CERT Errors - CPAPs and Accessories - JD DME

The CERT Review Contractor is currently reviewing claims related to Continuous Positive Airway Pressure (CPAP) and CPAP accessories. Noridian has reviewed and listed the top Comprehensive Error Rate Testing (CERT) error comments in efforts to assist suppliers by preventing or eliminating errors. The top CERT denial reasons noted by Noridian are listed below. The majority of the CERT denial reasons are related to the lack of clinical records supporting the medical need, proof of delivery issues and a missing a refill request. Listed below are three examples of recent CERT denials related to CPAP and accessories.

CERT Error Comment: Missing copy of the signed and dated treating / ordering physician medical records, dated within 12 months before the billed date of service to support the continued medical necessity of the CPAP device.

The initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription.

Examples of appropriate documentation that would qualify for continued medical necessity would include initial justification and:

1. A recent order/prescription by the treating practitioner for refills of supplies;
2. A recent order/prescription by the treating practitioner for repairs;
3. A recent change in an order/prescription;
4. A properly completed CMN or DIF obtained prior to DOS 01/01/2023, with an appropriate length of need specified;
5. Timely documentation in the beneficiary’s medical record showing usage of the item.

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:

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

Note: 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.

CERT Error Comment: Missing Refill Request: a) for items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill; b) for items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary; c) the refill request must occur and be documented before shipment; d) a retrospective attestation statement by the supplier or beneficiary is not sufficient.

Examples of appropriate documentation for a valid refill request would include:

1. Beneficiary’s name or authorized representative if different from the beneficiary
2. A description of each item that is being requested
3. Date of refill request
4. For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
5. For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., PAP and RAD supplies) the supplier must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. The supplier must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

As a general reminder when submitting documentation for reviews, 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.

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.

Examples of appropriate documentation that would qualify to support diagnosis:

Diagnosis of Obstructive Sleep Apnea (OSA) is based upon a sleep test (Type I, II, III, IV, Other) that meets the Medicare coverage criteria in effect for the date of service of the claim for the CPAP device.