In case you missed it in the August (K)notes session, today is kind of a big deal in the world of detailed written orders.

Beginning August 28, 2018, regardless of who created the order, detailed orders need only to establish a single “date of the order”. Previously, detailed written orders required both a start date and an order date.

According to new instructions, the date of the order should be “...the dispensing order date, i.e., the date the supplier was contacted by the prescribing physician (for verbal orders) or the date entered by the prescribing physician (for written dispensing orders).” The directive further clarifies that, so long as the written order is dated on or before the day of delivery, suppliers do not need to separately document affirmative receipt (e.g., fax stamp date).

Physicians must continue to sign and date their signature entries. The change permits the supplier to use the signature date on written orders to satisfy the order date requirement without a separate need for the supplier to populate a redundant “start date” or require another date on the form.  The only time a supplier would need to populate the order date would be for verbal orders, which are not frequently relied upon for delivery purposes in most DME practices.

CMS originally scheduled the changes to take effect on August 7, 2018. Transmittal 812 included a few minor edits, replaced Transmittal 806, and updated the effective date to August 28, 2018.
Suppliers should modify existing procedures and forms to eliminate duplicative or unnecessary steps, encourage consistency, and ensure compliance.

If you have any questions, give us a shout.

SOURCE LINKS
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R812PI.pdf

​CMS recently issued a Request for Information (RFI) seeking public input on ways to reduce the regulatory burdens associated with the the Stark Laws governing physician self-referrals. Interested parties should submit comments by August 24.

While the request is quite broad, the RFI emphasizes application of the Stark Laws to alternative payment models and other novel financial arrangements. Think non-traditional Medicare plans. For maximum impact, suppliers should ensure their comments address CMS’s specific concerns: does the law impede beneficiary access to quality care or encourage waste?

Of the 100+ comments received at the time of writing, nearly half discuss the Stark implications on sleep medicine. It is clear the physician community is extremely interested in providing PAPs and other DME items.

Adding doctors to the mix might infuse the market with new providers in the any-willing-provider era and perhaps reduce coordination of care burdens temporarily. Unsustainable reimbursement rates, however, impact physician-providers just as negatively and, in doing so, will grossly exacerbate conflict-of-interest pressures. Furthermore, physicians entering and exiting the market rapidly will only create more access problems for beneficiaries. Piling eligible providers on a reimbursement model that is flawed only magnifies the problem.

MiraVista believes, the progression of competitive bidding and fee schedule reductions are the cause of the current access issues … not Stark.

If you have any questions, give us a shout.

SOURCE LINKS
https://www.gpo.gov/fdsys/pkg/FR-2018-06-25/pdf/2018-13529.pdf
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CMS updated CMN forms to accommodate the new Medicare Beneficiary Identifier (MBI). The only notable difference, however, is a change to the policy number label from “HICN” to “Medicare ID.”

The update affects two DME Information Forms:

• Enteral/Parenteral
• External Infusion Pump

The update affects six CMN forms:

• Oxygen,
• Seat Lift Mechanisms,
• TENS,
• Pneumatic Compression Devices,
• Osteogenesis Stimulators, and
• The Continuation Form.

Updated forms contain a February 2017 (02/17) date for version control. Check with your software vendor to determine if the new forms are available in your system. Medicare will not require suppliers to revise previously completed CMNs but encourages early adoption for new setups.

If you have any questions, give us a shout.

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Source Links
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/2230703/cms-difs-and-cmns-updated

Suppliers delivering a Condition of Payment (COP) covered wheelchair base (HCPCS K0813-K0816, K0820-K0856, or K0861) on or after September 1, 2018, must request prior authorization before delivery. Authorization is a condition of payment, and all applicable claims without prior approval will deny.

Suppliers can submit prior authorization requests via mail, fax, or the DME MAC portals. Additionally, suppliers that pay for and utilize an esMD gateway through a certified HIH can upload requests through those channels.

CMS requires suppliers to secure an authorization even when Medicare is secondary to other insurance coverage.

Submission Requirements

CMS expects suppliers to include the following elements with their authorization request:

• MAC-approved Condition of Payment PA Coversheet
• 7-Element Order
• Face-to-Face (FTF) assessment
• Detailed Product Description (DPD)
• Specialty PT/OT Evaluation (if required)
• Any other relevant medical documentation

If an upgrade is involved, the FTF documentation and 7-element order must include the PMD base that is medically necessary for the beneficiary. Upgraded product information should appear on the Detailed Product Description with a note indicating when a supplier will deliver an upgraded item.

Accessories
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The MACs will review same and similar history in the course of their review. They will not, however, review medical necessity for every accessory. Specific options and accessories that address patient limitations can be considered as part of the prior authorization request when evaluations support the need. The MACs often review integral accessories such as:

• Power seating combination tilt and recline (E1007).
• Head control interface (E2327, E2328, E2329, E2330).
• Sip-n-puff interface (E2325).
• Joystick, other than a standard proportional joystick (E2312, E2321, E2373).
• Multi-switch hand control interface (E2322).
• Seat cushions.

The MACs exempt from review non-integral accessories such as:

• Headrests (E0955).
• Lateral hip/trunk supports (E0956).
• Swing away hardware (E1028).
• Electronics (E2310, E2311).
• Leg rests (K0195, K0108, E1012).
• Batteries.

While the Advanced Determination of Medicare Coverage (ADMC) process historically issued individual approvals for accessories, suppliers cannot use ADMC to secure approval of accessories attached to COP eligible bases.

[Get answers to your questions, and keep your team’s billing expertise sharp. Join us on August 16, 2018, at 1:00 PM (ET) for (K)notes.]

Decisions

After completing its prior authorization review, the applicable MAC will provide a provisional decision to the supplier. Upon request, MACs will send a copy of the decision to the beneficiary, but not to the physician.

MACs will respond within 10 business days of an initial submission or within 20 business days for repeat submissions. In special circumstances where the beneficiary’s life or health is in serious jeopardy, suppliers can request an expedited response and receive an authorization decision within two business days.

The authorization decision is not a claim determination. As such, prior authorization decisions cannot be appealed; appeal rights only apply to submitted claims. There is no limit on the number of authorization submissions. If the authorization process is bypassed, the MACs may choose to suspend and develop claims, but they have the discretion to outright deny these claims.

Claims Submission

For all decisions, the MACs issue a letter containing a Unique Transaction Number (UTN) that must be recorded in Box 23 on the 1500 claim form. Electronic claims transmit the UTN in loop 2400 REF02 where REF01 = G1. Always attach the UTN to the base line item and not to accessories.

​If the applicable MAC renders a non-affirmative decision, the supplier may:

• Resubmit the authorization request, or
• Issue an ABN based on the medical necessity failures and file the claim with the non-affirmed UTN.

Claims filed with a non-affirmed UTN will deny, but the denials can be appealed.

Suppliers will have up to six months to deliver the PMD after the MACs issue the UTN.

Effective Date

DME MACs will accept PA review requests for the COP program on August 18, 2018. To remain eligible, suppliers must plan to schedule delivery of the PMDs on or after September 1, 2018. DME MACs will honor all PMD Demonstration and Advanced Determination of Medicare Coverage (ADMC) decisions rendered prior to September 1, 2018.

For more information, the DME MAC websites contain a wealth of PMD resources, and CMS posted an updated FAQ on June 1, 2018, related to the COP prior authorization program.

If you have any questions, give us a shout.

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Source Links
https://www.gpo.gov/fdsys/pkg/FR-2018-06-05/pdf/2018-11953.pdf
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/transition-of-eligible-pmd-hcpcs-codes-in-the-pmd-demonstration-to-the-required-prior-authorization
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