of medical necessity from PT/OT• MSRP quote• Clinical wheelchair evaluation



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Transport Chairs/Rollabout Chairs• Adult/Pediatric covered if recipient needs to be

mobilized by caregiver• Covered when medically necessary• PA IS required for transport chairs• PA is NOT required for rollabout chair• For specific codes covered refer to: Attachment A, C:

Procedure Code(s) Lifetime Expectancies and Quantity Limitations for DME and Supplies, Transport Chairs



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Power Wheelchairs• Standard power wheelchair criteria plus additional

information has to be met• Height, weight, and body measurements must be

included in evaluation for Heavy Duty Power chairs• Manufacturer’s specified weight capacity is needed• Power Seat Elevation ONLY covered for 0-20 years of

age



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Power Wheelchairs• Face-to-face examination consisting of in-person visit

to treating physician required to request chair and comprehensive medical exam– Examination must be documented in detail in physician

chart– Must indicate major reason for visit was mobility exam– Must document recipient strength, mobility and

functional deficits to support need



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Power Wheelchairs• Face-to-face evaluation prior to physician’s order

– Information of condition and progression of disease– Ambulatory status– Medical justification for accessories billed– Additional clinical health care records can be

submitted to supplement



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Power Wheelchairs• Onsite written assessment of recipient’s home

required– Verifies, documents and supports use– Performed by supplier– Must include measurements of home layout, doorway

widths and thresholds and surfaces traveled



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Power Wheelchairs• MSRP quote from the manufacturer required

– Wheelchair supplier generated form MUST NOT be used for documentation of physician’s exam

– Backup chairs are not covered – Power wheelchair is not medically necessary when

condition is reversible and length of need less than 3 months



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Activity/Positioning Chairs• PA required and now reviewed at HPES• Recipients ages 0 - 20 years of age• Physical disabilities and positioning support to sit

and perform activities• Meet medically necessary criteria



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Osteogenesis Stimulator• Surgery removed as requirement• Requires 2 sets of radiographs prior to treatment• Radiographs require multiple views of facture site• Written interpretation by MD, PA or NP of no evidence

healing



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Continuous Glucose Monitoring System and Supplies

• Ages 0 - 20 years• PA required• Medicaid covered criteria:

– Insulin-dependent diabetes– Documentation of recurrent severe hypoglycemic

episodes or fasting hyperglycemia, nocturnal hypoglycemic episodes, hypoglycemic unawareness

– Recipient has external insulin pump which communicates with a CGMS



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High-Frequency Chest WallOscillation Device

• Diagnoses added to criteria– Neuromuscular diagnosis– Neuromuscular conditions– High level spinal cord injuries

• Covered diagnoses – Attachment A & B in Policy



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Cough-Stimulating Device• Diagnoses added to criteria

– Neuromuscular diagnosis– Neuromuscular conditions– High level spinal cord injuries

• Covered diagnoses – Attachment A & B in Policy



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Oral Nutrition Metabolic Formula• Metabolic formulas are covered for recipients ages

0 - 115– In-born errors of metabolism diagnosed at birth and

before the age of 10 years



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Oral Nutrition Metabolic Formula• Medical necessity must be re-established at specific

intervals by providing Oral Nutrition Product Request Form and CMN/PA– Every 12 months for diagnosed inborn error of metabolism– Every 6 months with documentation for other conditions– For recipients receiving modular components and feeding

devices, submit at either 6 or 12-month interval– http://www.ncdhhs.gov/dma/forms/OralNutritionProdReq.pdf



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Bath and Toilet Aids• Pediatric 0 – 20 years• PA now reviewed at HPES• Accessory Codes NO LONGER W4047• Accessory Codes NOW E0700



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PRIOR APPROVAL


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Due Process• Effective March 21, 2012• Notice of Request for Additional Information to

recipients and providers from HPES• Medicaid is requesting medically necessary

documentation to meet clinical policy criteria • Return all information initially submitted to HPES

plus the additional documentation requested• Not a denial but must be submitted timely• Submission deadline date on Notice of Request


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Prior Approval • See Basic Medicaid & N.C. Health Choice Billing

Guide Section 7• CMN 3-part required for all services• PA obtained before rendering a service, product or

procedure• Does not guarantee payment• PA not transferable• Usually takes 5 business days from receipt


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Prior Approval• Height and weight required on the CMN regardless of

diagnosis• CMN/PA forms in use prior to 2005 that did not

contain the height and weight requirement will no longer be accepted after June 1, 2012

• Contact HPES at: 1-800-688-6696 or 919-851-8888, option #2


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DME Prior Approval TipsCommon reasons for PA returns:• Original signed/dated CMN missing• Both state and national codes not included on CMN,

or incorrect code listed• Use of signature stamp not acceptable• Correction tape/fluid used on CMN• Sections 14 through 23 not completed correctly• All items including supplies & accessories need to be

listed separately


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DME Prior Approval TipsWheelchairs and Beds:• Include height and weight• Mark “Confined” in field 22 when appropriate• When “Not confined” is marked, provider must

complete “Walks” section and specify max distance walked

• Procedure codes in Groups 2 and 3 must include specific wound documentation


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DME Prior Approval TipsWound Documentation:• Be specific when documenting. Example: for

tunneling, do not write yes or no. Provide location, size, drainage, etc.

• Reviewed each month• Procedure codes in Groups 2 and 3 must include

specific wound documentation


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DME Prior Approval TipsOxygen:• When recertifying, include original qualifying oxygen

percent saturation level and the date (mm/dd/yy) taken

• At the end of 36 months, ALL recipients must be recertified


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DME Prior Approval TipsCPAP and ByPAP:• Diagnosis of Obstructive Sleep Apnea (OSA)• Sleep study done within 1 year must be provided

– Cannot be an in home sleep study


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Prior Approval Form (CMN)• Providers may obtain CMN/PA Forms by contacting:

HPES at 1-800-688-6696 or 919-851-8888, option #3

• CMN/PA forms that were in use prior to 2005 that did not contain the height and weight requirement will no longer be accepted after June 1, 2012


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Orthotics & Prosthetics Prior Approval Tips

All CMN requests should include:• Two provider numbers in Field 7• Two signatures in Field 27• Manufacturer’s price quote sheet for manually priced

items


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• Diabetic Shoes CMN criteria:– Recipient has diabetes mellitus– Recipient has one or more required conditions– Physician certification


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• PA Forms are found in Attachment G of Policy 5B for:– Component L5781 or L5782– Component L5930– Component L5968– Component L5980– Component L5987– Component L5988


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Prior Approval ContactsSend CMN to:HPES/PAP. O. Box 31188Raleigh, NC 27627

Health Choice Prior Approvals processed by HPES:N.C. Health ChoiceP. O. Box 322490Raleigh, NC 27622


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BILLING TIPS


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DME Labor/Repair/ReplacementEffective July 1, 2011 Medicaid & effective October 1, 2011 N.C. Health Choice will pay for:

• K0739 (labor)• Repair of medical equipment owned, not under

warranty• Installation of replacement parts• Repair estimate required• Breakdown of charges• Number of hours of labor • Prior Approval Required


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Labor/Repair/Replacement• Medicaid & N.C. Health Choice will NOT pay for:

– Pick up or delivery– Assembly of new equipment– Freight– Provider travel time or expense– Maintenance or service contracts

• Rental Equipment:– Service and repairs provided as part of rental rate– No additional payment by Medicaid or N.C. Health

Choice


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DME Labor/Repair/Replacement Example• Power Wheelchair K0823• Complaint – batteries will not charge• Solution – replace batteries• Labor – 2 units (installation of replacement parts)

If seat and housing to be removed, more complex repair• Labor – up to 4 units (installation of replacement parts)

Examples/scenarios are not all inclusive and labor units are rough estimates of what might be considered reasonable


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DME Labor/Repair/Replacement Example• Manual Wheelchair K0003• Complaint – Brake assembly fell off• Solution – Replace brake assembly• Provider – Provides and installs replacement parts• Labor – up to 3 units (installation)

Examples/scenarios are not all inclusive and labor units are rough estimates of what might be considered reasonable


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Nebulizer Billing by Pharmacies• Nebulizers and related supplies must be billed with

DME NPI & not as Point-of-Sale• Recipients must meet medical necessity

requirements as listed in DME Clinical Coverage Policy No. 5A

• Self-contained, ultrasonic nebulizer and related supplies require Prior Approval

• Attachment A - Specific HCPCS codes covered by Medicaid or N.C. Health Choice

• Attachment A - Procedure Code(s) Lifetime Expectancies and Quantity Limitations


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Q & A

Documents

DURABLE MEDICAL EQUIPMENT ORTHOTICS & PROSTHETICS WEBINARS MAY 2012