Transcript Slide 1

Medical Equipment
Updates
Presented by EDS Provider Field
Consultants
October 2008
Agenda
Welcome and Announcements
• Date of Service
• Provider Code Sets
• Provider Licensure
• Rental vs. Purchase
• Capped Rental
• Repair and Replacement
• Mail Order Incontinence, Ostomy, and
•
•
•
•
•
Urological Supplies
Billing Guidelines
Common Denials
Spend-down
Helpful Tools
Questions
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Session Objectives
• Following this session, providers will be able to:
– Understand Provider Licensure Requirements
– Understand Rental vs. Purchase
– Follow Capped Rental Policy
– Understand Repair and Replacement Guidelines
– Understand the Changes to the Mail Order Supply of
Incontinence, Ostomy, and Urological Supplies
– Understand Billing Guidelines
– Understand Rolling Calendar Year
– Understand DME Dates of Service
– Resolve Common Denials
– Understand Spend-down
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Date of Service
Reminder
• The date of service is the date the
equipment is delivered, not ordered
• For the IHCP to reimburse for medical
equipment, the member must be
eligible on the date of service (date of
delivery)
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Provider Code Sets
Effective August 1, 2006
• The IHCP established code sets to
ensure appropriate reimbursement for
medical equipment codes
• Providers must ensure that they are
enrolled as the correct provider type
and specialty
• The durable medical equipment (DME)
provider type is 25 and the following
are provider specialties:
– 251 – Home medical equipment provider
– 250 – DME/Medical supply dealer
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Provider Licensure Versus Non-Licensure
• Effective August 1, 2006, to bill for
home medical equipment (HME),
providers must have a valid HME
license from the Indiana Board of
Pharmacy on file
• Providers must also be enrolled as
an HME provider to receive
reimbursement for HME services
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Rental vs. Purchase
• The decision to rent or purchase
equipment is based on the least
expensive option available for
the anticipated period of need
• Items purchased with IHCP funds
become property of the Office of
Medicaid Policy and Planning
(OMPP)
• Members may contact the local
Division of Family Resources for
information on returning
purchased equipment which is no
longer needed
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Capped Rental
• Certain procedure codes are limited to
15 months of continuous rental
• Continuous rental is defined as rental
without interruption for a period of
more than 60 days
– A change in provider does not cause
an interruption in the rental period
• A complete list of procedure codes for
capped rental can be found in the
Indiana Health Coverage Programs
Provider Manual, Chapter 8
• The provider must service the item at
no cost to the IHCP
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Capped Rental
• Centers for Medicare and Medicaid Services (CMS)
changed the capped rental policy for DME
• The new policy states that the capped rental period is 13
months
– After 13 months, the member owns the DME
• Medicare will pay for reasonable and necessary
maintenance and service of the DME item
– This policy change applies to DME items in which the
first month of rental is on or after January 1, 2006
• At this time, Medical Policy has not been directed to
make changes to the IHCP’s capped rental policy
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Capped Rental
Claims Submitted for Capped Rental Items
• The allowed charge is the lower of the 1993 Medicare
rental fee schedule amount or the actual submitted
charge
• The IHCP pays claims until the number of rental
payments made reaches the capped rental number of
15 months
• The IHCP evaluates requests for approval of capped
rental items
– When the equipment reaches capped rental, it is
evaluated for documentation of long-term need
– In long-term needed situations, a decision may be
made to purchase the item
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Repair and Replacement
• Repair of purchased equipment may
require prior authorization based on the
Healthcare Common Procedure Coding
System (HCPCS) codes
• The IHCP does not pay for repair of
equipment still under warranty
• The IHCP does not authorize payment
for repair necessitated by member
misuse or abuse, whether intentional or
unintentional
• The rental provider is responsible for
repairs to rental equipment
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Repair and Replacement
• The IHCP does not cover payment for
maintenance charges of properly
functioning equipment
• The IHCP does not authorize replacement
of medical equipment more than once
every five years per member
– More frequent replacement is allowed
only if there is a change in the
member’s medical needs that is
documented in writing and significant
enough to warrant a different type of
equipment such request require PA
• A long-term care (LTC) facility’s per diem
rate includes repair costs for equipment
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Mail Order Incontinence, Ostomy, and
Urological Supplies
Contracted Vendors
• Effective February 1, 2008, the OMPP contracted with
three vendors to provide incontinence, ostomy, and
urological supplies to fee-for-service members
• The three contracted vendors are:
– Binson’s Home Health Care Center
1-888-217-9610
www.binsons.com
– Healthcare Products Delivery, Inc (HPD)
1-800-291-8011
www.hpdinc.net
– J & B Medical
1-866-674-5850
www.jandbmedical.com
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Mail Order Incontinence, Ostomy, and
Urological Supplies
• Members must obtain supplies via mail order
– The contracted vendor may make other
arrangements in emergency situations
• The contracted vendors began providing
services February 1, 2008, with full
implementation completed on June 1, 2008
• A full listing of codes affected by this change is
available in BT200823
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Mail Order Incontinence, Ostomy, and
Urological Supplies
Program Exclusions
• The following programs and claim types are not affected
by the contract:
– 590 Program
– Medical Review Team (MRT)
– First Steps
– Pre-Admission Screening and Resident Review (PASRR)
– Long Term Care (LTC)
– Waiver
– Medicare crossover claims
– Third-party commercial claims
• Risk-based managed care (RBMC) members are excluded
– Supplies for these members are billed to the appropriate
managed care organization (MCO)
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Mail Order Incontinence, Ostomy and
Urological Supplies
Nursing Assessment
• A needs assessment is part of the initial
enrollment process
• Members receive a telephone call from a
staff nurse or a questionnaire by mail
• The questionnaire gives the vendor
additional information regarding the
member’s supply needs
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Billing Guidelines
Diabetic Test Strips
• On December 1, 2004, the IHCP
began accepting Medicare
crossover claims for diabetic test
strip procedure codes with dates of
service that span 90 days
• Providers may submit claims
electronically using Web
interChange
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Billing Guidelines
Humidifiers
• The IHCP covers a non-heated (E0561) or a heated
(E0562) humidifier for use with a non-invasive
respiratory assistive device (RAD)(E0470 and E0471)
or a continuous positive airway pressure (CPAP)
(E0601), when ordered in writing by a physician,
based on medical necessity, and subject to prior
authorization
• Humidifiers E0561 and E0562, for use with a RAD or a
CPAP, are considered for coverage only when
physician documentation supports the medical
necessity of the humidifier
• Documentation must support the member’s need for
the service
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Billing Guidelines
CPAP
• Medicaid requires 30 episodes of apnea to qualify for
a CPAP machine
–Each apnea episode must last a minimum of 10
seconds during the six-to-seven-hour
polysomnogram
• A diagnosis of obstructive sleep apnea is required
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Billing Guidelines
Gloves
• Providers must bill A4927 per box
– This code is limited to five boxes
per month
• The IHCP does not separately
reimburse for gloves for IHCP
members who are residents of a
nursing facility or receiving endstage renal disease dialysis services
• See IHCP provider bulletin
BT200031 and banner page
BR200139 for more billing
information for sterile or non-sterile
gloves
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Billing Guidelines
Codes Added to Bypass Table
• The following codes have been added to the bypass
table, with an effective date of 9/29/2006:
– E0240, bath/shower chair
– E0247, transfer bench
– E0248, transfer bench
– E0445, oximeter device
• Procedures are not covered by Medicare, and do not
need to be billed to Medicare first
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Billing Guidelines
Sterile Saline and Water
• HCPCS codes A4217 and A4218 are not covered and are
non-reimbursable
– Both codes are end-dated due to coverage only
under the National Drug Codes (NDCs)
• A4214, Sterile saline and water; A4319, Sterile water
irrigation solution; and A4323, Sterile saline irrigation
solution should be billed by pharmacy providers using
the appropriate NDC
• Refer to IHCP provider bulletin BT200401
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Billing Guidelines
Power Wheelchair Codes
Provider Bulletin 200832 references Medicaid coverage
for:
• K codes for power mobility devices
• E codes for basic equipment
• Coverage criteria
• Prior Authorization Requirements
The codes have an effective date of January 1, 2007
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Billing Guidelines
Rolling 12-Month Period
• Is not:
– Based on a 12-month calendar year
– Based on a fiscal year
– Renewable on January 1 of each year
• Is:
– Based on the first date that services are
rendered by a particular provider
– Renewable one unit at a time beginning
365 days after the date that services are
rendered by a particular provider
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Billing Guidelines
Common Denials
• Edit 6000 – Manual Pricing Required
– Invoice requirements
•
Date
•
Billed amount per unit (for example, box, case,
and so forth)
•
Calories (enteral feeding)
•
Procedure code
•
Member name
•
Member ID number
•
Itemization of repairs
– Bulk Invoices – illustrate calculations specific to
the member
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Billing Guidelines
Common Denials
• Edit 4021 – Procedure Code Vs Program
Indicator
– Procedure code is not covered for the dates of
service for the program billed
– Please verify and resubmit
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Billing Guidelines
Common Denials
• Edit 0593 – Medicare Denied Detail
–At least one detail submitted contains
Medicare COB data resulting in a review of
all detail COB data
–Please review to ensure COB data for detail
in question does not contain all zeros or is
missing
• Edit 4033 - Invalid Procedure Code Modifier
Combination
–The modifier used is not compatible with the
procedure code billed
–Please verify and resubmit
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Billing Guidelines
Common Denials
• Edit 1012 - Rendering Provider Specialty Not
Eligible To Render This Procedure Code
– This provider type/provider specialty may not bill
this service
• Audit 6065 - DME Total Rental Amount Not To
Exceed Fee For Purchase
– This item has been rented up to the Medicaid
maximum allowed charge for purchase
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Billing the Member
• The following circumstances are the only situations in
which an IHCP provider may bill a member:
– The service rendered is determined to be non-covered by the
IHCP
– The member has exceeded the program limitations for a
particular service; for example, the services were denied prior
authorization (PA)
– Before receiving the service, the member must understand
that the service is not covered under the IHCP, and the
member is responsible for the charges associated with the
service
• Documentation must be maintained in the provider’s
record that the member voluntarily chose to receive a
service that was not covered by IHCP
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Spend-down Update
Policy Effective January 1, 2006
• For dates of service January 1, 2006, and after, no Form
8A is required
• Members are eligible for benefits on the first day of the
month
• Spend-down credits against the billed amount on the claim
• State mandated co-pays credit spend-down
• Providers may not refuse service to a member because the
spend-down may not be met
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Spend-down Update
Policy Effective January 1, 2006
• EDS mails spend-down summary notices on
the second business day of the month
following the month when services were
billed
• Members are not required to pay spend-
down until they receive their summary
notices
• Spend-down amounts show on an
adjudicated claim under ARC code 178 and
the State-mandated co-pay appears under
ARC 3
– The amount in ARC 3 is the amount the
member owes to the provider
• Providers must adhere to standard office
protocol for members who are unable to pay
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Helpful Tools
Web interChange
interChange Home
Indiana Medicaid
Check Inquiry
Claim Inquiry
Claim Submission
Eligibility Inquiry
PA Inquiry
PA Submission
Provider Profile
Help
FAQ
How to Obtain an ID
Contact Us
Logon
Logoff
Change Password
• Available at
www.indianamedicaid.com
• Claim submission directly to EDS
• Web access to claim and
member information
• Secure data transmission
• Available 24 hours per day
• Free
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Helpful Tools
Avenues of Resolution
• IHCP Web site at
www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or
paper)
• Customer Assistance
– 1-800-577-1278, or
– (317) 655-3240 in the Indianapolis local
area
• Written Correspondence
– P.O. Box 7263
Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
– View a current territory map and contact
information online at HCP Web site at
www.indianamedicaid.com
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Questions
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