Oxygen Documentation Requirements Presented by Noridian Medicare Provider Outreach and Education - DME and Part B September 2015 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 CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov • 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 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. September 2015 2 Acronyms • • • • • • • • • ABG: Arterial Blood Gas ABN: Advance Beneficiary Notice of Noncoverage CBA: Competitive Bidding Area CEDI: Common Electronic Data Interchange CERT: Comprehensive Error Rate Testing CMS: Center for Medicare & Medicaid Services CO: Contractual Obligation DMECS: Durable Medical Equipment Coding System DME MAC: Durable Medical Equipment Medicare Administrative Contractor September 2015 • • • • • • • • • • DMEPOS: Durable Medical Equipment Prosthetics Orthotics and Supplies HCPCS: Healthcare Common Procedure Coding System HHA: Home Health Agency HICN: Heath Insurance Claim Number HMO: Health Maintenance Organization IDTF: Independent Diagnostic Testing Facility IOM: Internet Only Manual IVR: Interactive Voice Response (system) LCD: Local Coverage Determination LON: Length of Need 3 Acronyms (2) • • • • • • • • • • • • LPM: Liters per minute LTOT: Long Term Oxygen Therapy mm Hg: Millimeters of Mercury M&S: Maintenance and Service MLN: Medicare Learning Network NCD: National Coverage Determination NSC: National Supplier Clearinghouse PA: Policy Article PHI: Protected Heath Information PIM: Program Integrity Manual POD: Proof of delivery • • • • • • • • • • PR: Patient Responsibility PTAN: Provider Transaction Access Number RA: Remittance Advice RA: Recovery Auditor RUL: Reasonable Useful Lifetime SAT: Oxygen Saturation SNF: Skilled Nursing Facility SOF: Signature on File TIN: Taxpayer Identification Number ZPIC: Zone Program Integrity Contractor https://med.noridianmedicare.com/web/jddme/help/acronyms-glossary • www.cms.gov/apps/acronyms September 2015 4 Objective • To provide clarity for both physician offices and Durable Medical Equipment (DME) suppliers on the documentation requirements for their Medicare patients who require home oxygen therapy. September 2015 5 Agenda • Coverage Criteria • Testing Requirements • Certificate of Medical Necessity • General Documentation • Relocation and Travel • Comprehensive Error Rate Testing (CERT) • Reminders and Resources September 2015 6 Coverage Criteria National Coverage Determination (240.2) Local Coverage Determination (L11457) Policy Article (A33677) Covered Home Oxygen Therapy 1. Severe lung disease or hypoxia related symptoms; and 2. Beneficiary’s blood gas study meets specific criteria; and 3. Blood gas study performed by physician or a qualified provider or supplier of laboratory services; and 4. Blood gas study performed under specific conditions; and 5. Alternative treatments ineffective September 2015 8 FAQ • Q: Could you expand on what constitutes alternative treatments? A: This can include a note/list showing other medications prescribed to treat the beneficiary's respiratory illness or other evidence that the physician considered alternative treatments before prescribing oxygen therapy. – Many disease conditions have standard treatment regimens associated with them. This would depend upon the disease being treated. September 2015 9 Home Oxygen – Not Reasonable and Necessary • Angina pectoris in the absence of hypoxemia • Dyspnea without cor pumonale or evidence of hypoxemia • Severe peripheral vascular disease in absence of systemic hypoxemia • Terminal illnesses that do not affect respiratory system September 2015 10 Group I • ABG at or below 55 mm Hg or SAT at or below 88% 1. 2. 3. 4. At rest, or During exercise (3 tests) During sleep (at least 5 min) During sleep (signs of hypoxemia) • Decrease in ABG more than 10 mm Hg or a decrease in SAT more than 5% from baseline for at least 5 minutes taken during sleep • Initial coverage limited to 12 months September 2015 11 Group II • ABG between 56 – 59 mm Hg or SAT at 89% – Same testing requirements as Group I • AND beneficiary has one of following conditions: – Dependent edema, suggesting congestive heart failure; or – Pulmonary hypertension or cor pulmonale; or – Erythrocythemia with a hematocrit greater than 56% • Initial coverage limited to 3 months September 2015 12 Testing Requirements Blood Gas Study • Qualifying test covered under Medicare • Part A or B • Test must be performed by provider qualified to bill Medicare: – – – – Part A Provider Laboratory Independent Diagnostic Testing Facility (IDTF) Physician • Test cannot be performed by: – Supplier September 2015 14 Testing • Types of qualifying tests: – Arterial blood gas (ABG) – below 60 mm Hg – Blood oxygen saturation (SAT) – below 90% – Most recent study prior to CMN initial date (w/in 30 days) • Study can be performed: – At rest – During sleep – During exercise • Can be formal exercise or exertion while performing daily activities • Three separate readings must be taken • Record reading taken during exercise breathing room air on CMN September 2015 15 Sleep Oximetry Studies • Oximeter must be: – Stand-alone overnight pulse oximetry – Tamper proof – Capable of downloading data that allows documentation of duration of O2 desaturation below specified value • Home based overnight oximetry tests – Performed under direction of Medicare enrolled IDTF – Can be delivered by supplier or shipping entity if: • Ordered by physician • Test results accessible only by IDTF • Lowest saturation reported on CMN – Lowest recorded during 5 minute qualifying period – 5 minute period does not have to be continuous September 2015 16 Overnight Oximetry, OSA AND PSG • Testing must be done in Chronic Stable State • Both oxygen LCD and PAP LCD must be followed • OSA sufficiently treated and lung disease unmasked September 2015 17 Overnight Oximetry, OSA AND PSG (2) • Overnight oximetry during home sleep test not eligible to be used for oxygen qualification. • Testing may only occur during a Titration Study and 1. Minimum 2 hours 2. During titration specific reduction in AHI/RDI criteria met 3. Only performed after optimal PAP settings determined 4. Nocturnal oximetry conducted during PSG shows <88% for 5 minutes. September 2015 18 Inpatient vs. Outpatient Testing • Blood gas study performed – Inpatient hospital stay, 2 days prior to discharge • Last test prior to discharge – Outpatient, while beneficiary is in a chronic stable condition • Not during acute illness or exacerbation of underlying disease September 2015 19 Certificate of Medical Necessity (CMN) Initial CMN 1. First claim to DME MAC – Testing and physician evaluation within 30 days of initial date 2. Break in need during 36 month rental period – Testing and physician evaluation within 30 days of initial date 3. Replacement due to RUL – No new testing or new physician visit required 4. Replacement due to irreparable damage, theft, or loss of the originally dispensed equipment – No new testing or new physician visit required September 2015 21 Recertification 5. Group I patients – 12 months after initial – Most recent qualifying test prior to 13th month 6. Group II patients – 3 months after initial – Most recent qualifying test between 61st – 90th day • Other requirements for 6 and 7: – Re-evaluation within 90 days prior to recertification – Above criteria not met, but use continues, coverage resumes when requirements are met • Recertification for replacement equipment: – Same timeframes apply – Repeat testing and re-evaluation not required – Use most recent qualifying value and test date September 2015 22 Revised CMN 7. Change in flow rate category a. Less than 1 liter per minute (LPM) b. 1-4 LPM c. Greater than 4 LPM 8. Length of need expired 9. Portable added to stationary 10. Stationary added to portable 11. New treating physician - oxygen order is the same 12. New supplier does not have the prior CMN Revised CMN does not change recertification schedule September 2015 23 Other CMN Notes • CMN Sections B and D completed by physician – Signature and date stamps are not acceptable for use on CMNs and DIFs – Form CMS-484 (09/05): www.noridianmedicare.com/dme/forms/docs/cms484.pdf • Misc. changes not requiring new CMN or testing – Flow rate changes but remains in same category – Change of modality – New written order is required though September 2015 24 Making Changes to a CMN • Two options – Draw line through error • Treating physician must initial and date correction • Must have similar capability for electronic CMN – Complete new CMN • Whiteout not acceptable www.noridianmedicare.com/dme/forms/cmn_dif_forms.html September 2015 25 Certificate of Medical Necessity www.noridianmedicare.com/dme/news/manual/docs/chapter4.pdf September 2015 26 Oxygen CMN Section A Supplier completes September 2015 27 Oxygen CMN Section B Physician completes September 2015 28 Oxygen CMN Sections C & D Supplier completes Physician completes September 2015 29 Documentation Authorized to Order • Treating MD or DO • Nurse Practitioner or Clinical Nurse Specialist – Treating beneficiary for condition for which item is needed – Practicing independently of physician – Bill Medicare for other covered services using own NPI – Permitted to do in state where services are rendered September 2015 • Physician Assistant (PA) – Meet definition of physician assistant found in Section 1861(aa)(5)(A) of Social Security Act – Treating beneficiary for condition for which item is needed – Practice under supervision of MD or DO – Have own NPI – Permitted to perform services in accordance with state law 31 Implementation vs. Enforcement Affordable Care Act Section 6407 • Implementation Date – For all requirements – July 1, 2013 • Enforcement Date – For WOPD requirements • Date of Service (DOS) January 1, 2014 – For F2F requirements • To be announced by CMS in 2014 September 2015 32 FAQ • Q: Do these requirements replace any existing F2F requirements that may already exist in a particular medical policy? • A: No. Suppliers are expected to comply with both these requirements of MM8304 and the ACA in addition to the existing requirements within each individual medical policy. September 2015 33 Face-to-Face Evaluation • Face-to-Face Documentation – Beneficiary was evaluated and/or treated for a condition supporting the DME ordered – All Medicare coverage and documentation requirements for DMEPOS apply • F2F Evaluation must take place within 6 months prior to the date on the written order (oxygen 30 day requirement supersedes) • Must be received by supplier prior to delivery of DME – Date stamp (or equivalent) upon receipt September 2015 34 FAQ • Question: Does the ordering physician have to be the same physician that conducts the face-toface evaluation? • Answer: No. The physician that signs the WOPD does not have to be the same physician that conducts the face-to-face evaluation. September 2015 35 Written Order Prior to Delivery (WOPD) • Basic elements – Beneficiary’s name – Physician’s name – Date of the order and the start date, if start date is different from the date of the order – Detailed description of the item(s) – Physician signature and signature date – Physician NPI • Only needed for those items that require a face-to-face per MM8304-Revised September 2015 36 WOPD: Additional Elements Items Provided on a Periodic Basis • • • • • • • Item(s) to be dispensed Dosage or concentration, if applicable Route of administration Frequency of use Duration of infusion, if applicable Quantity to be dispensed Number of refills September 2015 37 Acceptable Detailed Written Order • May be completed by someone other than physician – Treating physician must review, sign and date • Acceptable orders – – – – Fax Photocopy Electronic Original pen and ink • CMN can serve as the WOPD if sufficiently detailed September 2015 38 WOPD Update 8/28/2014 • Errors identified on WOPD prior to delivery – WOPD may be properly amended (Program Integrity Manual, Publ., 100-08, Chapter 3, Section 3.3.2.5) or – New WOPD may be created and sent to physician for signature and date • Errors identified on WOPD after delivery – Prior to claim submission, original supplier may recover delivered item(s), obtain WOPD and redeliver – After claim submission, original suppler can recover items and new supplier must complete transaction after complying with all requirements September 2015 39 Mix of Items Ordered • Special attention should be given to items ordered • Specifically related to Oxygen – Do require WOPD per MM8304 • E 0424, E0431, E0433, E0434, E0439, E0441, E0442, E0443, E0444 – Do Not require WOPD per MM8304 • E1390, E1392 September 2015 40 Preliminary/Dispensing Order • E1390/E1392 for O2 may be dispensed based on verbal/ preliminary order • E1390/E1392 provided based on a dispensing order must be followed up with a completed detailed written order September 2015 Description of Item Beneficiary’s Name Signature Physician’s Name Date of Order 41 Continued Use • Continued use describes ongoing utilization by a beneficiary • Must be periodically documented to confirm item continues to be used – Acceptable continued use documentation: • Beneficiary’s medical records or • Supplier records • Suppliers must discontinue billing if the item is no longer being used September 2015 42 Continued Need • Continued medical need justifies the item remains reasonable and necessary – Documentation justifying continued medical need includes: • • • • September 2015 A recent order by the treating physician for refills A recent change in prescription A properly completed CMN or DIF with the LON specified Timely documentation in the medical record showing usage 43 Medical Records IOM Program Integrity Manual (100-08, Chapter 5) *Must September 2015 be available upon request 44 Relocation and Travel Relocation and Travel • Months 1-36: – Supplier responsible for providing equipment for remainder of current rental month – For subsequent rentals months, home supplier encouraged to continue to provide equipment or assist the beneficiary in finding another supplier to take over • Months 37-60: – Home supplier required to provide or make arrangements for another supplier to provide equipment and all related items/services • Beneficiary responsible for airline oxygen services and services provided outside the United States September 2015 46 • CMS allows for replacement of oxygen equipment in cases where a supplier exits the business − Oxygen equipment considered lost − New 36 month rental period for new supplier − New RUL for new supplier •http://www.cms.gov/Outreach-andEducation/Outreach/FFSProvPartProg/Downloads/2014 -05-22-Enews.pdf September 2015 47 Comprehensive Error Rate Testing (CERT) Top Ranking Policies #1 http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medicare-FFS-Compliance-Programs/CERT/CERT-ReportsItems/Downloads/AppendicesMedicareFee-forService2014ImproperPaymentsReport.pdf?agree=yes&next=Accept September 2015 49 CERT Documentation Contractor Requests provider documentation sent to: Livanta CERT Documentation Contractor (CDC) 9090 Junction Drive, Suite 9 Annapolis Junction, MD 20701 Phone: 888-779-7477 Fax: 240-568-6222 www.certprovider.com September 2015 50 CERT Review Contractor Reviews documentation sent from Livanta: AdvanceMed CERT Review Contractor (CRC) 1530 E Parham Road Richmond, VA 23228 September 2015 51 Documentation Concerns • Physician authentication • Physician order must be present • Billed service covered by a NCD or LCD – Meet all aspects of coverage • Covered diagnosis code – Does not guarantee payment on post payment review • Medical records – Critical to support medical necessity for all DME items September 2015 52 Relevant Medical Records • Examples of relevant medical records include: – Physician medical notes – Non-physician clinical notes – Non-physician clinical evaluations September 2015 53 Supplemental Documentation • Other types of information not sufficient by themselves to document coverage criteria – Even if signed or initialed by treating physician – Not considered part of patient’s medical record • Will be given consideration if corroborated by medical record – Applies to documents created before delivery of item(s) September 2015 54 Examples of Supplemental Documentation • Forms (either narrative or check-off) devised by supplier and completed, signed and dated by physician • Summaries of patient’s medical condition prepared by supplier or physician • Forms (either narrative or check-off) developed by suppliers and completed by patient or caregiver September 2015 55 Signature Compliance • Ordering practitioner must be clearly identified in records – First name/last name/credentials/date • If illegible, must also type/print name • Review Purposes – Medicare requires that services provided/ordered be authenticated by the author. • Method used must be hand written or electronic – Stamp signatures are not acceptable • MLN 6698 - Signature Guidelines for Medical Review Purposes September 2015 56 Common CERT Oxygen Errors Missing clinical records to support condition Missing order Missing evidence of qualifying testing for CMN Missing re-evaluation within 90 days of recertification CMN September 2015 57 Combating CERT Errors • • • • • • Consistent intake process Internal audit process Review Medicare requirements (LCDs and PAs) Educate staff on how to respond to CERT Submit complete and legible records DME MAC Browse by DMEPOS Category – Select oxygen – https://med.noridianmedicare.com/web/jddme/policies /lcd/active/oxygen-and-oxygen-equipment September 2015 58 In Summary: • DME suppliers need physician community to successfully assist beneficiaries in payment of their claims • Orders must be complete and clearly notate what is needed for your patient • Medical records must be specific to each individual beneficiary – Detailed description of condition – Ongoing monitoring September 2015 59 Reminders and Resources DME Resources • LCD/Policy Article – https://med.noridianmedicare.com/web/jddme/policies/lcd /active • Supplier Manual – https://med.noridianmedicare.com/web/jddme/education/ supplier-manual • “Dear Physician” letters – https://med.noridianmedicare.com/web/jddme/policies/ physician-resources • Documentation Checklist – https://med.noridianmedicare.com/web/jddme/policies/ documentation-checklists September 2015 61 Newest DME Physician Resource • Physicians! Are you ordering oxygen for your patient? • https://med.noridianmedicare.com/web/jddme/ar ticle-detail/-/view/2230715/physicians-are-youordering-oxygen-for-your-patient• Published July 20, 2015 September 2015 62 Paper Claim Submitters • ICD-9 / ICD-10 indicator below required with claims dated 10/1/2015 or after – If indicator left blank, claim denies – Resubmit claim with single digit (between the vertical/dotted lines) • With indicator 9 for ICD-9 or a 0 (zero) for ICD-10 diagnoses – Enter the ICD indicator as a single digit between the vertical, dotted lines September 2015 63 Noridian Likes Website Feedback! •Provide constructive/complimentary feedback to continue Noridian website growth and improvement September 2015 64 Reminders • Attend entire workshop to earn CEU(s) • Take short polling survey – Pops up after closing out of webinar • CEU & Presentation PDF emailed within 3 days – Earn 1.0 CEU today • Q/A section – Type to all panelists, not host • Pertinent Q/As relevant to presentation posted to Noridian website around 30 business days September 2015 65 Thank you for attending! DME and Part B