Oxygen and Oxygen Equipment (HCPCS E0439 and E0434) Quarterly Results of Service Specific Prepayment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code E0439 and E0434. The quarterly edit effectiveness results from October 2014 through January 2015 are as follows:

The E0439 review involved 199 claims, of which 134 were denied. Based on dollars, this resulted in an overall potential improper payment rate of 68%.

The E0434 review involved 101 claims, of which 72 were denied. Based on dollars, this resulted in an overall potential improper payment rate of 54%.

Top Denial Reasons

  • No documentation of valid date stamp or similar for Written Order Prior to Delivery (WOPD)
  • No documentation was received in response to Additional Documentation Request (ADR) letter
  • No documentation of valid Written Order Prior to Delivery (WOPD)
  • Patient not in a chronic stable state at time of study

Going Forward

Based on the results of this review, Noridian will continue with the Prepayment Service Specific Review.

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Oxygen and Oxygen Equipment Local Coverage Determination (LCD) L11457 and Policy Article A33677.

Suppliers can also review a specific policy Documentation Checklist for Oxygen and Oxygen Equipment on the Noridian website.

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.

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

Policy Education

No documentation of a valid date stamp or similar for Written Order Prior to Delivery (WOPD)

A WOPD is a standard Medicare Detailed Written Order, which must be completed, including the prescribing physician's signature and signature date, and must be in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier's possession BEFORE the item is delivered.

A date stamp (or similar) is required which clearly indicates the supplier's date of receipt of both the face-to-face record and the completed WOPD with the prescribing physician's signature and signature date. It is recommended that both documents be separately date-stamped to avoid any confusion regarding the receipt date of these documents.

No documentation was received in response to Additional Documentation Request (ADR) letter

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 NSC. The supplier standards can be found in 424 CFR Section 424.57(c).

Please also remember, the documentation must be submitted to our office 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 letters or under the claims section on our website at https://www.noridianmedicare.com/dme/claims/edi.html.

No documentation of a valid Written Order Prior to Delivery (WOPD)

A detailed written order prior to delivery (WOPD) is required for E0439 and E0434. The supplier must have received a WOPD that has been both signed and dated by the treating physician and meets the requirements for a DWO before dispensing the item.

For an item addressed in this policy to be covered by Medicare, a written signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to receipt of a written order, it will be denied as noncovered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.

A WOPD is a standard Medicare Detailed Written Order, which must be completed, including the prescribing physician's signature and signature date, and must be in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) supplier's possession BEFORE the item is delivered. The WOPD must include all of the items below:

  • Beneficiary's name
  • Physician's Name
  • Date of the order and the start date, if start date is different from the date of the order
  • Detailed description of the item(s)
  • The prescribing practitioner's National Provider Identifier (NPI),
  • The signature of the ordering practitioner
  • Signature date

For any of the specified items provided on a periodic basis, including drugs, the written order must include, in addition to the above:

Item(s) to be dispensed

  • Dosage or concentration, if applicable
  • Route of Administration, if applicable
  • Frequency of use
  • Duration of infusion, if applicable
  • Quantity to be dispensed
  • Number of refills, if applicable

Note that prescriptions for these specified DME items require the National Provider Identifier to be included on the prescription. Prescriptions for other DMEPOS items do not have this NPI requirement. Suppliers should pay particular attention to orders that include a mix of items, to assure that these ACA order requirements are met.

Date and Timing Requirements

There are specific date and timing requirements:

  • The date of the face-to-face examination must be on or before the date of the written order (prescription) and may be no older than 6 months prior to the prescription date.
  • The date of the face-to-face examination must be on or before the date of delivery for the item(s) prescribed.
  • The date of the written order must be on or before the date of delivery.
  • The DMEPOS supplier must have documentation of both the face-to-face visit and the completed WOPD in their file prior to the delivery of these items.

A date stamp (or similar) is required which clearly indicates the supplier's date of receipt of both the face-to-face record and the completed WOPD with the prescribing physician's signature and signature date. It is recommended that both documents be separately date-stamped to avoid any confusion regarding the receipt date of these documents.

Patient not in a chronic stable state at time of study

Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:

  1. The treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and
  2. The beneficiary's blood gas study meets the criteria stated below, and
  3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and
  4. The qualifying blood gas study was obtained under the following conditions:
    • If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, o
    • If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease, and
  5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.

In this policy, the term blood gas study refers to either an oximetry test or an arterial blood gas test.

 

            Last Updated Mon, 24 Feb 2020 11:15:59 +0000