A new enforcement of quantity details on Detailed Written Orders for enteral nutrition is manifesting in claim denials. CGS recently updated the language on the Enteral Documentation Checklist (as of January 27, 2015) that mentions a new description for quantity on the Detailed Written Order to be represented on a “per fill” basis. This is new terminology and a compliance expectation that CGS and other MACs are now beginning to enforce. We have not seen these quantity errors in prior claims because the medical reviewers were using discretion to calculate proper quantities using other elements on the Detailed Written Order. However, because there are so many variations and fluctuations with the prescription and how claims are billed, they are now requiring the orders to be more specific to avoid denial. The Provider Education departments are also increasing their discussion of this expectation. The MACs are interpreting this nuance to be a part of the quantity requirement of the LCD.
The Office of Medicare Hearings and Appeals (OMHA) has announced the contract award for the next phase of process improvement for the third level of Medicare appeals (Administrative Law Judge or ALJ). On March 30, 2015, CACI Inc. was awarded the development contract for the Electronic Case Adjudication and Processing Environment (ECAPE) for OMHA. This tool is an effort to streamline the procedures of the ALJs after an exponential increase of third level appeals overwhelmed the office and pushed case assignment wait times to nearly two years. This tool will allow the ALJs to process cases electronically, and will feature functionality for...
In a listserve posted on June 4th, 2015, the CBIC announced the removal of Non-Invasive Pressure Support Ventilators from Round 1 2017. The E0464 was introduced as a stand-alone product category for this particular round of bidding in April 2015. Bidding for this round has not yet begun, which allows the CBIC to process these kinds of changes.
CMS has recently released a number of educational bulletins and Joint DME MAC publications to inform suppliers that Ventilators are not appropriate for the treatment of OSA and those conditions covered in the Respiratory Assist Device (RAD) policy (Complex Sleep Apnea, Central Sleep Apnea, Hypoventilation Syndrome, etc). Because of advancements in technology, some ventilators are able to operate in PAP or RAD modes, therefore suppliers are incorrectly utilizing these ventilators in place of a PAP or RAD device...