Spinal Orthoses Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) L0648 and L0650. The quarterly edit effectiveness results from January 2019 - March 2019 are as follows:

Based on dollars, the overall claim potential improper payment rate is 68%.

Top Denial Reasons

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Spinal Orthoses Local Coverage Determination (LCD) L33790, Policy Article A52500 [PDF] and Standard Documentation Requirements Article A55426.

Suppliers can also review specific policy resources for Spinal Orthoses to find information related to proper documentation requirements including a physician letter, documentation checklists, and FAQs.

Suppliers can also review a specific policy Documentation Checklist for Spinal Orthoses on the Noridian website.

Noridian provides education via supplier workshops, training opportunities, and presentations.

Information about probe/error validation reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

Policy Education

Documentation was not received in response to the Additional Documenations Requests (ADR) letter.

DOCUMENTATION REQUIREMENTS

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).

Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR webpage of Noridian's website.

No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.

MEDICAL RECORD INFORMATION

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider." It is expected that the beneficiary's medical records will reflect the need for the care provided. The beneficiary's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

General (PIM 5.7-5.9)

For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).

The patient's medical record is not limited to the physician's office records. It may include hospital, nursing home, or HHA records and records from other health care professionals.

Documentation must be maintained in the supplier's files for seven (7) years from date of service.

Claim is the same or similar to another claim on file.

SAME OR SIMILAR

Same or similar denials occur when the patient's CMN history indicates a piece of equipment is the same or similar to the equipment being billed.

To determine whether same or similar items have previously been provided, suppliers must obtain all possible information from a patient, which may include the following:

  • Patient's correct Health Insurance Claim number;
  • Whether the patient has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
  • If the patient currently has or had an identical or similar item in the past;
  • When the patient received the items and whether or not the items have been returned;
  • Where the item will be used; and
  • CMN or DIF information, if required.

By using the Suggested Intake Form, it assures this information is obtained. This form is available on our website under the Forms section and it contains beneficiary information, ordering physician information and questions for the beneficiary and the supplier. Suppliers can customize their own intake form to meet their needs as well.

The Noridian Medicare Portal or Interactive Voice Response System can be used to verify that a beneficiary has not had a same or similar item within the previous five years. Follow the steps listed under the manual on the Noridian Medicare Portal to check for same or similar items.

Documentation does not include verification that the equipment was lost, stolen or irreparably damaged in a specific incident.

REPLACEMENT

The definition of replacement is found in the CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entire identical or nearly identical item when it is lost, stolen or irreparably damaged.

Beneficiary owned items or a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage may be due to a specific accident or to a natural disaster (e.g., fire, flood). Contractors may request documentation confirming details of the incident (e.g., police report, insurance claim report).

Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. The RUL of DME is determined through program instructions. In the absence of program instructions, carriers may determine the RUL, but in no cases can it be less than 5 years. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement.

 

Last Updated Jul 18, 2019