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Date Stamp Rules Clarified by CMS

Friday, November 14th, 2014

Angela Hayden


CMS has released a clarification via a Joint DME MAC publication regarding the usage of date stamp protocols for compliance with the Affordable Care Act. Many suppliers have been struggling with denials stemming from improper date stamps. According to the Face-to-Face rule, implemented by the Affordable Care Act, “A date stamp or equivalent must be used to document receipt date.” This allows the auditor to verify that the DWO was in fact received prior to delivery per the requirements of the rule.


In this publication, CMS speaks to several “commonly accepted methods” of date stamping.  Those are: hard copy date stamps, hand-written dates, facsimile headers and electronic receipt dates.  The date stamp should include the word “received” and the month, day and year.


CMS goes on in the notice to caution providers utilizing facsimile headers to document receipt date.  Oftentimes, the headers can become distorted from multiple transmissions or can come across illegibly due to a poor connection. This makes it difficult for the auditor to determine the proper receipt date.  Another concern with facsimile dates is power outage or date reset – if the date resets and it is not caught timely it can invalidate orders down the road. When in doubt, utilize a physical date stamp to reduce risk.


Proper date stamping can make the difference between a payable claim and a denial.  Be sure that you have a date stamping protocol in place for all incoming documentation. See the update here: http://cgsmedicare.com/jc/pubs/news/2014/1014/cope27091.html

MiraVista Needs a Chief of Staff

Tuesday, September 16th, 2014


MiraVista LLC, a medical billing and consulting company, is searching for a chief of staff.


WTF is a Chief of Staff, you ask?


Wikipedia words it as eloquently as we can.  They describe a Chief of Staff, in part, as:


The coordinator of the supporting staff, adjutant, or primary aide-de-camp to an important individual, such as a president or a senior military officer.


Our Chief of Staff, working full time from our Columbia, South Carolina office, will have primary responsibility for the design, execution, and oversight of our internal administration.  Some of the matters our Chief of Staff would have handled last month include:

  • brainstorming with our managing member on the cost benefit of this position, the desired skills and characteristics of an ideal candidate, and the overall plan for recruitment and selection of this new position
  • reviewing resumes, conducting telephone interviews, and scheduling live interviews for candidates for accounts receivable associates
  • preparing employee agreements for new hires
  • coordinating our Columbia office expansion.  Tasks included:
    • reviewing lease provisions
    • scheduling construction to minimize impact on our work
    • working with our accountant on growth forecasts associated with the expansion
    • procuring equipment and setting up workstations
  • planning a trip for one of our officers to Seattle, WA that balances the costs of travel with the opportunity cost of being away from the office and general wear and tear on her poor soul
  • proofreading articles for publication in one of our educational publications, our blog, or national trade publication
  • preparation of invoices to our clients
  • working with our accountant on month end accounting reports, general bookkeeping, and weekly cash forecasts
  • assisting our IT manager with minor software updates, research, and
  • managing vendor relationships for office supplies and the like


To actively contribute to our work, we require:

  • Strong communication skills.  To contribute to our staff, you have to initiate discussion and participate in debate.  You cannot do that without strong communication skills.  Twitter only counts if you are truly compelling in 140 characters or less.
  • Decent desktop computer skills.  We use Microsoft Excel…heavily.  Most other applications we use pivot on the general knowledge necessary to get around Microsoft Office products and popular browser-based web tools.  There are no wildly specialized applications that we use, but you have to know your way around a computer.
  • Good research skills.  If you don’t know the answer to a question, you should be able to Google it…and get it…and then share it with us.
  • Hustle.  Period.


So why not just call our new position administrative assistant or office manager?  Mostly because administrative assistant focuses too much on doing tasks specifically assigned by someone else; office manager is too overused to mean essentially the same thing.  We need someone to handle the business of being MiraVista while we are focused on providing better results for our rapidly expanding list of clients.  The primary focus of this position is operational outcomes, not individual tasks.  Said another way, you will have to contribute to the decision making process, make decisions, and execute based on said decisions.


This position is important to our future growth strategy, so please…apply only if you have meaningful experience managing people and office operations.  This is not an entry level position for those in hopes of eventually working in medical billing, sales, or accounting.  We are not looking for a back up dancer that hopes to drop their single one day; we are looking for the band manager…metaphorically speaking, of course.


We are excited to meet you.  Send your resume and cover letter to resume@miravistallc.com.

Newest FTF Clarification Opens Doors for DME Suppliers

Monday, August 11th, 2014

Andrea Stark


A new FTF clarification that came through a joint DME MAC publication on August 7th gives providers a new flexibility concerning corrections to Detailed Written Orders (DWOs). The Policy Articles and prior education instructed that a DWO lacking all necessary components required under the FTF is incurable once the equipment has been delivered. Meaning once the equipment has gone out with a non-compliant DWO, the supplier can never receive payment on that equipment.


This latest clarification, however, defines new directives that permit modification and cure to the DWO in a new limited circumstance.  The clarification, posted to the NHIC website here http://www.medicarenhic.com/viewdoc.aspx?id=2760 reads:


“Medicare policy stipulates that a WOPD that is missing an element is not “curable” by a provider (i.e., a provider cannot make corrections to a WOPD) except as outlined below.


I.            If errors in the WOPD are found prior to delivery, the supplier has two options:


A.            The WOPD may be properly amended following the guidance in the Program Integrity Manual (Internet-Only Manual, Publ. 100-08), Chapter 3, Section; or,


B.            A new WOPD may be created and sent to the physician for signature and date.


II.            If errors in the WOPD are found after delivery of the item, the supplier has two options:


A.            If the error is discovered prior to claim submission, the original supplier may recover the delivered item(s), obtain a compliant, complete WOPD and then may re-deliver the item(s) to the beneficiary; or,


B.            If the error is discovered after submitting a claim, the original supplier can recover their items and a new supplier must complete the transaction after complying with all requirements.”


This newest development opens the door for suppliers struggling with errors in the DWO found after delivery. The clarification allows suppliers the opportunity to collect a new compliant DWO after delivery but before billing and still remain compliant with FTF requirements.  In this instance, the supplier would be required to pick-up the equipment issued under the non-compliant order, obtain the new DWO with all necessary components to comply with the FTF rule and then redeliver the equipment, and allow the new claim to bill for reimbursement.


This is a major shift from prior education that opens reimbursement opportunities in the event of proactively identified DWO errors.


CMS has not yet issued information on when the second phase of the FTF rule will be rolled out regarding collection of the FTF notes prior to delivery that will also require NPs, PAs and CNSs to secure a physician co-signature on their notes. Stay tuned to the MiraVista blog for updates on this and other important topics impacting reimbursement.



CMS Announces Next Steps for Competitive Bidding

Monday, July 21st, 2014

Angela Hayden


The gavel has come down on next steps for the Competitive Bidding program as CMS has issued notice for a Recompete of both Round 2 and National Mail Order contracts. The original Round 2 and NMO contracts are in effect until June 30, 2016. Speculation has been circulating concerning what CMS’ next steps for the program would be since the issuance of a request for comment on a nationwide competitive bidding program in February 2014.  While the most recent announcement shifts focus toward the Recompete process, we fully expect the Nationwide Competitive Bidding effort to move forward in the days ahead via a separate notification process.


While most aspects of the program will remain the same for the Round 2 Recompete (R2RC), there were some minor, notable tweaks. For example, Round 2 encompassed a total of 91 Metropolitan Service Areas (MSAs) with 100 Competitive Bid Areas (CBAs) to sub divide the larger MSAs. However, for the Recompete there will be 90 MSAs and 117 CBAs; 16 of the MSAs in R2RC are divided into multiple CBAs to break up the expansive metropolitan areas and to avoid multiple-state bid areas. Additionally, any zip code changes that have taken place since Round 2 implementation have been translated into the R2RC zones.


As for products, the R2RC has been updated to reflect much of what we saw with the R1RC. Many categories have now been grouped rather than broken out for individual bid.  Under the R2RC Oxygen, CPAP, RADs and their related supplies and accessories have been grouped together into the Respiratory Equipment and Related Supplies and Accessories category.  Nebulizers which were grouped into the respiratory category for R1RC, have now been broken out into their own bid category for the R2RC.


Hospital beds and Group 1 and 2 support surfaces have been grouped together under the General Home Equipment and Related Supplies and Accessories category, which now includes three new products (commode chairs, patient lifts and seat lifts).  Under Round 1 Recompete TENS units were grouped into this General product category, however, for the Round 2 Recompete TENS devices and supplies will be included in an independent category for bid.


Walkers, which were previously a stand-alone product category, have now been pushed into the Standard Mobility Equipment and Related Accessories category. This category now encompasses walkers, standard power and manual wheelchairs, scooters, and related accessories. The product category we do not see up for bid in this round which was included with the R1RC is External Infusion Pumps; CMS has indicated that this product will not be bid in the R2RC. See below for a full R2RC product list:


  • Enteral Nutrition, Equipment and Supplies
  • General Home Equipment and Related Supplies and Accessories (hospital beds and related accessories, group 1 and 2 support surfaces, commode chairs, patient lifts, and seat lifts)
  • Nebulizers and Related Supplies
  • NPWT Pumps, Related Supplies and Accessories
  • Respiratory Equipment and Related Supplies and Accessories (oxygen, oxygen equipment and supplies; CPAP devices; RADs; and related supplies and accessories)
  • Standard Mobility Equipment and Related Accessories (walkers, standard power and manual wheelchairs, scooters, and all related accessories)
  • TENS Devices and Supplies

The National Mail Order program will also be subject to Recompete at the same time as Round 2 with no notable changes to that program.


With the announcement, CMS also issued important dates for all suppliers to consider. The bidding schedule will be announced this Fall. During this time, suppliers that wish to participate in the bidding program will begin the registration process to obtain a User ID and password.  The actual bidding for the Recompete will not begin until winter of 2015; therefore suppliers will have roughly a year to prepare for the formal bidding process. Those who are currently contracted under Round 2 will be eligible to participate in the Recompete as long as all requirements are met for bidding. This is a new opportunity for suppliers that were not awarded a contract under Round 2 to participate in the newest round for contracting.


In order to be eligible to participate in the bidding process suppliers must have an accurate record with the Provider Enrollment, Chain and Ownership System and the National Supplier Clearinghouse. All participating bidders must be licensed for the product that they wish to supply in the state in which they are bidding in prior to submitting a bid. Additionally, all locations the supplier intends to offer product from must be accredited by a CMS approved accrediting organization for the items that they provide in a product category.  All other standard bidding rules will apply – more information on those rules can be found on the CBIC website at www.dmecompetitivebid.com.


Prior Authorization for General DME: Good or Bad?

Friday, June 27th, 2014

Angela Hayden


A proposed rule was published on May 28th, 2014, seeking comment on a prior authorization program for certain DMEPOS items. In the proposal, CMS collected a Master List of 139 HCPCS that have been determined to have frequent,   unnecessary utilization. The list includes a variety of products such as hospital beds, RADs, Power Wheelchairs, Manual Wheelchairs, CPAPs, Support Surfaces and Lower Limb Prostheses.  The proposal suggests that a certain portion of the HCPCS within the Master List would be carved out and that list (referred to in the proposal as the Required Prior Authorization List) would contain those HCPCS subject to the Prior Authorization requirement. Not all items within the Master List would be rolled out at once; instead CMS seeks to slowly infuse those HCPCS to the master list over time.


Once the final list of HCPCS subject to the rule is determined, the list would be released with a 60 day notice for providers to get prepared for implementation. If the proposal is finalized, the program would be rolled out on both a national and local level depending on the scale of unnecessary utilization uncovered during data analysis of each area.  Also within the notice is a provision for CMS to use its discretion, at any time, to pause or suspend the program without creating a separate rule.


Should the rule become final, suppliers would be required to submit a request for Prior Authorization when billing for any of the selected HCPCS.  The request would need to be submitted to the DME MAC and would have to include documentation to support that the item complies with all coverage, coding and payment rules. The DME MAC would then have 10 days from receipt of all applicable information to render its decision.  In the instances where an expedited decision is necessary to preserve the life or health of the beneficiary, the proposal has included a provision for the DME MAC to render a decision within two business days of the receipt of all required documentation. Any claim submitted for one of the affected HCPCS without a valid prior authorization number would automatically be denied.


An interesting section of the proposal speaks to the applicability of this proposal to Competitive Bidding Areas: “We note that this proposal would apply in competitive bidding areas because CMS conditions of payment apply under the Medicare DMEPOS Competitive Bidding Program.”  This means that contracted suppliers would not be exempt from this protocol should the final rule come into action.


The proposal goes on to indicate that because of the existing PMD Demonstration Program, PMDs would be excluded from the initial rulemaking  – but this could be revisited once the original Demonstration has ended. The current PMD Prior Authorization Demonstration is active in seven states and not slated to expire until August 31, 2015.  A proposal to expand that program into 12 additional states is already in the works as of April 4, 2014.  The comment period for that proposal closed on April 18, 2014, with all comments in favor of an expansion.


For PARs that are denied or non-affirmed, the supplier would not be limited (based on this proposal) by a specific number of times that a request can be submitted for re-examination. The DME MAC would have 20 days to review the resubmission before rendering a decision.


The comment period for this proposal is open until 5pm Eastern Time on July 28, 2014.  Suppliers that wish to submit comment can do so using this link: http://www.regulations.gov/#!submitComment;D=CMS-2014-0070-0001

Update on FTF Directives for Multiple Physicians

Tuesday, May 13th, 2014

Andrea Stark


MiraVista has it on good authority that a clarification from CMS is imminent regarding scenarios where multiple physicians participate in the order process and whether this will be allowed under the FTF directives.  While we can only speculate on what the directive will actually contain, we are optimistic that the change will be a welcomed one by providers.


Currently, CMS has directed the DME MACs that only the physician that documents the FTF can be the one that orders the equipment.  However, the industry has presented CMS with numerous examples of instances where multiple practitioners can be involved.  One such example is a patient visiting a primary care physician with signs of obstructive sleep apnea.  After evaluation, the patient is referred to a sleep lab where the interpreting physician orders the CPAP and suggests an appropriate pressure setting.  Other scenarios are complicated in a hospital setting where multiple physicians evaluate the patient during rounds and the physician coordinating the discharge may or may not be the one that documented the prior evaluation(s).  Each of these two scenarios present suppliers with a predicament in the context of existing guidance.


MiraVista will continue to monitor for this development and will provide an update to our subscribers when the final direction is made available.


Still confused about Face-to-Face requirements? 

You are not alone.


The rules and requirements have continued to unravel since the publication of the Face-to-Face rule and many providers are still scratching their heads about implementation in the real world. Join our webcast “Face-to-Face in the Real World: How to Comply in Its Current Form” on June 3, 2014 at 3pm ET as Andrea Stark partners with HME News to discuss the Face-to-Face rule as it currently exists for DME providers and what to anticipate as we move forward.  Register on our webinars/seminars page.


Comment Period Closing for CMS Competitive Bidding Proposal

Tuesday, March 25th, 2014

Andrea Stark


On February 26, 2014, CMS released a proposal to solicit public comment on how to apply the pricing and methodologies of the current competitive bidding programs to the remainder of the country. The proposal, located on the federal registry website, outlines the techniques being considered by CMS to adjust fee schedule payment amounts for DMEPOS items and services furnished in areas that are not included in the current competitive bidding programs. Among the considerations, CMS has explored the possible testing of a bundled payment system for certain items of DME which would completely transform the capped rental category as it is currently known.  The proposal puts a few ideas on the table and reiterates CMS’s intent to move forward with its expansion of the competitive bidding program by 2016. Providers have a unique opportunity to affect the outcome of this dialogue by submitting comments electronically via regulations.gov. As of 11:59 PM on March 24th, only 13 comments have been documented as received by CMS. It is vital that providers understand what is being proposed, contemplate the impact and provide feedback to CMS.


The electronic comment period for this proposal closes March 28th, 2014 at 11:59 PM ET.


Much to the dismay of the DME industry, the Competitive Bidding initiative is pushing forward with no signs of slowing down. To protect reimbursement as this moves forward, CMS must hear from the DME suppliers that will ultimately be impacted by these proposed changes.


Not sure what this proposal means for your business? 

Join the discussion as DME Consultant and Reimbursement Expert Andrea Stark dives into this proposal and discusses the major components during our March 27th webinar “CMS Sparks Conversation with DME – FTF, RAC Transition and Nationwide Competitive Bidding” at 3 PM ET. Register on  our website at http://www.miravistallc.com.

Newest FTF Development – Audits Begin for WOPD

Friday, March 7th, 2014


On December 3, 2013 CMS posted a clarification on the Face-to-Face rule that rattled the DME community.  The F2F rule, has effectively been divided into two major directives: 1) the requirement for a documented F2F within the six months prior to the written order, and 2) the requirement to secure a Written Order Prior to Delivery. CMS intends to enforce the Written Order Prior to Delivery for claims processed in January 2014.


Prior to the December announcement, enforcement of the Rule was delayed on two separate occasions.  The first was a three month delay in the enforcement from the original July 1, 2013 start date, and the second offered an unspecified delay of enforcement through an unspecified date in 2014.  However, on December 3rd, CMS came forward to indicate that only the F2F provisions were intended for delay and they never intended a delay for the WOPD requirement.  Amid several remaining unanswered questions, CMS and the MACs continue to move this portion of the directive forward.


As of February 18, 2014, we are beginning to see the first of what we except to be many audits as a result of this announcement.  The Jurisdiction C DME MAC posted a notice of a service-specific prepayment review of a number of HCPCS affected by the F2F rule:


  • E0607 – Home Blood Glucose Monitor
  • K0001 – Standard Manual Wheelchair
  • K0002 – Standard Hemi Manual Wheelchair
  • K0003 – Lightweight Manual Wheelchair
  • E0748 – Osteogenesis Stimulator
  • E2510 – Speech Generating Device
  • E2402 – Negative Pressure Wound Therapy Electrical Pump


This pre-payment review is an effort to verify compliance with the Face-to-Face provisions concerning the detailed written order prior to delivery (DWOPD) requirements.  Claims subjected to this audit will be developed for additional documentation including:


  • Written Order Prior to Delivery
  • Delivery Documentation
  • Pertinent patient records
  • Copy of the ABN if used


While this audit was announced by the Jurisdiction C DME MAC, we expect that the other MACs will be following suit in the days ahead.


Face-to-Face Clarifications Rattle DME Community

Monday, December 9th, 2013

Andrea Stark and Angela Hayden


A ground breaking clarification posted by the Centers for Medicaid and Medicare Services to the Face-to-Face Encounter home page on December 3rd, 2013, has sent providers reeling.  The clarification states “The delay of enforcement only applies to the face-to-face requirements in CFR §410.38(g)(3). CMS expects full compliance with the remaining portions of the regulation.” Earlier this year the final rule mandating Face-to-Face Encounters for select items of DME, affecting 166 HCPCS, indicated an effective date of July 1, 2013.  However, CMS issued a delay to October 1, 2013, and then further delayed enforcement until a date yet to be announced in 2014.  This rule not only requires that a face-to-face encounter with a physician, nurse practitioner, physician’s assistant or clinical nurse specialist take place and be documented within six months prior to the detailed written order, but an additional requirement also establishes the necessity to collect a Detailed Written Order prior to delivery (even in cases where a verbal or dispensing order had previously been sufficient).


CMS begun instructing contractors to educate providers on a few key expectations, notably that they are expecting DME providers to follow all of the written order prior to delivery requirements set forth in the rule (dating back to July 1, 2013).


We have discovered that behind the scenes, the Program Integrity Manual has already been updated in several key sections through Revision 468.  This revision cites it was: Issued: 05-31-13; was Effective 07-01-13; and has an Implementation of 07-01-13.  The Program Integrity Manual (PIM) is the instruction manual used by the auditing contractors to enforce Medicare policy.  These citations clearly state they are in effect and implemented as of July 1, 2013 which is quite troubling from a retroactive audit standpoint.  The following are brand new sections that detail CMS expectations about procurement of a written order prior to delivery for items subject to the face-to-face rule:  Section Detailed Written Orders for Face-to-Face Encounter, – Face-to-Face Encounter Conducted by the Physician, – Face-to-Face Encounter Conducted by a Nurse Practitioner, and – Detailed Written Order for Covered Items.


Another curveball popping up in education sessions from some of the DME MACs includes instructions that they expect providers to have signed medical record notes in hand before delivering equipment to comply with the rule (after the delay expires).  If CMS maintains this course, this interpretation will be particularly burdensome to physician practices that send all their documentation out for transcription prior to making the documents available.  The interpretation is also counter intuitive to several critical need products such as oxygen and other items on the list.


Providers and advocate agencies have been reaching out to specifically discuss the impossibility of a retroactive enforcement of these additional provisions due to the inextricable connected nature to the Face-to-Face provisions.  The industry has been told that a Med Learn Matters article is forthcoming, but we are hopeful we can come to a mutual understanding of the key issues prior to the release of formal education on these issues.  Uncertainty still remains regarding several key issues, however, as more information on this topic develops, MiraVista will continue to disseminate key updates.  Please see additional education on this topic on our blog and via our Products menu.


PECOS Edits Officially Coming in January – Will Your Claims Deny?

Thursday, November 7th, 2013

Anglea Hayden


After nearly four years of operating under Phase I of the PECOS project, CMS has officially released the implementation date for Phase II edits via MLN Matters Article SE1305. Phase II was originally set to go into effect on May 1st of this year, however an eleventh hour delay published on April 29th pushed the implementation to an unspecified future date.  Medicare Contractors have now been officially instructed to deny claims that are linked to an ordering or referring physician that is not PECOS enrolled as of January 6, 2014.


DME providers have seen PECOS Phase I warning messages dating back to October 1, 2009, when the project was first initiated.   Providers initially received warning messages via claim status reports. Those warning messages were then migrated to the Medicare Remittances in the form of remark code N544 after the 5010 conversion, where they are currently still reported.  The N544 remark code is an indicator that future claims tied to the same non-PECOS enrolled ordering or referring physician will deny.  Once the edits take effect in January, these claims cannot be reprocessed until that physician is officially enrolled, and providers risk an unnecessary hold on reimbursement for these claims.


With the PECOS surrogate program now underway, providers have a better chance at getting busy physicians properly enrolled with PECOS to mitigate claim denials.  The surrogate program allows physicians to delegate the enrollment process to employees or third parties.  When working with overwhelmed referral sources, DME providers certainly understand just how valuable this tool can be.


While getting non-enrolled physicians to enroll in PECOS is an important part of the compliance process, most denials will be a result of non-matching records.  The PECOS Phase II edits require that the physician’s record match exactly to what is being submitted on the claim, which means that any typographical errors  in the spelling of the physician’s name, or transpositions of the NPI number within your records will cause the claim to deny.  Providers that have not already begun to scrub their files for these errors should do so immediately to ensure all records are clean prior to January 6, 2014.


The key to this process is to be proactive.  The majority of the denials that will result from the implementation of Phase II can be avoided by taking action now to scrub your physician records. Providers have enough uncertainty in the current market; don’t let the implementation of Phase II be another barrier between you and your Medicare reimbursement.


For more information on the steps to take to avoid claims denials and to better understand how the PECOS project will impact your business join us for our special webinar PECOS Revisited conducted by Reimbursement Consultant Andrea Stark on December 12, 2013 at 3pm (see details on registration here) or contact our office to schedule a consult with Andrea at 803-462-9959 ext. 246


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