RETIRED - Coverage Reminder - Osteogenesis Stimulators - JA DME

Joint DME MAC Publication

A recent examination of Comprehensive Error Rate Testing (CERT) reviews for osteogenesis stimulator claims has identified common errors in the information submitted in support of claims payment. This article will review the findings and related policy requirements.

Reasons for Denial

• Prescriptions
  • Physician's detailed written order is missing, incomplete, or invalid - 25%
• Reasonable & Necessary (R&N)
  • National Coverage Determination (NCD) for osteogenesis stimulators (150.2) coverage criteria for radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with E0747 not met - 53%
• Other
  • Face to Face requirement not met - 6%
  • Missing Certificate of Medical Necessity (CMN) - 3%
  • Unsigned Clinical Notes or use of Signature Stamps - 9%

Payment Rules

Prescriptions:

All items billed to Medicare require a prescription. A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

ACA 6407 requires a written order prior to delivery (WOPD) for the HCPCS codes E0747, E0748, and E0760 as specified in the table contained in the Policy Specific Documentation Requirements Section of the Local Coverage Determination (LCD) for Osteogenesis Stimulators. The supplier must have received a complete WOPD that has been both signed and dated by the treating physician and meets the requirements for a DWO before dispensing the item.

Face-to-Face Documentation:

ACA 6407 requires face-to-face documentation that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered for the HCPCS codes E0747, E0748, and E0760 as specified in the table contained in the Policy Specific Documentation Requirements Section of the LCD for Osteogenesis Stimulators.

Reasonable and Necessary (R&N) Criteria:

The NCD and LCD for Osteogenesis Stimulators both mandate that coverage for a non-spinal electrical osteogenesis stimulator (E0747) is covered for nonunion of a long bone fracture defined as radiographic evidence that fracture healing has ceased for three or more months prior to starting treatment with the osteogenesis stimulator (criteria 1). Nonunion of a long bone fracture must be documented by a minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator, separated by a minimum of 90 days, each including multiple views of the fracture site, and with a written interpretation by a physician stating that there has been no clinically significant evidence of fracture healing between the two sets of radiographs.

Documentation

In the event of a claim review:

• Medicare requires a WOPD.
• Medicare requires Face-to-Face documentation.
• Medicare requires that there be sufficient detailed information contained in the beneficiary's medical record to demonstrate that the relevant policy requirements were met.

This article presents a summary of the policy requirements related to the errors identified in a CERT review. There are additional requirements necessary for coverage that are not discussed in this article. Please refer to the Osteogenesis Stimulator LCD and related Policy article for complete information.

Further education regarding this policy is available on your DME MAC contractor website.

Publication History