Medicare Supplier Documentation

Pick-up Slips

Medicare regulation specifically forbids payments for multiple claims for rental of the same or similar equipment from either the same or a different supplier during the same rental month.

For purposes of this section, a pick-up slip is written confirmation, provided by you, that you have removed an item of DME from the beneficiary’s home. When making determinations, DME MACs or UPICs must ascertain not only whether equipment is present in the home, but must determine which equipment is actually being used by the patient. Therefore, it is inappropriate to determine, solely based on lack of a pick up slip that a piece of equipment may still be in use. Likewise, it is inappropriate for DME MACs or UPICs to deny claims solely based on lack of a pick up slip. DME MACs or UPICs should develop these claims to determine which piece of equipment is medically necessary.

Backup Equipment

Backup medical equipment is defined as an identical or similar device that is used to meet the same medical need for the beneficiary but is provided for precautionary reasons to deal with an emergency in which the primary piece of equipment malfunctions. Medicare does not pay separately or make an additional payment for backup equipment.

When a determination is made that if a particular piece of equipment breaks down or malfunctions it will result in immediate life-threatening consequences for the beneficiary, Medicare will place that item in the frequent and substantial servicing payment category (see Chapter 5 of this manual for information about payment categories). For items in this payment category, Medicare will reimburse for monthly rental payments for as long as the equipment is medically necessary. Consequently, you are responsible for ensuring that there is an appropriate and acceptable contingency plan to address any emergency situations or mechanical failures of the equipment.

The expectation is that an acceptable plan would involve input from the beneficiary and the treating practitioner and would take into account the severity of the beneficiary’s condition and time restraints in providing emergency support. This means that you are responsible for ensuring that the beneficiary’s medical needs for the use of this equipment will be met on a continuous and ongoing basis and that there is a plan to deal with any interruptions in the use of the equipment that would be life-threatening to the beneficiary. The plan may be as simple as furnishing backup equipment; however, Medicare will not pay separately and/or make any additional payment for the backup equipment. The payment for the primary piece of equipment would include the cost of that piece of equipment and the frequent and substantial servicing plan that you must provide to ensure that the beneficiary always has a piece of equipment that is in working order. If the backup equipment is billed, it will be denied as not being reasonable and necessary.

Backup equipment must be distinguished from multiple medically necessary items that are defined as identical or similar devices, each of which meets a different medical need for the beneficiary. Although Medicare does not pay separately for backup equipment, Medicare will make separate payment for a second piece of equipment if it is required to serve a different purpose that is determined by the beneficiary’s medical needs.

Examples (not all-inclusive) of situations in which multiple items may be covered are:

1. A beneficiary requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of device (e.g., positive pressure respiratory assist device with a nasal mask) during the rest of the day.
2. A beneficiary who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed. Without both pieces of equipment the beneficiary may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.
3. A beneficiary requires one type of infusion pump for a particular drug (e.g., a pump with patient control features for parenteral morphine) and needs a different type of pump for another drug (e.g., continuous infusion chemotherapy).

Examples (not all-inclusive) of situations in which a second or other multiple piece of equipment would be considered a backup and therefore would not be covered are:

1. A ventilator-dependent beneficiary is confined to bed and a second ventilator of the same or similar type is provided at the bedside as a precaution in case of malfunction of the primary ventilator.
2. The drug epoprostenol (Flolan®) is administered using an ambulatory infusion pump, and a second infusion pump is provided and billed as a precaution in case of malfunction of the primary pump. Because interruption of a continuous infusion of this drug results in immediate life-threatening consequences, a unique code, K0455, has been established for an infusion pump used to administer this drug, and the code is in the frequent and substantial servicing payment category.

Correct Coding

Correct coding is a determination that the item(s) provided to the beneficiary are billed using the appropriate HCPCS code for the item. You are required to correctly code for the items billed. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, or MAC articles. Information that is sufficiently detailed to unambiguously identify the specific product delivered to the beneficiary and the HCPCS code used to bill for that item must be maintained by the supplier and be available upon request.

For LCDs that use ICD-10 diagnosis codes, correct coding of the ICD-10 code is required. A diagnosis is correctly coded when it meets all the coding guidelines listed in International Classification of Diseases Guidelines (ICD), CMS ICD policy or guideline requirements, LCDs, or MAC articles. Information that is sufficiently detailed to unambiguously justify the ICD-10 code used to bill for DMEPOS items must be contained in the beneficiary’s medical record and be available upon request.

Miscellaneous HCPCS Codes

Unusual services and items are generally reported to the contractor with miscellaneous HCPCS codes. These miscellaneous HCPCS codes do not have established fee schedule reimbursement rates. Each item/service is processed based on individual consideration. In these situations you must furnish documentation describing the service or item, manufacturer name, product name and number, supplier price list (PL) amount, and HCPCS code of related item (if applicable). If it is a customized option/accessory, the statement must clearly describe what was customized. When necessary, consultants’ advice will be obtained.

If the description, manufacturer name, product name, and product number, supplier price list (PL) amount, and HCPCS code of related item (if applicable) are not provided with the claim, the claim will be rejected for missing information and you will be responsible for resubmitting the claims with the appropriate information.

Claims for option/accessory codes as a replacement must be submitted with the make and model name of the equipment base the item is being added to, the date of the purchase of the equipment base, and documentation of the medical necessity for the item.

The definitions of HCPCS codes are meant to be broadly inclusive. All related components are included in the codes and should generally not be billed separately unless specifically allowed in the definition or description of a HCPCS code. If you choose to bill separately for an included component, HCPCS code A9900 (miscellaneous DME supply, accessory and/or service component of another HCPCS code) must be used and will be denied as not separately payable. If an included component is billed with a miscellaneous HCPCS code, then that claim line will be rejected as incorrect coding.

11. Evidence of Medical Necessity: Power Mobility Devices (PMD)

As the result of the way that the Social Security Act defines durable medical equipment, a power mobility device (PMD) is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. The beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the user of an appropriately fitted cane or walker. If the PMD is needed in the home, the beneficiary may also use it outside the home.

In order for Medicare to provide reimbursement for a PMD, there are several statutory requirements that must be met:

1. There must be an in-person practitioner-beneficiary encounter (the in-person visit and medical examination together are often referred to as the “face-to-face” exam). The practitioner may refer the beneficiary to a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), to perform part of the face-to-face examination. This person may have no financial relationship with the supplier.
2. The medical examination for the specific purpose of assessing the beneficiary’s mobility limitation and needs must be recorded in the beneficiary’s medical record.
3. The evaluation should be tailored to the individual beneficiary’s conditions. The history should paint a picture of your beneficiary’s functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the beneficiary’s ambulatory difficulty or impact on the beneficiary’s ambulatory ability. The evaluation must clearly distinguish the beneficiary’s mobility needs within the home from their needs outside the home.
4. Documentation can also include copies of previous notes, consultations with other practitioners, and reports of pertinent laboratory, x-ray, or other diagnostic tests if they will help to support the severity of the beneficiary’s ambulatory problems.
5. The prescription must only be written AFTER the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements.
6. The prescription and medical records documenting the in-person visit and examination report must be sent to you, the equipment supplier, with in 45 days of the completion of the examination. For those instances of a recently hospitalized beneficiary, you must receive the written order within 45 days after the date of discharge from the hospital.

You must document the receipt date with a date stamp or equivalent.

The written order, also referred to as the 7-element order, for the PMD must be written, signed, and dated by the treating practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist) who performed the face-to-face examination. The face-to-face examination requirement does not apply when only accessories for power mobility devices are being ordered.

The written order/prescription must contain the following seven elements:

1. Beneficiary’s name.
2. Description of the item that is ordered. This may be general—e.g., power operated vehicle, power wheelchair, or power mobility device—or may be more specific.
3. Date of completion of the in-person examination.
4. Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair.
5. Length of need.
6. Practitioner’s signature.
7. Date of practitioner signature.

Once you have determined the specific power mobility device that is appropriate for the beneficiary based on the practitioner’s 7-element order, you must prepare a written document (termed a detailed product description). This detailed product description (DPD) must comply with the requirements for a detailed written order as outlined in that section of this chapter and the CMS Program Integrity Manual (CMS Manual System, Pub. 100-8), Chapter 5. Regardless of the form of the description, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.

The practitioner must sign and date the detailed product description and you must receive it prior to delivery of the power wheelchair or power operated vehicle. A date stamp or equivalent must be used to document your receipt date. The detailed product description must be available upon request.

An on-site home assessment must be conducted to consider the home’s physical layout, doorway widths, doorway thresholds, and floor surfaces. The beneficiary’s home must provide adequate access between rooms, maneuvering space, and surfaces for the operation of the PMD. The assessment must be done prior to or at the time of delivery of the PMD. The written report of this evaluation must be available on request.

You should refer to the individual medical policies for specific coverage and payment provisions.

As defined in the CMS Manual System (Pub. 100-08, Medicare Program Integrity Manual, Chapter 3), if data analysis indicates potentially aberrant billing, contractors shall continue to follow the general guidance for performing medical review on claims.

For more information regarding mobility devices, please consult the appropriate Local Coverage Determination (LCD) and Policy Article.

12. Comprehensive Error Rate Testing (CERT)

The Centers for Medicare & Medicaid Services (CMS) developed the Comprehensive Error Rate Testing (CERT) program to produce national, contractor-specific, and service-specific claim error rates. The program has independent reviewers who periodically review representative random samples of Medicare claims. The independent reviewers medically review claims that are paid and claims that are denied to ensure the claim decision was appropriate. CERT was implemented in order to achieve goals of the Government Performance and Results Act of 1993, which sets performance measurements for Federal agencies.

Each month the CERT contractor selects a random sample of claims processed by each Medicare contractor, including the DME MACs. They then request medical records, Certificates of Medical Necessity, and supporting documentation from the provider of the service to verify services billed were delivered and medically necessary and that claims were processed appropriately. If you are contacted for a CERT review, you will be provided with the details regarding the needed information and how to submit it.

When no medical records or supporting documentation are received, a denial decision is made which ultimately results in a request for refund from the provider if the claim had been paid originally. These claims may be appealed through normal channels at the DME MAC (see Chapter 13 of this manual for information about appeals).

When records and/or documentation are received, the CERT contractor’s medical review staff (includes nurses, physicians, and other qualified healthcare practitioners) then perform a complete review of the claims. If documentation fails to support the item(s) billed, an error is called and a refund will be requested. Documentation that supports the medical need will result in no further action needed by the provider.

Additional information about CERT may be found on the CMS website at http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/index.html or through our website at http://www.cgsmedicare.com/jc/claims/cert/index.html.