What Successful Rehab Providers need to know about Georgia
What Successful Rehab Providers need to know about Georgia
What Successful Rehab Providers
need to know about Georgia
Presentation to: GAMES/GRTC Winter Meeting
Courtney Haynes, DME/O&P Program Specialist
Linda Wiant, Director of Pharmacy
February 4, 2014
We will provide Georgians with access to
affordable, quality health care through
effective planning, purchasing and oversight.
We are dedicated to A Healthy Georgia.
Topics for Discussion
Quote Invoices for Manually Priced Items
Post-assessment PT/OT Evaluation
K0108 vs. K0739
Complex Rehab Equipment POS 31/32
Audit Preparedness- (If it isn’t documented it wasn’t done)
I am Courtney Haynes,
The DME and O&P Program
For Georgia Medicaid
Recent Changes for Rehab Equipment
E0240- Billing Guidance added for modifiers NU and U1. Note: Refer to the DME SMAP for
pricing of the shower/bath chair. Refer to Appendix D for manual pricing applied to modifier U1 for
other rehab toilet aids (excluding noncovered items).
Physical Therapist Post-assessment for PMDs- This Requirement has been removed Effective
01/01/2014. For PMDs delivered on or before 12/31/2013 this requirement is valid and the
assessment should be on file. For PMDs delivered on or after 01/01/2014 this requirement no
longer exists (this information has been removed from Chapter 1102 #7 and the Q&A Section- #8
has been revised to reflect this information).
You will find a revised manual on MMIS within the next week containing the revised
information for the changes to the Physical Therapist post-assessment.
NCCI EDITS (PTP/MUE)
The National Correct Coding Initiative (NCCI) contains two types of edits:
1. NCCI procedure-to-procedure (PTP) edits that define pairs of Healthcare
Common Procedure Coding System (HCPCS)/Current Procedural
Technology (CPT) codes that should not be reported together for a variety
of reasons. The purpose of this is to prevent improper payments when
incorrect code combinations are reported.
2. Medically Unlikely Edits (MUEs) define for each HCPCS/CPT code the
maximum units of service (UOS) that a provider would report under most
circumstances for a single beneficiary on a single date of service.
HCPCS codes do not allow the use of CPT modifiers
What to do if you disagree with an NCCI edit
NCCI Contact Information
This webpage provides information to states, providers, and other interested parties
regarding implementation of NCCI methodologies in the Medicaid Program.
Concerns about specific NCCI edits may be submitted in writing to the CMS NCCI
technical contractor at:
Medicaid National Correct Coding Initiative
Correct Coding Solutions, LLC
PO Box 907
Carmel, IN 46828-0907
© 2013 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without
– NCCI edits are in effect. You will begin seeing denials for claims from
01/01/2013 for PTP and MUEs. You should become familiar with these edits
to avoid unnecessary denials. http://www.medicaid.gov/medicaid-CHIPprogram -information/by-topics/data-and-systems/national-correct-codinginitiative.html
– These are front end edits that are Federally mandated. These edits cannot be
appealed unless the line has an indicator of “1”, however, if CMS or the NCCI
contractor makes revisions to the NCCI tables DCH will reprocess claims
– Indicator- “0” cannot appeal,- 2nd line is mutually exclusive of primary code
– Indicator- “1” Line two may be approved in rare circumstances (RT/LT etc)
– Indicator- “9” line has been end dated/ deleted
Quotes for Manually Priced Items
– HOT TOPIC–
Submit the Actual Quote from the Manufacturer DO NOT ALTER THIS DOCUMENT.
There must be a quote number that can be traced to the paid invoice.
The patient for which the quote was created must be identified.
Providers may attach an additional document with the unaltered quote that includes any
comment/suggestion they may have. We are aware that some manufacturers try to
code items that may or may not be accurate.
– If you disagree with the manufacturers code you should provide the code that more
accurately describes the item provided and provide the line number/part number and
any other information that is necessary for review.
– You can cross reference you item on the DME PDAC website if needed.
– NOTE- K0108 is limited to the list of codes in the table provided so do not
Add items on any attachment with this code unless you have referenced the table.
– Copies of generic forms printed offline, retail order sheets not sent in and returned with
a quote number linked to a specific beneficiary, or copies of catalogue pages will not be
– The DME Provider can create a template to provide to the PT to ensure that
current Policy Guidelines are met
– The DME provider can work with the PT/OT to ensure the appropriate
equipment is provided based on the results of the seating evaluation
– The DME provider CANNOT complete any portion of the Physical Therapists
Clinical Evaluation. This is a clinical evaluation that is reimbursed to the
physical therapist, and this PT/OT should specialize in this type of rehab
– DCH has identified issues with DME Providers completing this evaluation in its
entirety and having the document signed by a licensed PT/OT. This is strictly
prohibited by both parties.
This is no longer a requirement
Claims with a DOS on or before
12/31/2013 must have this
documentation in the medical record
to be in compliance with DCH Policy.
K0108 -vs- K0739-U2
K0108 is used to report certain miscellaneous components for a wheelchair during the initial
purchase of the items.
-See APPENDIX E Wheelchair Accessory Supplies/Services (K0108)— Categorized List For Invoice
Pricing for items that are covered under K0108.
For Repairs/Parts after the initial purchase of the wheelchair that are not covered under warranty and not
described by another code report
A repair is a correction or replacement of the original part(s) of a purchased item. The labor component for repairs is
coded K0739 U1 (Repair or non-routine service for durable medical equipment requiring the skill of a
technician, labor component). K0739 U2 is reported in conjunction with K0739 U1 when repairs are for custom
or specialty parts that do not have a HCPCS code. If modifier U2 is used to report custom repairs/parts, then
an itemized list must be submitted and the total price must be the submitted charge.
**DO NOT report K0108 for parts that are being replaced**
All modifications/repairs listed on the certificate of medical necessity must also be on the original Prior Authorization
form. If modifications/repairs are being requested for a wheelchair, a recommendation from a physical or occupational
therapist, actively involved in the member’s care, must accompany the medical necessity statement. The therapist may
be associated with a school, hospital, clinic or developmental center, but cannot be a vendor or be employed by a
vendor. This does not apply to consumable items (batteries, tires, items under $200.00) that are routinely replaced or
items that did not require a PT/OT evaluation for the initial order.
E0240 – Shower/Bath Chairs or Other
Rehab Toilet Aids
Shower chairs are coded as follows:
E0240-NU represents a shower/bath chair, with or without wheels, any size only. This code
is listed in the DME-SMAP with standard pricing applied. No PA is required.
E0240-U1 is applicable to other rehab toilet aids that are covered by Medicaid. This code
MUST not be used for items that are noncovered by Medicaid (i.e. Bath lifts for patients over
21 etc.) see 906. Of this manual for the list of noncovered items (this includes items not
specifically listed not listed as covered in the policy manual or DME-SMAP). Physician must
document specific physical limitations. An OT/PT evaluation/recommendation is required.
Suppliers must be CRTS. Providers must submit ta quote meeting the guidelines for
manually priced items that contains the price and the manufacturer’s model number
for the items on the PA request.
COMPLEX REHAB EQUIPMENT -SNFs
DCH understands that there are times when patients who require custom/complex rehab equipment
will be enrolled in a SNF/NF and will cover equipment in the event this occurs, however, this should
be rare, and in most cases the equipment would be a replacement and not a new issue. This is
limited to Power Mobility Devices for members less than 21 years of age.
-Patients typically do not develop the need for this equipment during a SNF enrollment period
-Since equipment is normally issued as a purchase and is issued for a long standing diagnoses that
lead up to the need for such equipment, most patients have this type of equipment before the
enrollment in to a skilled nursing facility.
GMCF will review cases submitted for patients in this situation on a case by case basis.
Specificity of Diagnoses for Complex
The diagnoses submitted for a patient requiring custom/complex rehab equipment
must be coded to the highest level of specificity to prevent delays in the prior
approval process. A general diagnosis may not support the need for such
equipment especially if there is a more specific diagnosis for the patient’s condition
Patient has Infantile Cerebral Palsy with paralysis affecting both sides of the body
(343.3- CONGENITAL DIPLEGIA; DIPLEGIC INFANTILE CEREBRAL PALSY)
Provider submits: CEREBRAL PALSY NEC; OTHER SPECIFIED CEREBRAL
PALSY 343.8 (This does not support the equipment requested and delays your
request by the need for additional supporting documentation and the correct
Time limits for Documentation
should receive the F2F within 45 days from the date it is
completed in most cases-Equipment should be delivered within 120 days from the date the PA
is approved under normal circumstances. If this time limit needs to be
extended the provider must request this extension from GMCF
DME that is not considered Complex Rehab Equipment should be
received by the provided within 30 days as identified in the policy
-Create Checklists (example)
Detailed Product Description
F2F Evaluation Notes/Dates
Invoices (Quote converted to purchase)
Proof of Delivery
READ THE MANUALREVIEW THE UPDATES – THEY ARE ITEMIZED AT THE BEGINNING OF THE MANUAL
SO YOU DO NOT HAVE TO GUESS WHAT HAS BEEN UPDATED!!!
Submit Timely Claims/Adjustments
-Submit claims within six months of the
date of service.
-Adjust claims within 90 days of paid date.
-Attach new RA to auto crossover claims
from Medicare. If Medicare was not
rebilled you cannot adjust the claim.
See the Medicaid Policy and Procedures
Manual, Part I, Chapter 200 for detailed
information on Timely Submission.
Surviving An Audit
Be Audit Ready- It starts internally1) Perform Quantitative Analysis- Do I have ALL the required documentation needed to
get a Prior Approval ??
2) Perform Qualitative Analysis- Is ALL my documentation complete? All signatures and
dates are in place and all components required to be in compliance with GA Medicaid
Policies and Procedures are documented?
3) Did you follow policy guidelines (diagnosis/age/limitations/restrictions/max units/
reasonable useful lifetime, prior authorization)?
4) You submitted unaltered quotes with quote numbers that are linked to purchased
Invoices in your records? Is the patient clearly identified on the quote?
5) Did you submit the authorized dollars and authorized units for payment of manually
priced items? If not did you receive an overpayment?
YOU MUST BE PREPARED- IF YOU GET AUDITED YOUR #1 GOAL IS TO ENSURE YOUR
DOCUMENTATION SUPPORTS THE LEVEL OF SERVICES PROVIDED AND ITEMS PROVIDED.
If there is a new type of equipment that is not described by an existing HCPCS code the
Manufacturer must apply for a HCPCS code for consideration to be made for coverage. This
will promote coverage at a national level and CMS will issue coverage guidance and
appropriate reimbursement fees.
The application form and process can be found on the CMS website at the link listed above.
Any new type of equipment that does not fit the criteria of an existing HCPCS code is
considered emerging technology and the manufacturer must apply for a HCPCS code and
obtain FDA approval etc. Miscellaneous codes are almost always used by GA Medicaid as
options/accessories/additions to base equipment that falls within a current HCPCS code.
Emerging technology would be considered base equipment and therefore does not qualify
for the use of a miscellaneous code.
Provider Resources- Policy Information
Provider Resources- Websites
For additional questions concerning policy information, contact the Provider
Services Contact Center (PSCC) at 800-766-4456.
The PSCC can also be reached by initiating a “Contact Us” inquiry on the Web
WHEN IN DOUBT – INQUIRE!
To search for key words in the provider manual select “Control F”
and a “find/search” tool will pop up which allows you to type key words
this will keep you from searching through 200 pages of information in the manual!
Provider Resources- Websites
– GAMMIS Website for Provider Manuals/ Schedules of Maximum Allowable
– DCH ICD-10 FAQs & Fact Sheet <<<<Please be ready –Go live is 10/01/14!!!
– DCH Provider Resources
HP Enterprise Services http://mmis.georgia.gov
Provider Resources- Phone Numbers
MEMBER CONTACT CENTER
FRAUD and ABUSE
Resources for Coders/ Health IT
• We welcome your questions and comments related to
Who to contact:
-Teresa-GAMES Representative- [email protected]
Teresa will collectively send your Questions/Comments the appropriate staff at
Linda Wiant, Director of Pharmacy or
Courtney Haynes, DME/O&P Program Specialist/Compliance Auditor
Please contact HP with questions regarding claims, Prior Authorizations,
Mass Adjustments etc. If necessary, HP will contact DCH for policy
Questions & Comments
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