Last issue (Issue 11.5-September/October 2016), we began this article on DME; this is the second and final installment.

I am including the Table (Table C) referenced in the first part to show the Cross-Walk.  You will notice that HCPCS code L0631 cross-walked to L0648 and L0631.

In the ZPIC audit referred to part I, one deficiency cited by ZPIC auditors was the incorrect use of the L0631 code.  The documentation submitted by the practice did not contain the required wording to indicate that the brace was "fitted and adjusted" to the patient as they continued to incorrectly use the code that they had been billing for these braces prior to 01/01/2014, which were intended to represent prefabricated Off-the-Shelf back braces that required only "minimal self-adjustment by the patient."

The back braces billed after January 1, 2014, however, were taken from inventory on hand at the practice and the labels still had the L0631 code on them.  This fact contributed to the incorrect assignment of code L0631 after that date for a code that now required fitting and adjustment to the patient.

Now, mind you, if you look up the allowable for both L0631 and L0648 (in my locale, at least), they are the same!  Therefore, using an incorrect code did not cost the federal government financially.  However, the practice referred to in this article filed a Redetermination and was not successful in getting this point of confusion across, and as a result, Health Integrity determined the appeal unfavorable.

There were other items, however, that impacted the Redetermination decision.  After you have a chance to look at the table below, I will point out very important details that you must have in your documentation to successfully withstand an audit.

 

What is required to document in the Medical Record for these items in order to prevent denial due to Medical Necessity?

 Failure to follow LCD guidelines can indicate the reason for denial and recoupment. 

The tips below may help to ensure that you prevent an unfavorable audit result for your practice/clinic.

2. Follow the coverage guidelines for establishing medical necessity and make sure that the same wording is used in the documentation and required forms when appropriate for each specific patient.  Sharing this information with your providers can help them understand what needs to be included in the medical record for sufficient documentation.

Each LCD begins with the statement concerning General Coverage Guidance that provides the basis for proper payment by the Medicare Administrative Contractor (MAC) for your region. 

It states:
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.  For items addressed in this local coverage determination, the criteria for "reasonable and necessary," is based on the Social Security Act § 1862(a) (1) (A) provisions, are defined by the following coverage indications, limitations, and/or medical necessity. 

3.  Follow the specific guidelines in the documentation for the item(s) covered in the LCD such as the following for spinal orthoses:

For spinal orthoses definitions of Off-The-Shelf (OTS), custom fitted and custom fabricated, see the related policy Article Coding Guidelines section.

A spinal orthosis (L0450-L0651) is covered when it is ordered for one of the following indications:

If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary. 

Note:  Again, they are very serious when they make the above statement, and in an audit situation, will repeat these statements back to you over and over.  Some physicians do not realize that when they sign the Medicare contract (or any private carrier contract), they are attesting that they know the pertinent coverage guidelines for services being billed and will follow them.  They may not understand the complexities that the billing specialists and/or the coders have to understand and take into consideration (i.e., NCCI edits, the quarterly changes that are made by insurance carriers, specific  insurance contract coverage guidelines and accepted codes)  in order to obtain accurate reimbursement.

I refer to these coverage requirements as the "magic words" to include in the clinical documentation for the ordering of items and/or testing in the physician's narrative.

4.  Read and be very familiar with the CPT©, HCPCS, and ICD-10-CM codes that you are billing on the federal claim form.  For the codes mentioned in the crosswalk as the most frequently used codes for back braces, let's look at the specific code descriptions:

L0631 - Lumbar-sacral Orthosis, Sagittal Control, with Rigid Anterior and Posterior Panels Posterior Extends From Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Padding, Shoulder Straps, Pendulous Abdomen Design, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, or Otherwise Customized To Fit a Specific Patient by an Individual with Expertise.

L0648 - Lumbar-sacral Orthosis, Sagittal Control with Rigid Anterior and Posterior Panels, Posterior Extends from Sacrococcygeal Junction to T-9 Vertebra, Produces Intracavitary Pressure to Reduce Load on the Intervertebral Discs, Includes Straps, Closures, May Include Packing, Shoulder Straps, Pendulous Abdomen Design, Prefabricated, Off-The-Shelf.   (Note: this brace requires "minimal self-adjustment.")

5.   Know and share with your physicians and clinicians the specific medical record and form requirements such as the following taken from this LCD for Spinal Orthoses:

Documentation Requirements:  Section 1833 (e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider."  It is expected that the beneficiary's medical records will reflect the need for the care provides...
 
Prescription (Order) Requirements: General - All items billed to Medicare require a prescription.  An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.  Items dispensed and/or billed that do not meet these prescription requirements and those below must be submitted with an EY modifier added to each affected HCPCS code.

(Note:  When the LCD states "signed and dated by the treating physician," they are very serious about this clause. If it is not both signed and dated, it will not be given credit as a medically necessary order upon audit.)

Dispensing Order(s): Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery.  A dispensing order may be verbal or written.  The supplier must keep a record of the dispensing order on file. 

It must contain:

For the date of the order described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders). The dispensing order must be available upon request. For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim.

Detailed Written Orders (DWO): A detailed written order is required before billing. Someone other than the ordering physician may produce the DWO.  However, the order physician must review the content and sign and date the document. 

It must contain:

For items provided on a periodic basis, including drugs, the written order must include:

Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed.  Reimbursement shall be based on the specific utilization amount only.  Orders that only state "PRN" or "as needed" utilization estimates for replacement frequency, use, or consumption are not acceptable.

The detailed description in the written order may be either a narrative description or a brand name/model number.

Signature and date stamps are not allowed.  Signatures must comply with the CMS signature requirements outlined in the Program Integrity Manual (PMI) 3.3.2.4.

The DWO must be available upon request. A prescription is not considered as part of the medical record.  Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. (PIM 5.2.3).

Medical Record Information: General (PIM 5.7-5.9)
The Coverage Indications, Limitations and/or Medical Necessity section of this LCD contains numerous reasonable and necessary (R&N) requirements.  The Non-Medical Necessity Coverage and Payment Rules section of the related Policy Article contains numerous non-reasonable and necessary, benefit category and statutory requirements that must be met in order for payment to be justified. 

Suppliers are reminded that:

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs.  The medical record is not limited to physician's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).  Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.

Proof of Delivery (PIM 4.26, 5.8): Proof of delivery (POD) is a supplier standard and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers are required to maintain POD documentation in their files.  For medical review purposes, POD serves to assist in determining correct coding and billing information for claims submitted for Medicare reimbursement.  Regardless of the method of delivery, the contractor must be able to determine from delivery documentation that the supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.

Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e. acting as a designee on behalf of the beneficiary).  The signature and date the beneficiary or designee accepted delivery must be legible.

The LCD continues by giving very specific instructions and requirements for each method of delivery.

6.  Have written policies and procedures in place in order to ensure that all processes are followed to ensure that each of these requirements are met and continuously monitored for appropriate documentation, requirements of the LCD, and for properly signed and dated documents.

Staff training and re-training on the procedures can potentially save your physicians thousands of dollars if these records are audited.

In the issue of the January 2014 changes in the Spinal Orthoses codes, Medicare explains in the LCD that there is no physical difference between the two braces.  The only difference is what is performed upon delivery.

Therefore, because the small group practice mentioned earlier continued to use L0631 as a prefabricated OTS back brace which required minimal self-adjustment for the patient and, due to the fact that the code description had changed (not the brace, just the description), they had to repair hundreds of thousands of dollars!

7.  Finally, upon request of records from a ZPIC contractor, it is extremely important that you contact an expert to direct you in the appropriate steps to take before sending out the records.  You need to be aware of any supporting documentation that you can submit that could help your case.  If in doubt, it is wise to ask for some assistance because it you receive an unfavorable decision, the process of appeal can be costly and lengthy.

Also remember to check private carrier coverage requirements, some of which are less stringent than Medicare-while others follow Medicare guidelines.

Maxine Collins, MBA, CPA, CMC, CMOM, CMIS
Director of Compliance, Audit and Education
And
Shirley Kretz, COO, CMOM,
CoreMD Partners, LLC.