Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II 1 Department of Medical Assistance Services

Elizabeth Flaherty, RNBarbara Seymour, BSWHealth Care Compliance Specialist II

http://dmasva.dmas.virginia.gov 1

Department of Medical Assistance Services

Durable Medical Equipment(DME) Training Presentation

http://dmasva.dmas.virginia.gov/ 2


AGENDA• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352)

Requirements/Time Frames/Exceptions Completion of CMN

• General Documentation Requirements• Specific DME Guidelines & Documentation Requirements• Rent vs. Purchase• DME Repairs• Service Authorization• Pricing Methodology/Billing• Quality Management Reviews• Resources



DME Program

DME and supplies are a covered services available to the entire Medicaid population. The Department of Medical Assistance Services (DMAS) may cover DME supplies when the individual is under age 21 and the item or supply could be covered under the Virginia State Plan for Medical Assistance (State Plan) through the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT.)



Freedom of Choice

Virginia Medicaid fee-for-service members are free to choose a Medicaid enrolled medical equipment and supply provider when medical equipment and supplies are a covered service. Provision of “free” supplies or items to Medicaid members as an enticement for their business may violate federal law. If a provider is utilizing this practice, DMAS may impose a civil money penalty sanction against the DME provider.



AGENDA• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352)





Covered Services and Limitations

All medically necessary DME may

be covered only if they

are medically necessary

To carry out a treatment

plan prescribed

by a practitioner(12 VAC 30-

50-165)



Covered Services – Medical Necessity

Medically necessary DME and supplies shall be:

Ordered by a practitioner on the CMN/DMAS-352

Ordered by the MEDALLION primary care physician (PCP) or referred for the service by the MEDALLION PCP, if the individual is enrolled in MEDALLION

A reasonable and medically necessary part of the individual’s treatment plan




• Consistent with the individual’s diagnosis and medical condition, particularly the functional limitations and symptoms exhibited by the individual

• Not furnished for the safety or restraint of the individual, or solely for the convenience of the family, attending physician, or other practitioner or supplier




Consistent with generally accepted professional medical standards (i.e. not experimental or investigational)

Furnished at a safe, effective, and cost effective level, and

Suitable for use in the individual’s home environment



Covered Services - Limitations

• Non-covered services can be found in Chapter IV of the DME Medicaid Provider Manual

• Non-covered DME may be explored for coverage through the EPSDT program(if individual under age of 21)

• HCPCS Codes not listed in Appendix B does not mean the item is a non-covered item



Covered Services – Nursing Facilities

• Requests for coverage of resident specific, customized items for nursing facility residents are made through the DMAS Map-225 process by the nursing facility

• DME providers can assist in this process by providing the nursing facility with– an invoice reflecting updated national codes – documentation of cost to the DME provider for

each code



Agenda• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352)





Certificate of Medical Necessity (CMN) Requirements

DME Provider

Physician

Licensed Healthcare Professional

The CMN must be:

Signed by Practitioner

Dated by Practitioner

Signed/Dated for DMAS Compliance



CMN Requirements

• There must be a completed CMN for all DME supplies/items ordered

• The physician must sign and date the CMN within 60 days of the begin date indicated on the CMN

• DMAS will not reimburse the DME provider for services provided prior to the date of the physician’s signature when the signature is not obtained within 60 days of the begin service date (section III of CMN)



CMN Requirements

The CMN allows for up

to 12 DME items/supplies

to be listed

Multiple CMN’s

must be completed if more that 12

items are ordered

Blanket orders,

i.e., “misc.

supplies” are not

acceptable



CMN Requirements

• The CMN shall not be changed, altered or amended after the attending physician has signed and dated the CMN

• If changes are necessary, as indicated by the individual’s condition, for the ordered DME or supplies, the DME provider must obtain a new CMN/DMAS-352



CMN Requirements

• Alternate versions of the CMN/DMAS-352 are not accepted

• Refer to the DMAS web portal for a copy of the CMN/DMAS-352 (www.virginiamedicaid.dmas.virginia.gov )

http://www.virginiamedicaid.dmas.virginia.gov/



CMN Requirements – Length of Certification

The CMN Shall be Valid:

Maximum period of 6 months

Individuals 21 years of age and younger



CMN Requirements – Length of Certification

• DMAS, including service authorization contractor, has the authority to determine a different length of time needed based upon the medical documentation submitted with the CMN.

• The validity time of the CMN begins with the Begin Date in Section III. If a begin date is not present it begins with the physician signature date.

• The validity of the CMN shall terminate when the individual’s medical need for the DME or supplies ends.



CMN Exceptions

• When the DME service is for nutritional supplements, the CMN/DMAS-352 is valid for six months, regardless of the individual’s age.

• DMAS may make an exception to the 60-day practitioner signature requirement if retroactive eligibility is determined. All remaining criteria, e.g., fully completed CMN, documentation requirements, and specific coverage criteria, must be satisfied in accordance with the State Plan and DMAS policy guidelines.



CMN ExceptionsA CMN is not required in the following circumstances:• Glucose monitor and diabetic supplies for

Pregnant Women - Maternity Risk Screen (DMAS - 16)• Medicare Primary- If claims come to Medicaid as

a crossover claim then a CMN is not required. (Unless denied by Medicare)

Note: If the provider knows in advance that Medicare will not cover an item/supply a CMN should be obtained.



CMN Exceptions

Glucose monitor

and diabetic supplies

for Pregnant Women-Maternity Risk Screen (DMAS-16)

Medicare Primary

– if claims submitted to Medicaid as a crossover

claim, a CMN is not required (Unless

denied by Medicare!)

A CMN is not

required in

these circumstances



Completion of the CMN

• Complete all information in section I • Individual Data• ID # is the 12 –digit Medicaid ID #• A new CMN is not required if this number changes




If questions on left are yes, describe the limitation and how the item treats the medical condition on the right. Refer to documentation guidelines in Chapter IV. Provider may also include this information in the supporting documentation

Completing ALL information in Section II assists in describing the medical necessity and helps the provider meet documentation requirements.



Completing the CMN

• ICD code is optional – if it is not supplied then

clinical diagnosis-narrative MUST be identified• Diagnosis MUST be related to item requested• Check appropriate line for date of onset




• All required sections MUST be completed

• This is the physician’s order for treatment and requests will be pended, and/or retractions will be made upon post payment review, if this section is incomplete




Begin Service Date – Mo/Day/Year• Begin Service date for CMN is optional• Starts the time clock for CMN validity time frame• If blank, CMN validity begins with physician

signature date




• HCPCS Code is optional, however the correct code must be submitted for billing.

• Identify Appropriate HCPCS code using Appendix B

• Use E1399 if a code is not found in the Appendix B

• A new CMN is not required if the national code ends during the validity time of the CMN.




Item ordered description (Required Field)• Must include a narrative description• Should clearly identify each item ordered• Each item should be ordered separately on the CMN




Length of time needed (Must be on CMN or in Supporting Documentation signed by physician

• Identify how long individual needs the DME service• Do not confuse with the CMN validity time




Quantity Ordered x 1 Month (Required Field)

• Should be based upon the quantity required to carry out the physician’s order for the person over the lifetime of the CMN

• List supplies needed for one month including overages and allowables for one month

• Durable items: complete total quantity of item needed, e.g. 1, 1 pair, 2.




Quantity/Frequency of Use Justification/ Comment• Do not use PRN frequency• Ranges many be used, e.g. 7-8 times per day• Frequency validates quantity ordered• Must be on CMN or in supporting documentation

signed and dated by the physician



Completing the CMN

• MUST be signed and dated by the physician

• Physician prescription will not be accepted

• Ordering physician’s name, printed on form

• Physician provider number is optional

• Physician telephone number (include area code) is optional



Completing the CMN – Page 2

If orders or additional information continue on the back page the physician MUST sign and date this page as well!



CMN Record Retention

• The fully completed CMN (and supporting documentation) must be kept in the individual’s record and available for review during an audit

• Copies of CMN and supporting documentation may be sent to a new servicing provider if required

• CMN and supporting documentation MUST be maintained for at least 6 years from the date of service



CMN Record Retention

• The fully completed CMN and supporting documentation:• Must be kept in the individual’s record and available for review

during a quality management review

• Copies of the CMN and supporting documentation:• May be sent to a new servicing provider if necessary

• The CMN and supporting documentation:• MUST be maintained in the clinical record for at least 6 years from

the date of service



Agenda• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352)

Requirements for use of CMN Completion of CMN




General Documentation Requirements

There must be a fully completed CMN and the documentation must identify on the CMN or the supporting documentation:

The medical need for DME

The diagnosis related to the reason for the DME request



General Documentation RequirementsDocumentation for all DME and Supplies

Must Identify:

• The individual’s functional limitation and its relationship to the requested DME

• How the DME service will treat the individual’s medical condition

• How the needs were previously met- identify what changes have occurred which necessitate the DME




Documentation for all DME and Supplies Must Identify:

• The quantity needed and why that amount is needed

• The frequency of use• The estimated length of use of the equipment• Conjunctive treatment related to the use of the

DME/supplies




Documentation for all DME and Supplies Must Identify:

• How the service will be used (and is required) within the individual’s home environment,

• The individual or caregiver’s ability, willingness, and motivation to use the equipment, and

• Alternatives explored/tried and describe success/failure




Documentation for all DME and Supplies must identify:• Assessments/evaluations from other Healthcare

Professionals:– Nurses– Rehabilitative Therapists– Rehabilitative Engineers– Trained DME Professionals

• All supporting documentation must be signed/dated by the physician



Requirement for Supportive Documentation

Supporting documentation does not replace the requirement of the fully completed CMN

The dates on supporting must coincide with the dates of service on the CMN

Examples of supporting documentation: physician’s letter, licensed therapist evaluation, etc.



Agenda• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352) Requirements for use of CMN Completion of CMN

• General Documentation Requirements• Specific DME Guidelines & Documentation

Requirements• Rent vs. Purchase• DME Repairs• Service Authorization• Pricing Methodology/Billing• Quality Management Reviews• Resources



Requirements for Specific DME



Guidelines of Specific DME

In addition to the Medical Necessity guidelines described in Chapter IV, and the previously discussed documentation requirements for all DME and supplies, specific additional medical justification and/or documentation requirements are in place for the following DME.



Guidelines and Documentation - Specific DME

• Wheelchairs• Wound Care

Supplies• Enteral Nutrition• Home Infusion

Therapy• Orthotics

These DME items will be discussed in the upcoming slides



Guidelines and Documentation – Specific DME

• Hospital Beds• Patient Lifts• Augmentative

Communication Devices• Rehabilitative Equipment• Respiratory Equipment• Therapeutic Beds and

Mattresses

Guidelines regarding these additional specific DME items can be found in Chapter IV, Virginia Medicaid DME Provider Manual, located on the DMAS portal:

www.virginiamedicaid.dmas.virginia.gov





Specific Guidelines - Wheelchairs

• Specialized or customized wheelchairs may include HCPCS codes in the DME list which do not require service authorization, but that may require a specialty hands on evaluation. Customized equipment is defined as equipment that is uniquely constructed or substantially modified by the provider from the standard product for a specific member according to the description and orders of a practitioner, and in such a way that the equipment can only be used by the specific member.

• Specialized wheelchairs must have a “hands on” evaluation completed by a licensed health care professional experienced in fitting wheelchairs

• This evaluation must be signed and dated by the physician



Specific Guidelines - Wound Care

• Documentation must include:– The related diagnosis, number of wounds with

stages, measurements, and description of the wound

– Who is doing the wound care

• Wound care supplies used during the course of a home health visit are included in the Home Health visit rate



Specific Guidelines - Enteral Nutrition

• Coverage is available for nutritional supplements regardless of whether or not the supplement is administered orally or through a Nasogastric or gastrostomy tube

• Oral coverage however, does not include the provision of “routine” infant formulae

• For the general Medicaid population, coverage is limited to when the supplement is the sole source form of nutrition and necessary to treat a medical condition



Specific Guidelines – Enteral Nutrition

• SOLE SOURCE: 75% or greater of the calories per day come from the enteral nutrition

• Exceptions include those individuals authorized through the Technology-Assisted Waiver, where the supplement must be the primary source of nutrition, is administered orally or through a nasogastric or gastrostomy tube, and is necessary to treat a medical condition

• DMAS will reimburse under EPSDT for medically necessary formula and medical foods when used under physician direction to augment dietary limitations or provide primary nutrition to individuals via enteral or oral feeding methods




• Brand name of supplement or category of Enteral nutrition must be documented

• Provider must supply a specific supplement, if physician ordered one

• Prior authorization is not required for nutritional supplements




• The CMN/DMAS-352 form is required for all nutritional supplements and supplies regardless of whether or not the individual is enrolled in a waiver program

• The CMN must specify either a brand name of the supplement being ordered or the category of Enteral nutrition that must be provided. If a physician orders a specific supplement, the DME provider must supply the brand prescribed




• The CMN must be signed and dated by the physician within 60 days of the begin service date

• If not signed within 60 days of the begin service date, it will be valid on the date of the physician’s signature




• If the physician order changes, a new CMN is required

• The CMN ordering nutritional supplements is valid for a maximum of six months from the CMN begin service date, regardless of the age of the individual



Specific Guidelines-Enteral Nutrition

• A new CMN is required every six months for ongoing nutritional supplement services.

• The DMAS-115 form is no longer required The required information from the nutritional assessment must be on the CMN or in supporting documentation signed and dated by the physician



Specific Guidelines – Home Infusion Therapy

Definition: Intravenous (IV) administration of fluids, drugs, chemical agents, or parental nutritional substances to individuals in the home setting.



Specific Guidelines-Home Infusion Therapy

Home Infusion Therapy

Medically necessary to treat the individual’s medical conditionIn accordance

with accepted medical practice; and

Not for the convenience of the individual or the caregiver




The individual must:• Must reside in either a private home or

assisted living facility or group home.• Must be under the care of a physician who

prescribes the home infusion therapy and monitors the progress of the therapy




• Must have body sites available for IV catheter or needle placement or have central venous access

• Must be capable of self-administering or have a caregiver that can be adequately trained, is capable, and willing to administer/monitor home infusion therapy safely and efficiently




The home IV payment methodology is not applicable to:

• Subcutaneous delivery• Intramuscular delivery• Clysis delivery• Site care• Enteral/Foley care



Specific Guidelines - Orthotics

Includes the services necessary to design the device, including measuring, fitting, and instructing the individual in it’s use.

Orthotic coverage includes devices that support or align extremities to prevent or correct deformities, or improve functioning.



Specific Guidelines - Orthotics

• Orthotics, including braces, splints, and supports, are not covered for the general adult Medicaid population under the DME program, with the exception of coverage while participating in an inpatient Intensive Rehabilitation program

• All medically necessary orthotics are covered for children under the age of 21 years through the EPSDT program



Agenda• Introduction• DME Covered Services and Limitations• Certificate of Medical Necessity (CMN/DMAS-352) Requirements for use of CMN Completion of CMN• General Documentation Requirements• Specific DME Guidelines & Documentation Requirements• Rent vs. Purchase• DME Repairs• Service Authorization• Pricing Methodology/Billing• Quality Management Reviews• Resources



Rent vs. PurchaseRENTAL

• SHORT-TERM USE• CONDITION IS EXPECTED TO CHANGE• APPENDIX B IDENTIFIES THE RENTAL CODES AND DEFINES THE

LENGTH OF TIME CONSIDERED TO BE SHORT-TERM

PURCHASE• LONG-TERM USE• CONDITION IS NOT EXPECTED TO CHANGE

RELATIVE TO THE LENGTH OF TIME THE DME SERVICE IS ORDERED ON THE CMN



Rental vs. Purchase

DMAS will NOT pay for rental days that DME service/item is not used by the individual

Rental beyond the allowable limits in the DME Listing requires service authorization

When it is determined a DME item was rented; however, should have been purchased DMAS will only provide

reimbursement up to the established purchase price



Rental vs. Purchase

• There are rental/purchase guidelines in the Manual for specific DME items:– Apnea Monitors– CPAP– TENS Units– Augmentative Communication Devices

• DMAS requires documentation of individual’s benefit and compliance






DME Repairs

• The cost to repair rental equipment is considered the DME provider’s responsibility

• Charges for repair(s) to medically necessary, individual owned equipment may be billed to DMAS using the proper DMAS HCPCS code. The provider should document in the individual’s record if the equipment is individual owned

• Labor charge is for repairing the equipment and not administrative service or driving time to/from the individual’s home



DME Repairs

The provider must accept Medicaid payment as payment

in full, and may not bill the individual for any portion of

the repair, including shipping and handling charges.






Service Authorization

Service authorization (SA) is the process to approve specific services for an enrolled Medicaid, FAMIS Plus or FAMIS individual by a Medicaid enrolled provider prior to service delivery and reimbursement. Some services do not require SA and some may begin prior to requesting authorization.



Service Authorization-Purpose

The purpose of service authorization is to validate that the service requested is medically necessary and meets DMAS criteria for reimbursement. Service authorization does not guarantee payment for the service nor does it supersede any of the documentation requirements.



Service AuthorizationPayment is contingent upon passing all edits contained within the claims payment process, the individual’s continued Medicaid eligibility, the provider’s continued Medicaid eligibility, and ongoing medical necessity for the service. Service authorization is specific to an individual, a provider, a service code, an established quantity of units, and for specific dates of service.



Service Authorization

• The DMAS SA contractor has information related to the service authorization processes for all Medicaid programs they review

• Fax forms, service authorization checklists, trainings, methods of submission and much more are on KEPRO’s website. Providers may access this information by going to:

http://dmas.kepro.com

http://dmas.kepro.com/



Service Authorization – Appeals

• Reconsiderations for denied service authorizations must be requested and mailed to DMAS within 30 days of the denial to the unit performing the preauthorization function

• Appeals of adverse reconsiderations may be mailed within in 30 days of the denial to: Director, Appeals Division

600 East Broad Street

Richmond, VA 23219






Pricing Methodology/Billing

DME items that:• Have a national code and a set fee the

rate will be the Medicare Competitive Bid Rate, if available or the DMERC rate minus 10%

• Have a July 1, 2010 rate, but do not have a national code, bill the E1399 miscellaneous code. The rate will be the posted in the Appendix B




DME items that:• Have a national code, but no DMERC or July 1,

2010 rate - the rate will be Individual Consideration (IC) = provider’s cost, minus shipping and handling charges, plus 30%

Documentation in individual’s record must show the provider’s cost on an invoice from manufacturer or supplier (a quote is not acceptable for final documentation).




DME items that: • Do not have a national code, or a July 1, 1996

rate, the E1399 miscellaneous code will be used; the rate = manufacturer’s cost (to the provider) plus 30%

Documentation in individual record must show the provider’s cost via invoice from manufacturer or supplier



Billing Changes

If a member has a primary insurance and the provider asserts the item is not covered by the primary insurance the provider must bill the primary insurance at least 1 time and then attach the EOB to all claims – regardless of how long the item is supplied by the provider.






Quality Management Reviews (QMRs)

• The Department of Medical Assistance Services routinely conducts compliance reviews to ensure that the services provided to Medicaid members are medically necessary and appropriate and are provided by the appropriate provider. These reviews are mandated by Title 42 C.F.R., Part 455



QMR – Provider Review

DMAS’ contractors will be conducting on-site or desk review activities throughout the state!



QMR – Provider Responsibility

Providers are to:• Verify individual’s Medicaid eligibility• Obtain SA when required• Deliver only item(s) ordered by the

physician on the CMN/DMAS-352• Deliver only the quantities ordered by the

physician on the CMN/DMAS-352• Deliver only the item(s) for the periods of

service covered on the physician’s order




Providers are to:• Maintain physician’s order and supporting

documentation• Document and justify the description of

services • Document all equipment and supplies

provided to an individual in accordance with physician’s order




• Document of service provision The delivery ticket must document the:

– Individual name– Date of delivery– Item/supply was delivered – to include

accessories to primary item ordered on CMN

– Quantity delivered



QMR – Retractable Issues

DMAS will deny or retract payment when the following occur:

• Invalid CMN/DMAS-352• Documentation does not verify the

item/supply was provided• Lack of medical documentation to justify

provision of the DME• DME item does not meet DMAS criteria



QMR – Top Discrepancy Issues

• CMN: Missing / Invalid / Incomplete / Expired / Outdated or Altered

• Insufficient medical documentation• Service provided in excess of physician’s

order/CMN• Medical necessity not justified• Service delivery not documented




• Item not covered or does not meet DMAS coverage criteria

• Items rented vs purchased• Frequency does not justify quantity

provided




• Supplying two different mobility devices on the same date without documentation to support each device

• Services included in other program reimbursement (standard parts, home health nursing, etc.)

• Billing for supplies used outside the home (M.D. office or home health clinic)



QMR – Top Discrepancy Issues• Enteral Nutrition Policy:

– Failure to obtain a new CMN every six months

– Nutritional assessment information is missing from CMN or no supporting documentation

– Improper calculation of units for billing– Not following policy of “sole source” of

nutrition for adults



QMR –Provider Appeals

A provider may appeal an adverse decision where a service has already been provided, by filing a written notice for a first-level Informal Appeal with the DMAS Appeals Division within 30 calendar days of the receipt of the adverse decision.



QMR – Provider Appeals

If a provider is dissatisfied with first-level decision, the provider may file a written notice for a second-level appeal. The notice for a second-level Formal Appeal must be filed within 30 calendar days of receipt of the first-level Informal Appeal decision.



Provider Appeals

The notice(s) of appeal is considered filed when it is date stamped by the DMAS Appeals Division. The notice must identify the issues being appealed. Notices of Appeal must be sent to:

Appeals Division Department of Medical Assistance Services 600 East Broad Street, 6thFloor Richmond, VA 23219






Contact Information

Division of Long Term Care Fax number: 804-612-0050

Address:DMAS-Division of Long Term Care600 East Broad StreetRichmond, Virginia 23219



Medicaid Resources

Web Site: www.dmas.virginia.govWeb Portal:

www.virginiamedicaid.dmas.virginia.gov

These sites provide a wealth of information to providers and provides access to such resources as: manuals, memos, training presentations, and provider forms.

http://www.dmas.virginia.gov/




Medicaid Resources

DMAS has a dedicated email address specifically for providers for questions about DME. ([email protected]) This is not a secure email so please do not include individual specific information.

mailto:[email protected]



Medicaid Resources

E-mail questions should pertain to polices, codes, or rates and should not pertain to SA, billing, or claims. Please refer these questions to the appropriate unit.

Service Authorization Contact Information:Kepro - 888.827.2884 or via email at [email protected] or [email protected]

Billing/Claims – Call the helpline at 800-552-8627.





DME Presentation

Thank You!Elizabeth Flaherty, RNBarbara R. Seymour, BSW

Documents

Elizabeth Flaherty, RN Barbara Seymour, BSW Health Care Compliance Specialist II 1 Department of Medical Assistance Services