google ad placement

Saturday, January 20, 2018

Congregate Living Health Facilities and Durable Medical Equipment (DME), What's reimbursable?

Everyday, we still get a lot of folks asking about what is covered with DME and what is not covered as part of the daily rate with MediCal.  The best way to handle this I feel, it is a simple breakdown that we have collaborated with State officials to come up with a quick and easy way of explaining this to newbies in Congregate Living Facilities.  So here is our attempt to make this clear as mud for you, lol.  (formatting will be odd because of the blog formating restrictions, so sorry bout this)

All supplies, equipment and services necessary to provide a
Separately Reimbursable designated level of Long Term Care (LTC) are included in the LTC
Items rate unless listed in LTC regulations as separately reimbursable.  CCR, Title 22, Section will continue to apply for subacute recipients.  Items listed as separately reimbursable for non-subacute LTC recipients are as follows:
·    Allied health services ordered by the attending physician
·    Alternating pressure mattresses/pads with motor
·    Atmospheric oxygen concentrators, enrichers and accessories
·    Blood, plasma and substitutes
·    Dental services
·    DME as specified in CCR, Title 22, Section 51321(g)
·    Insulin
·    Intermittent positive pressure breathing equipment
·    Intravenous trays, tubing and blood infusion sets
·    Laboratory services
·    Legend drugs
·    MacLaren or Pogon Buggy




·    Medical supplies as specified in the Welfare and Institutions Code (W&I Code), Section 14105.47
·    Nasal cannula
·    Osteogenesis stimulator device
·    Oxygen delivery systems (stationary and portable gaseous oxygen, stationary and portable liquid oxygen and oxygen concentrator)
·    Oxygen contents (gaseous and liquid)(except emergency)
·    Parts and labor for repairs of DME originally separately payable or owned by recipient
·    Physician services
·    Portable aspirator
·    Pre-contoured structures (VASCO-PASS, cut out foam)
·    Prescribed prosthetic and orthotic devices for exclusive use of recipient
·    Reagent testing sets
·    Therapeutic air/fluid support systems/beds
·    Traction equipment and accessories
·    Variable height beds


Nursing Facility:  Billing                 Canes, crutches, wheelchairs and walkers for Nursing Facility (NF)
Requirement for Canes,               Level A and B recipients are reimbursable only when the items must
Crutches, Wheelchairs                  be custom-made or modified to meet the unusual needs of the
and Walkers                                 recipient and the need is expected to be permanent.  When billing with an approved Treatment Authorization Request (TAR), a statement that the item was custom-made or modified must be entered in the Additional Claim Information field (Box 19) of the claim, or on an attachment included with the claim.  If using an “unlisted” procedure code for any of these items, also include a notation whether the item is taxable or nontaxable.  Refer to “Nursing Facility TAR Requirements” in this section for more information about these items.





Recipient Responsibilities             Recipients are responsible for appropriate use and care of DME purchased for their use under the Medi-Cal program.


Provider Responsibilities               Pursuant to CCR, Title 22, Section 51321 (i), rendering providers of DME shall ensure that all devices and equipment are appropriate to meet the recipient’s medical needs.  Providers shall instruct recipients in appropriate use and care of DME and notify recipients that they are responsible for appropriate use and care of DME purchased for their use under the Medi-Cal program.  If a piece of equipment or a device, when in actual use, fails to meet the recipient’s needs, and the recipient’s medical condition has not significantly changed since the device/equipment was dispensed, the rendering provider shall adjust or modify the equipment, as necessary, to meet the recipient’s needs.  The rendering provider, at no cost to the Medi-Cal program, shall replace any equipment or device that cannot be adjusted or modified.



Eligibility Requirements             To receive reimbursement, a recipient must be eligible for Medi-Cal on the date of service.



Prescription Requirements        A written prescription of a licensed practitioner within the scope of his or her practice as established in California law is required for authorization of purchase, rental, repair or maintenance of DME, per
CCR, Title 22, Section 51321.  A copy of the signed and dated written
prescription (or electronic equivalent) must accompany the TAR.

Note:  The physician must retain the prescription for his or her
records.

In addition to the physician’s signature (written or electronic), the
following specific information must be supplied clearly on or with the prescription form or as an attachment to the TAR:
·    Full name, address and telephone number of the prescribing
physician, if not pre-printed on the prescription form.
·    Copy of dated prescription.
·    Item(s) being prescribed.  If multiple or above-standard items are prescribed, these facts must be separately specified.
·    Medical condition or diagnosis necessitating the particular DME item.  This shall include the patient’s medical status and functional limitation(s), and a description of how the specific item being requested is expected to improve the medical status or functional ability(ies) of the patient, stabilize the patient’s medical condition, or prevent additional deterioration of the medical status or functional ability(ies) of the patient.



·    Estimated length of time the item is medically necessary.  The term of use should be stated as precisely as possible; for example, short-term use in months and long term use as “permanent,” “indefinite” or “lifetime.”


Face-to-Face Encounter               For all DME items a face-to-face encounter with a physician, nurse practitioner, clinical nurse specialist or physician assistant that is related to the primary reason the recipient requires the DME item is required.  Face-to-face encounters may be done via telehealth.  For all DME items that require replacement or replacement parts, a new prescription written by the physician for the DME item is required annually.

The following conditions must be met in order for the face-to-face encounter to be satisfied:
·    The provider performing the face-to-face encounter must communicate the clinical findings of that face-to-face encounter to the ordering physician.
·    The clinical findings from the face-to-face encounter must be incorporated into a written or electronic document included in the recipient’s medical record.
·    The physician prescribing the DME must document that the
face-to-face encounter, which is related to the primary reason the patient requires the DME, has occurred within six months prior to the date on the DME prescription.
·    The physician writing the DME prescription must document who conducted the face-to-face encounter and the date of the encounter.



Non-Physician Medical               Policy information about Non-physician Medical Practitioners

Practitioners:  Furnishing or      (NMPs) furnishing or ordering drugs or devices can be found in the
Ordering Drugs or Devices        Part 2 General Medicine manual under Medical Services on the
Medi-Cal website at www.medi-cal.ca.gov.




TREATMENT AUTHORIZATION REQUEST (TAR) INFORMATION

Authorization                               The following DME authorization criteria are required:
·    For the purchase of DME, when the cumulative cost of purchasing items within a group exceeds $100 within the calendar month.  Providers may refer to the Durable Medical Equipment (DME):  Billing Codes and Reimbursement Rates section in this manual to determine if items are related within a group.  Items grouped together under specific headings, such as “Hospital Beds” or “Bathroom Equipment,” are considered within the same group.
·    For the repair or maintenance of DME items within the group, when the cumulative cost exceeds $250 within a calendar month.
·    For labor to repair patient-owned DME when cumulative cost exceeds $250 or 12 units within a calendar month.
·    For the rental of DME when the cumulative cost of rental for items within the group exceeds $50 within a 15-month period. This includes any daily amount that an individual item, or a combination of a similar group of DME items, exceeds the $50 threshold.  The 15-month period begins on the date the first item is rented.
·    For the purchase, rental, repair or maintenance of any unlisted devices or equipment, regardless of the dollar amount of the individual item or cumulative cost.
·    Medical records submitted with a TAR for wheelchairs require extensive documentation.  Refer to the Durable Medical Equipment (DME):  Bill for Wheelchairs and Wheelchair Accessories section of the Part 2 manual for more specific TAR requirements.





For oxygen contents, oxygen equipment and respiratory equipment, authorization is required:
·    For the purchase, rental, repair or maintenance of all oxygen contents, oxygen equipment and respiratory equipment except for all of the following, which require authorization only for quantities exceeding the stated billing limit:
   A7005 (administration set, with small volume nonfiltered pneumatic nebulizer, nondisposable) – billing limit of one every 6 months
   E0484 (oscillatory positive expiratory pressure device,
non-electric, any type, each) – billing limit of two per 12 months
·    For the purchase, rental or maintenance of any unlisted devices or equipment, regardless of the dollar amount of the individual item or cumulative cost



Certificate of Medical                  Except as noted below, providers must complete the applicable
Necessity                                    DHCS 6181 form when submitting documentation to support Treatment Authorization Requests (TARs) for DME:
·    DHCS 6181:  Certificate of Medical Necessity for All Durable Medical Equipment (DME) (Except Wheelchairs and Scooters)
·    DHCS 6181-A, DHS 6181-B and DHS 6181-C:  Refer to the Durable Medical Equipment (DME):  Bill for Wheelchairs section for information about these forms.
In lieu of DHCS 6181, providers must submit the following Department of Health Care Services (DHCS) forms or equivalent information for oxygen contents, oxygen equipment and respiratory equipment:
·    Certificate of Medical Necessity for Apnea Monitors
·    Certificate of Medical Necessity for Nebulizers
·    Certificate of Medical Necessity for Oxygen
Note:  Sample forms can be found following this section.





Nursing Facility                             DME items supplied for recipients in Nursing Facility Levels A and B
TAR Requirements                       (NF-A, NF-B) require authorization according to California Code of Regulations (CCR), Title 22, Section 51321(h).  Authorization may be approved as follows:
Unusual Medical Needs
If the equipment is necessary for the continuous care of the patient to meet the unusual medical needs of that patient.  A patient may be considered to have unusual medical needs when a disease or medical condition is exacerbated by physical characteristics such as height, weight and/or body build.  Physical characteristics, in and of themselves, do not constitute an unusual medical condition.
Canes, Crutches, Wheelchairs, Wheelchair Cushions and Walkers
These items are reimbursable only when the item must be
custom-made or modified to meet the unusual needs of the recipient and the need is expected to be permanent.
Suction Positive Pressure Apparatus
Suction and positive pressure apparatus may be authorized only when the item will be continuously used by the patient or must be immediately available to the patient for one month or more.




Required Information                    TARs for DME, oxygen contents, oxygen equipment, and respiratory equipment and parenteral infusion equipment require the following information:
·    Date of request
·    Medical justification relevant to the item being requested, as specified; some respiratory equipment requires a DHCS form or equivalent information to be completed
·    Location of where the recipient resides
·    Description of item, including:
-    Whether new or used
-    How long item has been rented to this recipient
-    Whether duration of usage will be short or long-term
-    Manufacturer’s name and/or model type/serial
-    Procedure code
-    Appropriate modifier
-    Estimated length of need, whether rental or purchase is being requested, and associated charges
·    A copy of the prescription, which must contain all the data listed in “Prescription Requirements” in this section
·    Rendering provider identification, including name, address, telephone number, contact name, contact telephone number and National Provider Identifier (NPI)
·    Unlisted DME requires copies of the catalog pages and medical justification to substantiate why a listed item is insufficient to meet the recipient’s medical needs
·    Purchase price, if applicable
·    Monthly rental charge


Medical Criteria                             Medical criteria for the authorization of specific DME items may be found in the Manual of Criteria for Medi-Cal Authorization (MOC).  MOC information is available at:
www.dhcs.ca.gov/services/medi-cal/Pages/MediBen_Svcs.aspx

Medical criteria for oxygen contents, oxygen equipment and respiratory equipment may be found in the Durable Medical Equipment (DME): Bill for Oxygen and Respiratory Equipment section in this manual.





Negotiated Prices                         Refer to the TAR Completion section in this manual.


Medicare/Medi-Cal                        Authorization is not required for the purchase, rental, repair or
Recipients                                    maintenance of DME for recipients covered by both Medicare and Medi-Cal (crossover recipients).  However, if Medicare does not approve the purchase, repair or maintenance of DME, the claim is subject to all Medi-Cal authorization requirements.

Retroactive authorization from Medi-Cal must be obtained if the service has already been rendered and denied by Medicare.  A copy of the denial must accompany the TAR and prescription.  Providers must then submit the claim directly to Medi-Cal, including the TAR Control Number (TCN), for reimbursement denied by Medicare.

Any questions about this authorization policy should be addressed to the Telephone Service Center (TSC) at 1-800-541-5555.



BILLING INFORMATION



“By Report”                                 DME items (except wheelchairs and wheelchair modifications and
Requirements                             accessories, and replacement parts for all patient-owned DME) with no specified maximum allowable rate will be reimbursed “By Report” and require the following information (see appropriate DME section for requirements for the specific group of DME products):
·    Manufacturer’s purchase invoice and the manufacturer’s suggested retail price (MSRP) (a catalog page)
·    Item description
·    Manufacturer name
·    Model number
·    Catalog number
Claims that do not include all required documentation will be denied.





Documentation Requirements      Providers who also manufacture DME items need to submit the MSRP
for Provider/Manufacturer             with claims only for items they manufacture.  For dates of service on or after January 1, 2013, submit the catalog page showing MSRP published on or prior to the date of service.  For dates of service on or after September 1, 2006, MSRP must be an amount published by the manufacturer prior to June 1, 2006.  If the item was not available prior to these dates, providers must submit the following:
·    Date of availability in the Additional Claim Information field (Box19) of the CMS-1500 claim
·    Catalog page that initially published the item
·    MSRP



Sales Tax                                    Refer to the Taxable and Non-taxable Items section in this manual.



Repair or Maintenance               Repair or maintenance of equipment is billed with applicable HCPCS
of Equipment                               codes for replacement parts and one of the following codes for labor:
HCPCS Code     Description
K0739                repair or non-routine service for DME other than oxygen equipment requiring the skill of a technician, labor component per 15 minutes
K0740                repair or non-routine service for oxygen equipment requiring the skill of a technician, labor component per 15 minutes


Labor                                           Claims for labor for patient-owned equipment require the following information:
·    HCPCS code K0739 or K0740 (no modifier required or allowed)
·    A statement that the labor is performed on “patient-owned equipment” in the Additional Claim Information field (Box 19) or on an attachment to the claim
·    A notation detailing the equipment that was repaired or serviced (either the specific procedure code for the equipment or a description)
·    Reason/justification for repair
·    Labor time to accomplish the work (HCPCS code K0739 or K0740) is billed in 15-minute units; labor time may be rounded to the nearest quarter hour for the total repair.  For example, 1 hour and 20 minutes = 6 units.
·    Labor rate or hourly charge


Note:  Separate reimbursement for labor charges (HCPCS codes K0739 and K0740) are not allowed for the delivery, installation, setup, or instruction for use of rented or newly purchased DME items, or for the repair, maintenance or routine servicing of rented DME items (California Code of Regulations [CCR], Title 22, Section 51521[f]).  Labor charges also are not separately reimbursable during the warranty period following the purchase or repair of DME equipment (CCR, Title 22, Section 51521[g]).  For more information about warranties, refer to “Guarantees” in the Durable Medical Equipment (DME):  Billing Codes and Reimbursement Rates section of this manual.


Labor Rate                                   The hourly labor reimbursement rate for DME repair is $65.88.  HCPCS codes K0739 and K0740 are reimbursed in 15-minute units at $16.47 per unit.


Replacement:  Listed Items          Claims for replacement items for which there is a specific HCPCS code must be billed with that code and modifiers RB and NU on the same claim line.  Modifier RB must be listed first. (Example:  E0995RBNU).


Repair of Listed                            Claims for repair must be billed with the HCPCS code for the item
Non-Wheelchair Items                  being repaired and modifier RB (only).  The following documentation is required in the Additional Claim Information field (Box 19) or on an attachment to the claim:
·    Description of the service provided
·    Reason/justification for repair
·    Manufacturer name
·    List of parts used with their catalog number and cost
·    A statement that the repairs are being made to equipment that is patient-owned





Repair and/or Replacement:         Claims for repair and/or replacement of unlisted items require the
Unlisted Items                              following.  On the claim, both modifiers must be entered on the same claim line, with modifier RB first.
·    Unlisted wheelchair items:  HCPCS code K0108 (wheelchair, other accessories) and modifiers RB and NU
·    Unlisted replacement items for non-wheelchair equipment:  Use appropriate HCPCS code and modifier RB
·    The following documentation in the Additional Claim Information field (Box 19) or on an attachment to the claim:
   Description of the service provided
   Manufacturer name
   List of parts used with their catalog number and cost
   A statement that the repairs/replacement items are for equipment that is patient-owned
   A statement next to each item indicating whether the item is “taxable” or “nontaxable”



Accessories or Supplies            The following HCPCS codes are DME accessories or supplies
Reimbursable Only for               reimbursable only if they are billed for equipment owned by the
Patient-Owned Equipment          patient.  The codes must be billed with modifier NU.  Modifiers RB and RR are not allowed.  Claims for these codes must include either the appropriate HCPCS code or a description of the specific DME item and a statement that the equipment is patient-owned in the Additional Claim Information field (Box 19).  Labor charges (HCPCS code K0739 or K0740) for these items are not separately reimbursable:
·    A4281, A4282, A4283, A4284, A4285, A4286, A4556, A4557, A4595, A4635 – A4637, A4640, A4663, A7020, A9281,
E0155 – E0159, E0167, E0607, E0621, K0552 and
K0601 – K0605


Supplies for Cough                      When billing for supplies or replacement parts for a cough stimulating
Stimulating Device                        device, alternating positive and negative airway pressure (HCPCS code E0482), providers must use code A7020 (interface for cough stimulating device, includes all components, replacement only).

HCPCS code A7020 is not separately reimbursable when billed with the rental and/or initial purchase of a cough simulating device.  Claims that bill codes A7027 – A7045 with code E0482 will be denied, regardless of whether the recipient owns the device or if Medi-Cal is renting the device.



Accessories or Supplies            The following HCPCS codes identify DME accessories or supplies
Separately Reimbursable           that are separately reimbursable with the rental or purchase of their
for Associated Equipment          associated equipment.  Claims for these codes must be billed with modifier RR or NU.  Labor charges (HCPCS code K0739 or K0740) for these items are not separately reimbursable:
A4230 – A4232 *, A6550, A7000, A7001, E0352, E0766 †,
E2360 – E2367, E2371, E2372 and E2377
*   Must be billed as a medical supply.  These codes do not require a modifier.
†  Must be billed with modifier RR.  Do not bill this code with modifier NU.



Stand-Alone Items                      The following HCPCS codes identify stand-alone DME items.  Labor charges (HCPCS code K0739 or K0740) for these items are not separately reimbursable:
·    Claims for the following codes must be billed with modifier NU (new equipment):
A4566, A4660, A4670, A7048, E0241 – E0246, E0710, E0780 and S8265
·    Claims for the following codes must be billed with modifier NU or RR (rental):
E0100, E0105, E0110, E0112, E0114, E0117, E0188, E0189, E0199, E0210, E0484, E0602, E0942, E0944 and E0945



REIMBURSEMENT



Upper Billing Limit                      Claims for DME and accessories should not exceed an amount that is lesser of:
·    The usual charges made to the general public or
·    The net purchase price of the item, which must be documented in the provider’s books and records, plus no more than a 100 percent markup, pursuant to CCR, Title 22, Section 51008.1.

Additional reimbursement information is contained in subsequent DME sections.





Net Purchase Price                    The net purchase price is the actual cost to the provider to purchase the item from the seller, including any rebates, refunds, discounts, or any other price reducing allowances known by the provider at the time of billing the Medi-Cal program for the item, that reduces the item’s invoice amount, pursuant to CCR, Title 22, Section 51008.1(a)(2)(A).

It shall reflect the price reductions guaranteed by any contract to be applied to the item(s) billed to the Medi-Cal program, pursuant to CCR Title 22, Section 51008.1(a)(2)(B).

It shall not include provider costs associated with late payment penalties, interest, inventory costs, taxes or labor, pursuant to CCR, Title 22, Section 51008.1(a)(2)(C).

Providers shall not submit bills for items obtained at no cost, pursuant to CCR, Title 22, Section 51008.1(b).

Claims for items of rented DME are excluded from the Upper Billing Limit provisions regarding “net purchase price” of an item as noted above, pursuant to CCR, Title 22, Section 51008.1(c).



Purchase Frequency                  Select DME items and accessories are subject to purchase
Limits                                          frequency limits.  These frequency restrictions are applied to any provider billing the procedure code within the designated time frame(s).  For additional information about frequency limits for DME purchases, refer to the Durable Medical Equipment (DME):  Purchase Frequency Limits section in this manual.



Rental Reimbursement Cap        Pursuant to California Code of Regulations (CCR), Title 22, Section 51321(c)(5C), except for life support equipment, such as ventilators, and other equipment that requires ongoing service or maintenance, when previously paid rental charges equal the maximum allowable purchase price of the rented item, as specified in Section 51521(i), the item is considered to have been purchased and no further reimbursement to the provider shall be made unless repair or maintenance of the item is separately authorized.

When the Department of Health Care Services (DHCS) determines it is medically necessary to purchase an unlisted item of durable medical equipment that had been rented for a Medi-Cal patient, DHCS and the provider shall determine the purchase price and the amount of the rental charges that may be applied to the purchase price.



MEDICARE/MEDI-CAL CROSSOVERS



Reimbursement                          Providers of DME items may bill Medi-Cal for reimbursement of the difference between Medicare’s rate and Medi-Cal’s rate for items provided to Medicare/Medi-Cal dually entitled recipients.  This method of reimbursement is the result of a preliminary injunction in the case of Charpentier v. Kizer in which the court has mandated that for Medicare Part B items and services (excluding physician services), DHCS may not limit reimbursement to 20 percent of Medicare's “reasonable charge” limit.


Authorization                                Providers should obtain authorization for DME items before dispensing the item and billing Medicare.  A Treatment Authorization Request (TAR) or electronic TAR (eTAR) shall be completed and submitted using the Medi-Cal DME code(s) that most accurately describe the item provided.  The TAR must include all medical justification and documentation that would normally accompany a Medi-Cal-only TAR and include the message “Medi/Medi:  Charpentier/Rates,” “Medi/Medi: Charpentier/Benefit Limitation,” or “Medi/Medi:  Charpentier/Both Rates and Benefit Limitation” in the Medical Justification area.  The Medi-Cal field office will review the TAR and return an Adjudication Response (AR) to the provider.

Note:  This policy is applicable only when billing for the difference between Medicare and Medi-Cal’s allowable rate for DME items.

A TAR is not required when billing for crossover items/services not affected by the Charpentier v. Belshe (Coye/Kizer) court case.




Billing Procedures                        After receipt of the AR, providers should follow normal
for Supplemental                          Medicare/Medi-Cal billing procedures.  Currently, some claims
Reimbursement                            automatically cross over to Medi-Cal for reimbursement of residuals while others require hard copy billing.  There is no change to this process.  However, to receive the difference, if any, between the Medicare and Medi-Cal rate, providers must bill using the CMS-1500 claim and follow these billing instructions:
·    The provider must bill using the Medi-Cal DME code(s) that most accurately describe the item being provided.  The code(s) used must be the same as the code(s) used on the TAR.  The words “Medi/Medi:  Charpentier/Rates” must appear in the Additional Claim Information field (Box 19) of the claim.
·    The 11-digit number from the AR must be entered on the claim in the Prior Authorization Number field (Box 23).
·    The sum of previous reimbursement from Medicare, Medi-Cal and any other health insurance carrier(s) must be indicated on the claim in the Other Coverage field (Box 11D).
·    The residual billing must be billed with a delay reason code “7” in the bottom, unshaded area of the EMG field (Box 24C) if it is billed more than six (6) months after the month of service.
Note:  If an emergency code is also needed in Box 24C, the emergency code is entered in the unshaded area and the delay reason code is entered in the shaded area.
·    The Explanation of Medicare Benefits (EOMB)/Medicare Remittance Notice (MRN), Remittance Advice Details (RAD) and proof of payment or denial from any other health insurance carrier(s) must be included as attachments.
·    Providers should place an “R” (rate limitation), “L” (benefit limitation) or “T” (for both rate and benefit limitation) in the Resubmission Code field (Box 22).


Pricing the Supplemental             The DME item will be priced as is currently done with straight
Reimbursement                            Medi-Cal claims, and the supplemental reimbursement to providers, if any, will be determined.

For more information about Medicare/Medi-Cal crossover billing procedures and the Charpentier v. Belshe (Coye/Kizer) court case, see the Medicare/Medi-Cal Crossover Claims section in this manual.




Photo via   Pexels A Senior’s Guide to Successful Downsizing in Retirement Downsizing can be a stressful process. This is especia...