CERT Errors - Nebulizers and Drugs - JA DME

The Comprehensive Error Rate Testing (CERT) Review Contractor is currently reviewing claims for nebulizers and related drugs. Noridian has reviewed the top CERT error comments in efforts to assist suppliers in how to prevent or eliminate these errors, particularly for inhalation drugs. The majority of the CERT denial reasons are related to the base item being denied; therefore, any accessory/supply is denied, missing documentation to support coverage criteria and an inadequate proof of delivery. Listed below are three examples of CERT denials related to nebulizers and related drugs.

CERT Error Comment: Base item on the claim is denied; therefore, the related addition to the base, accessory, or supply fee is denied.

1. If none of the drugs used with a nebulizer are covered, the nebulizer and related accessories/supplies will be denied as not reasonable and necessary.
2. Nebulizers can be covered if a beneficiary’s ability to breathe is severely impaired. Refer to Durable Medical Equipment Reference List National Coverage Determination (NCD) 280.1.
3. The Local Coverage Determination for nebulizers (L33370) identifies the usual maximum daily dose of inhalation drugs covered by Medicare. Refer to the Nebulizers LCD for information about the maximum covered quantities of drugs or about the coverage of combinations of drugs in the same therapeutic class.

CERT Error Comment: Documentation to support coverage criteria. DMEPOS items are covered by Medicare when the beneficiary’s medical record contains sufficient information about the beneficiary’s medical condition(s) to substantiate the necessity for the type and quantity of items. The information should include: a) the beneficiary’s diagnosis; b) functional limitations; c) therapeutic interventions and results; d) and any past experience with related items.

1. When initially ordering inhalation drugs, nebulizers, and accessories, it is important to clearly document in the medical records the beneficiary’s diagnosis and other clinical information relating to the need for these items.
2. Inhalation drugs, nebulizers, and related accessories are covered for many respiratory conditions and/or diseases.
3. Refer to the Nebulizers Local Coverage Determination (LCD) for details regarding coverage of specific types of nebulizers.

CERT Error Comment: Missing proof of delivery that includes: a) package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service records; b) detailed description to identify the item(s) being delivered; c) quantity delivered; d) date of delivery.

Examples of appropriate documentation that would qualify for a valid proof of delivery for method 2, delivery via a shipping service:

1. Beneficiary's name
2. Delivery address
3. Delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records.
4. A description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number
5. Quantity delivered
6. Date delivered
7. Evidence of delivery

If a supplier utilizes a shipping service or mail order, suppliers have two options for the DOS to use on the claim:

1. Suppliers may use the shipping date as the DOS. The shipping date is defined as the date the delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation.

2. Suppliers may use the date of delivery as the DOS on the claim.

As a general reminder when submitting documentation for review, it is important to follow the signature requirements for medical documentation. The requirements are listed below:

CMS Internet Only Manual (IOM), Publication 100-08, Program Integrity Manual (PIM), Chapter 3, Section 3.3.2.4 - Signature Requirements: This section is applicable for Medicare Administrative Contractors (MACs), Unified Program Integrity Contractors (UPICs), Supplemental Medical Review Contractors (SMRCs), Comprehensive Error Rate Testing (CERT), and Recovery Audit Contractor (RACs), as indicated.