7/11/2016
DME Repairs and Replacements
Presented by
Noridian Provider Outreach and Education
July 2016
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Disclaimer
This information release is the property of Noridian Healthcare Solutions, LLC.
It may be freely distributed in its entirety, but may not be modified, sold for profit
or used in commercial documents.
The information is provided “as is” without any expressed or implied warranty.
While all information in this document is believed to be correct at the time of
writing, this document is for educational purposes only and does not purport to
provide legal advice. All models, methodologies and guidelines are undergoing
continuous improvement and modification by Noridian and the Centers for
Medicare & Medicaid Services (CMS). The most current edition of the
information contained in this release can be found on the Noridian website and
the CMS website.
The identification of an organization or product in this information does not
imply any form of endorsement. CPT codes, descriptors, and other data only
are copyright 2016 American Medical Association (or such other date of
publication of CPT). All Rights Reserved. Applicable FARS/DFARS apply.
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Noridian Medicare Website (https://med.noridianmedicare.com)
CMS Website (https://www.cms.gov)
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Workshop Protocol
• Attendee lines are muted upon entry
• Questions
– Written questions in Q & A section
– Verbal questions at the conclusion of the material
• Certificate of Completion
– CEUs are NOT offered for this course
– 1 AAPC CEU is offered for this course
– Certificate of Completion emailed to all attendees with
2-3 business days following the workshop
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How to Ask a Written Question
• Click on the Q and A
tab
• Address “All
Panelists”
• Type your question
into the box
– Limit 256 characters
– Be concise
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Acronyms
• CERT:
Comprehensive Error
Rate Testing
• DMEPOS: Durable
Medical Equipment,
Prosthetics, Orthotics
and Supplies
• DOS: Date of Service
• DWO: Detailed
Written Order
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• LCD: Local Coverage
Determination
• MLN: Medicare
Learning Network
• OIG: Office of
Inspector General
• POD: Proof of
Delivery
• POS: Place of
Service
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CERT 2015 Improper Payment Rates
• CERT Improper Payment Rate webpage
(https://www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/MedicareFFS-Compliance-Programs/CERT/index.html)
Improper Error Rate
Improper Payment Amount (2)
Inpatient Hospitals
6.2%
$7.0 Billion
Durable Medical Equipment
39.9%
$3.2 Billion
Physician/Lab/Ambulance
12.7%
$11.5 Billion
Non‐Inpatient Hospital Facilities
14.7%
$21.7 Billion
Overall
12.1%
$43.3 Billion
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Service Type
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Agenda
Definitions
Repairs
Repair Parts
Labor
Loaner Equipment
Replacement (Reasonable Useful Life)
Resources
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Definitions
• Repair
– Fix or mend, put back in good condition after damage or
wear
• Replacement
– Replacing an identical or nearly identical item
• Change in item because of change in need is NOT a
replacement for purposes of this training
• Irreparable wear
– Deterioration sustained from day-to-day use
• Reasonable useful lifetime (RUL)
– Expected lifetime of an item
• Irreparable damage
– Refers to specific accident or natural disaster
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Repairs to Equipment
Purchased by Medicare
• Beneficiary owns equipment
• Equipment is reasonable and necessary
– If Medicare paid for base equipment initially, medical
necessity for the base equipment has been
established
• Timely continued need documentation required
• Necessity of the repair in the physician’s or
suppliers records
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Repairs to Equipment
Not Purchased by Medicare
• Equipment meets definition of a benefit category
• Reasonable and necessary criteria met
– Documentation supporting LCD requirements met
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Repairs Denied
• Repair not allowed if:
– Beneficiary-owned but not paid for by Medicare and
equipment does not meet coverage criteria
– Rented equipment including:
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Frequent and substantial serviced items
Oxygen Equipment
Capped rental items
Rented IRP items
– Previously denied equipment
– Beneficiary owned equipment that is under warranty
– Routine maintenance is not a repair
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Parts
• When replacing a part as a repair use the
appropriate HCPCS code
– NOC codes should be used ONLY when an
appropriate HCPCS code does not exist
• K0108, E1399, A9999 must include a description of the item
– Do not bill separately for nuts, bolts, screws which are
included in the allowance of the item being
replaced/repaired
– Narrative description of the repair, base piece of
equipment that is being repaired, and date of
purchased
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Wheelchair Options and
Accessories, and Seating
• Options, accessories and seating systems may
require component parts to repair
• Replacing the entire option, accessory or
seating system is considered a replacement
– Refer to the appropriate policy for coverage criteria
• Competitive bid rules apply when replacing
wheelchair options, accessories and seating
systems
– Refer to the MLN Matters Article on Repairs and
Replacements
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Example
• Elevating legrest
– Entire elevating legrest replaced
• Not a repair
• New order required
– A component of a non-function elevating legrest is
replaced to make the item functional
• This is a repair
• A new order is not required
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Labor
• Labor charge not allowed if item is under warranty
– Supplier Standard Six:
• A supplier must notify beneficiaries of warranty
coverage and honor all warranties under
applicable State law, and repair or replace free
of charge Medicare covered items that are
under warranty.
• K0739 repair or nonroutine service for DME other
than oxygen requiring the skill of a technician
– One UOS = 15 minutes
– Suppliers must document reason for repair
• Common Repairs Labor Policy must be followed
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Repair Labor Billing and Payment Policy
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Repairs Up to Purchase Price
• Cost of repair allowed up to cost of replacement
– No payment made for amount in excess
– Cannot charge beneficiary for amount in excess
• Malicious damage, culpable neglect, wrongful
disposition of equipment should be reported to
the DME MAC for investigation and if
appropriate referred to program integrity
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Loaners and Service Charge
• K0462 is temporary replacement for patient-owned
equipment being repaired, any type
– Limited to one month's rental per repair
– Narrative on claim must include the temporary
replacement item, the item being repaired and a
description of the repair
• Example: Temp K0823 repairing K0823 broken
foot plate on order
• Loaners are not replacements
– Example: cannot swap out a CPAP and bill for
one month of a loaner
• Cannot charge beneficiary a service charge
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Repair Part Modifier
• RB replacement of a part of DME furnished as
part of a repair
• KC replacement of special power wheelchair
interface
– RB not required in this case
• Repairs do not require a new physician order
and/or CMN
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Medicare Covered Replacement
• Replacement for loss, theft or irreparably
damaged
• Replacement due to reasonable useful lifetime
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Must be at least five years
No automatic timeframe
Replacement is reasonable and necessary
RUL determined when beneficiary received
equipment
• Not the age
• Similar equipment dispensed due to change in
medical condition is not considered replacement
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Replacement Due to Wear
Inside RUL
• Medicare does not cover replacement due to
wear inside five years
• If replacement required, cannot charge
beneficiary
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Oxygen Replacement
• Allowed any time after five year RUL
– New 36 month rental period begins
• If supplier retains ownership and beneficiary
does not elect new equipment no separate
payment for accessories or repairs
– Payment can continue for oxygen contents
• If supplier transfer title to beneficiary all
accessories, maintenance and repairs are
statutorily non-covered
– Payment can continue for oxygen contents only
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Replacement
• New physician order and/or CMN required
• RA modifier required for:
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Loss
Theft
Irreparable damage
Oxygen RUL reached
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Resources and Reminders
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Sync the Audio to Ask a
Verbal Question
• Click on Event Info
tab
• Verify Identity code
• Enter # you number #
on your telephone
keypad
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Asking a Verbal Question
• To ask verbal
question:
– Click on the
Participant tab
• Click on the hand icon
– The telephone
handset or computer
headset must be
present beside your
name
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Resources
• Policies
– LCD/Policy Article
– Documentation Checklists
– “Dear Physician” Letters
• Education & Outreach
– Noridian Supplier Manual
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Resources (cont.)
• Acronyms
– CMS Acronym List
(https://www.cms.gov/apps/glossary/)
– Bottom of the Noridian Medicare Website
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New Supplier Education Curriculum
• General and policy
specific
• Short presentations
grouped by relevance
• Quiz at conclusion
with certificate
• Great for new and
existing suppliers
July 2016
• Suppliers encouraged
to view both general
and policy specific
curriculum
• Located on the
Noridian Medicare
Website
– Browse by Topic >
Welcome New
Supplier
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Denial Code Guidance
• Each denial code webpage includes:
– Claim adjustment reason code and description
– Claim adjustment remark code and description
– Common reason why Noridian uses that
reason/remark code
– Next step (re-file, redetermination, reopening, etc.)
– How to avoid these types of denials
– Applicable resources
• Located on the Noridian Medicare Website
– Browse by Topic > Remittance Advice (RA) > Denial
Code Guidance
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PECOS Requirement
• Claims may be denied if:
– The ordering physician is NOT in PECOS
– The ordering physician is not of the specialty to order
– If the physician's name submitted on the claim does
not match their name in PECOS
• PECOS Edits located on the Noridian Medicare
Website
– Claims and Appeals > Claim Submission > PECOS
Edits
• View the PECOS DME on Demand
(http://www.brainshark.com/noridian/vu?pi=zHlz
qyKBpz87uMz0)
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ICD-10 Questions?
• ICD-10 Implementation took place 10/1/15
• ICD-10 Resources
– ICD-10 Webpage located on the Noridian Medicare
Website
• Browse by Topic > ICD-10
– CMS ICD-10 Webpage
(https://www.cms.gov/medicare/coding/icd10/index.ht
ml)
– “Road to 10” Website (www.roadto10.org)
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Email Updates
• Tuesday and Friday
• Latest updates and
announcements
• Customizable
• Sign-up in the lower
right corner of our
website
• Click “subscribe”
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Website Survey
• Your feedback is
valuable
• Click “Yes, I’ll give
feedback”
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One-on-One Medical Review
Education
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Fee Schedule Lookup
From the home page click on View Fee Schedules, then click on Fee
Schedule Lookup Tool
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Electronic Submission of Medical
Documentation (esMD)
• Transmit documentation electronically for review
• Who accepts documentation via esMD?
– DME MAC (Noridian)
• Complex Medical Review and PMD PAR
– CERT
– Recovery Auditor
– ZPIC
• CMS esMD Webpage (www.cms.gov/ResearchStatistics-Data-and-Systems/Computer-Dataand-Systems/ESMD/index.html?redirect=/esmd)
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MREP
• Medicare Remit Easy Print
– Free software!
– View, search and print remits
– Print and export reports
• CMS Brochure
(www.cms.gov/MLNProducts/downloads/Medica
reRemit_0408.pdf)
• MREP Software
(www.cms.gov/AccesstoDataApplication/02_Me
dicareRemitEasyPrint.asp)
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Medicare Learning Network (MLN)
•
•
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Guides
Articles
Educational Tools
Booklets Brochures
Fact Sheets
Training
Presentations
• Web-Based Training
• And more!
July 2016
• MLN Webpage
(www.cms.gov/Outrea
ch-andEducation/MedicareLearning-NetworkMLN/MLNGenInfo/ind
ex.html)
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Noridian Medicare Portal
• Replaced Endeavor
– Same functionality
as Endeavor
– Endeavor
decommissioned
May 1, 2016
• Five roles:
– Provider
Administrator
• Must register first
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Provider End User
Vendor Administrator
Vendor End User
Dual Role
• Noridian Medicare
Portal webpage
located on the
Noridian Medicare
Website
– Browse by Topic >
Noridian Medicare
Portal
• Login
• User Manual
• Registration Guide
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Noridian Medicare Portal
Functions
•
•
Eligibility
Claim Status
–
•
•
•
•
•
Availability
• Eligibility
Nurse claim processing comments Prepayment review Complex Medical
and Documentation Compliance
Same or Similar
Same or Same (Includes A, L, & V
codes.)
Claim-Specific Remittance Advices
Overpayments
Reopening/Redetermination
– 24 hours/day, 7 days/week
• All other functions
– 6 a.m. – 8 p.m. CT, Mon.– Fri.
– 7 a.m. – 3 p.m. CT, Sat.
– Submission
– Status Inquiry
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•
PMD Prior Auth Request Status
Additional Documentation Requests
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–
–
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Complex Medical Reviews
Documentation Compliance Reviews
Upload documentation with confirmation
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We Are Coming To You!
• “Catch the JD Express
to Medicare Success”
• Half day Sessions
• Register online
• Located on the
Noridian Medicare
Website
• Fall Seminar locations
to be announced this
summer!
– Education and Outreach
> Schedule of Events >
In-person Seminars
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Education Opportunities
• Web-Based Workshops
• Q & A Sessions
– 2nd Monday of each month @ 3 p.m. CT
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•
•
•
DME On Demand
Education Request
Ask the Contractor Teleconference (ACT)
Education and Outreach Webpage located on
the Noridian Medicare Website
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Single Toll Free Line
Jurisdiction A
866-419-9458
– Interactive Voice
Response (IVR)
– Supplier Contact
Center
– Telephone
Reopenings
• Monday – Friday
• 8 a.m. – 6 p.m. CT
July 2016
Jurisdiction D
877-320-0390
– Interactive Voice
Response (IVR)
– Supplier Contact
Center
– Telephone
Reopenings
• Monday – Friday
• 8 a.m. – 6 p.m. CT
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Beneficiary Contact Information
• Beneficiaries who need assistance can be directed
to:
– 1-800-Medicare (800-633-4227)
• Question on claims and coverage of
equipment
– Social Security Administration (800-722-1213)
• Update name/address, questions on
premiums, Medicare entitlement
– Benefits Coordination Recovery Center (800-9991118)
• Primary insurance information update
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Questions?
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Thank you for attending!
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