Diabetes Billing

Diabetic Billing, Diabetic Billing, Documentation and SuppliesDocumentation and Supplies

Presented by: Medicare Part B & DME MAC

Provider Outreach and Education (POE)( )September Encore 2012

Workshop Protocol

• Entering workshopEntering workshop– Attendee lines are muted upon entry– Enter attendee names, provider, city in Chat (not Q&A)– Print slides in Adobe PDF

• https://www.noridianmedicare.com/partb/train/workshops/index.html

• Throughout workshop– Questions pertinent to workshop slide addressed– Address Q & A to “all panelists”; not to host directly– All other questions, call Part B Provider Contact Center

Address all written questions in Q&A section not Chat– Address all written questions in Q&A section, not Chat• Workshop conclusion

– Take short polling survey– Asking questions aloud? Use “raise/lower hand” feature Asking questions aloud? Use raise/lower hand feature – MUTE phones – do not place on HOLD

September 2012 2NAS, LLC Proprietary

CEU Process

Att d ti k h t i Ch t• Attend entire workshop - type names in Chat• Take short polling survey at conclusion• Part B Practitioners

• To retrieve CEU certificate and print– http://www.noridianmedicare.com

• Education Center/Workshops (next to registration)E d ( id d k h l i ) • Enter password (provided at workshop conclusion)

• DME Suppliers• Certificate will be sent via email


DISCLAIMER

This information release is the property of Noridian Administrative Services, LLC (NAS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by NAS and CMS. The most current edition of the information contained in this release can be found on the NAS website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2012 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.


Agenda

Di b ti S i• Diabetic Screening• Diabetic Self Management Training (DSMT)

M di l N i i l T (MNT)• Medical Nutritional Treatment (MNT)• Documentation • Glucose Monitors & Testing Supplies• Therapeutic Shoes for Persons with Diabetes• External Insulin Infusion Pump• Resources and Reminders


Objective

T i t id d li ith b tt • To assist providers and suppliers with a better understanding of the NAS Medicare Part B and Durable Medical Equipment (DME) roles in Durable Medical Equipment (DME) roles in providing Diabetic billing, coverage, documentation and supplies.


DIABETIC SCREENINGDIABETIC SCREENING

Diabetic Overview

• Diabetes is 7th leading cause of death in USA• Diabetes is 7th leading cause of death in USA• Diabetes can lead to severe complications:

– Glaucoma (significant risk factor) Glaucoma (significant risk factor) – Heart disease– Kidney failure– Stroke

• Medicare provides several diabetes-related preventive services for eligible beneficiariespreventive services for eligible beneficiaries

• Implanted pump for insulin infusion – not covered– To treat diabetes To treat diabetes


Diabetes Screening Risk FactorsFactors

• Risk Factors for Diabetes:• Risk Factors for Diabetes:– Hypertension– High Cholesterol– Obesity– Elevated impaired fasting glucose/glucose intolerance

• Previous Identification

• With any two following risk factors:– Overweight

• Body Mass Index (BMI) > 25Body Mass Index (BMI) > 25– Family history of diabetes– Age 65 or older

Gestational diabetes history or deli ery of baby o er 9 lbs– Gestational diabetes history or delivery of baby over 9 lbs


Glucose Screening Lab CodesGlucose Screening Lab Codes

CPT Descriptorsp82947 Glucose; quantitative, blood (except reagent strip)

82950 Glucose; post glucose dose (includes glucose) 82950 Glucose; post glucose dose (includes glucose)

82951 Glucose; tolerance test (GTT), three specimens (includes glucose) ( g )

Diagnosis•Non Pre-diabetes, V77.1 diagnosis•Covered one per 12 month periodDiagnosis

V77.1Covered one per 12 month period

•Pre-diabetes, V77.1, modifier TS (follow-up) •Covered twice/12 month periodCovered twice/12 month period


Glaucoma Screening

• Covered for these high risk groups:Covered for these high risk groups:– Individuals with Diabetes Mellitus– Glaucoma family history individuals– African-Americans over 50African Americans over 50– Hispanic-Americans age 65 or older

• Deductible/coinsurance waived• Glaucoma screening includes:Glaucoma screening includes:

– Dilated eye examination (intraocular pressure measurement)– Direct ophthalmoscopy examination, or – Slit-lamp biomicroscopic examinationSl t la p b o c oscop c e a at o

• Recommended once every 12 months, test performed/supervised by ophthalmologist legally allowed to provide in their statep


Glaucoma Screening CodesGlaucoma Screening Codes

HCPCS DescriptorsHCPCS Descriptors

G0117 Glaucoma screening for high risk patients –furnished by optometrist/ophthalmologistfurnished by optometrist/ophthalmologist

G0118 Glaucoma screening for high risk patients –f i h d d di i i f furnished under direct supervision of optometrist/ophthalmologist

Di i S i l i f l i l d DiagnosisV80.1

Special screening for neurological, eye, and ear diseases, glaucoma


Hyperbaric Oxygen (HBO) Therapy Therapy

T d

Standard wound care-diabetic wound patients:

– Vascular status assessment

– Correction of vascular

– Treatment not covered if measurable signs of healing not demonstrated in 30 day Correction of vascular

problems– Maintenance of clean,

moist bed of granulation

demonstrated in 30 day period

– Optimization of:• Glucose controlmoist bed of granulation

tissue– Necessary treatment to

l i f i

• Glucose control• Nutritional status

– Debridement by any t resolve infection

– Failure to respond - 30 days

means to remove devitalized tissue

– Evaluated at least every 30 d d i HBO

y30 days during HBO

September 2012 NAS, LLC Proprietary 13

HBO Therapy CoverageHBO Therapy Coverage

Type I / Type II diabetes with lower extremity wound Type I / Type II diabetes with lower extremity wound due to diabetes – patient must have one of these diagnoses

99183 Physician attendance and supervision, per session (adjunctive therapy only, after no measurable signs of healing at least 30 days of treatment)

Diagnoses 250.60 – 250.63 gDiabetes Mellitus with neurological manifestations

250.70 – 250.73 Diabetes Mellitus with peripheral circulatory disorders

250.80 – 250.83 Diabetes Mellitus with other specified manifestationsDiabetes Mellitus with other specified manifestations


DIABETES SELFDIABETES SELF--DIABETES SELFDIABETES SELFMANAGEMENT MANAGEMENT

TRAINING (DSMT)TRAINING (DSMT)TRAINING (DSMT)TRAINING (DSMT)

DSMT Coverage

B fi i i ( ll i li d d t) ith hi h • Beneficiaries (usually insulin dependent) with high risk from complications of the foot, kidney complications or retinopathycomplications or retinopathy

• Program educates self-monitoring:– Blood GlucoseBlood Glucose– Diet and Exercise Education– Insulin Treatment Plan

• Not covered– Services hospital inpatient, hospice, home health or Skilled

Nursing Facility (SNF) – included in ongoing care


Eligible DSMT PractitionersEligible DSMT Practitioners

• Until Medicare Benefit Policy Manual (100-02 Chapter 15 Until Medicare Benefit Policy Manual (100-02, Chapter 15, Section 300) is revised, Medicare recognizes DSMT services may be furnished by individual CDE, RD, RN or pharmacists – Not just in rural settingsj g– Does NOT affect who qualifies as "certified providers" to bill DSMT

• Certified program usually provided by team of individuals– Determine individual/group DSMT with signed statement of needg p g

• Registered Dietitian (RD)/certified diabetic educator (CDE) – May bill on behalf of DSMT program and accept claim assignment– Must have a Medicare Provider Transaction Access Number (PTAN)( )

• Accredited by diabetes self-management education program – American Diabetes Association (ADA)/Indian Health Service

(IHS)/American Associate of Diabetes Educators (AADE) – Taught by providers with special diabetes education training


DSMT Coding

• Physician must refer / certify with plan of care • Physician must refer / certify with plan of care – Includes # of sessions, frequency and duration

• Nutrition portion of program must be billed using: Nutrition portion of program must be billed using: – G0108 (individual session, 30 minutes)– G0109 (group session, 2 or more, 30 minutes)

• Hour session = 2 (Item 24G/electronic equivalent)• E/M billing not mandatory before billing DSMT• Payment to non-physician practitioners billing on

behalf of DSMT program made at 100% MPFS rate• Coi s c /d d ctibl still l• Coinsurance/deductible still apply


DSMT Coding Tips

DSMT d MNT b fit b id d t • DSMT and MNT benefits can be provided to same beneficiary in same year, but not same day– DSMT and MNT require separate referralsDSMT and MNT require separate referrals

• When patient has been diagnosed with diabetes:– Initial: Up to 10 hours for a continuous 12-month periodInitial: Up to 10 hours for a continuous 12 month period– Subsequent: If eligible, another two hours of follow-

up/year covered with another doctor’s written order

• DSMT provider must maintain documentation– Original order/training plan with instructions – Bill with no particular diagnosis


MEDICAL NUTRITION MEDICAL NUTRITION TREATMENT (MNT)TREATMENT (MNT)TREATMENT (MNT)TREATMENT (MNT)

MNT Coverage

C d i f di t• Covered services for disease management:– Initial nutrition and lifestyle assessment– Nutrition counseling– Managing lifestyle factors affecting diet– Follow-up sessions to monitor progress

• Medicare Part B News, #243 February 15 2008– Overview of Covered Diabetes Supplies/Services– Med learn Number (MLN): SE0738 Revised


Who Can Treat MNT?

• Physician prescribes services to be performed by a • Physician prescribes services to be performed by a registered dietitian (RD) or nutritional professionals (e.g. Certified Diabetic Educator – CDE)( g )– 900 hours supervised dietetics and licensed/certified

• Provided by team of individuals with the certified program– Cannot be sole provider of MNT– Must accept claim assignmentMust accept claim assignment– “Incident to” does not apply– Need Medicare Provider Transaction Access Number

(PTAN) & N i l P id Id ifi (NPI) S (PTAN) & National Provider Identifier (NPI) – Spec. 71


MNT Requirements

• Medicare provides MNT coverage when • Medicare provides MNT coverage when coverage conditions are met:– Diagnosed with diabetes and/or renal disease g– Referral from treating physician indicating

diabetes/renal disease diagnosisN h i i titi t f f – Non-physician practitioners cannot refer for MNT

• DSMT and MNT benefits can be provided to same DSMT and MNT benefits can be provided to same beneficiary in same year, but not same day

• DSMT and MNT require separate referralsDSMT and MNT require separate referrals


MNT Billing/Coverage

M i MNT I di id l G b i• May receive MNT as Individual or Group basis• Deductible/coinsurance waived• Therapy Initial Year:• Therapy – Initial Year:

– 3 hours one-on-one counseling (no carryover)– Subsequent years (with physician referral) - 2 hours/yearSubsequent years (with physician referral) 2 hours/year

• 97802, 97803, 97804, G0270, G0271• MNT may be performed as telehealth servicesMNT may be performed as telehealth services


Telehealth Services Expansion Expansion

I di id l d t i i DSMT i • Individual and group training - DSMT services – G0108 and G0109

E ff ti i j ti t i i• Ensures effective injection training

• Individual and group therapy – MNT services 97803 (i di id l) d 97804 ( ) – 97803 (individual) and 97804 (group)

• Group health and behavior assessment and intervention (HBAI) servicesintervention (HBAI) services– 96153 and 96154


CMS Guide to Medicare Preventive ServicesPreventive Services

Guide includes: Medicare's preventive benefits including coverage frequency Medicare s preventive benefits including coverage, frequency, risk factors, billing and reimbursement


DOCUMENTATION DOCUMENTATION REQUIREMENTS REQUIREMENTS REQUIREMENTS REQUIREMENTS

Intake Process for DME Suppliers

• Assists in accurate claim submission• Assists in accurate claim submission• Assures appropriate documentation collected• Ask questions based on item dispensedAs questions based on ite dispensed

– Have you had this equipment in the past?– Did you receive supplies last month from someone else?

HMO?– HMO?

• Suggested intake form– https://www.noridianmedicare.com/dme/formsp– Specialize your intake process

• Documentation checklisth // idi di /d / /– https://www.noridianmedicare.com/dme/coverage/


Authorized to Order DMEPOS

• Treating Physician, MD, or • Physician Assistantg yDO

• Nurse Practitioner or Clinical Nurse Specialist

y– Meet definition of

physician assistant found in Section 1861(aa)(5)(A) of Social Security ActClinical Nurse Specialist

– Treating patient for condition for which item is needed

– Practicing independently of

of Social Security Act– Treating beneficiary for

condition for which item is neededg p y

physician– Bill Medicare for other

covered services using own

– Practice under supervision of MD or DO

– Have own NPINPI

– Permitted to do in state where services are rendered

– Permitted to perform services in accordance with state law


Dispensing Order

• Most DMEPOS may be dispensed based on • Most DMEPOS may be dispensed based on verbal/preliminary order

• ElementsElements– Description of item– Beneficiary’s name– Physician’s name– Date of order– Physician signature (if a written order) or supplier Physician signature (if a written order) or supplier

signature (if verbal order)

• Items provided based on a dispensing order must be followed up with completely detailed written order


Detailed Written Orders

R i d i t l i b i i• Required prior to claim submission– Append EY modifier if not received

• Basic elements• Basic elements– Beneficiary’s name– Detailed description of item Detailed description of item – All options or additional features– Physician’s signaturey g– Date order is signed – Initial date if provided based on dispensing order


Additional Elements

F it id d i di b i th itt • For items provided on a periodic basis, the written order must include:– Item to be dispensedItem to be dispensed– Dosage or concentration– Route of administration– Frequency of use– Duration of infusion– Quantity to be dispensed– Number of refills


Acceptable Detailed Written OrderOrder

M b l t d b th th h i i • May be completed by someone other than physician – Treating physician must review, sign, and date

• Acceptable orders• Acceptable orders– Fax– PhotocopyPhotocopy– Electronic – Original pen and ink g p


When is a New Order Required?

N li• New supplier• New physician

Ch d i i l• Changes to order, i.e. equipment, accessory, supply• Equipment reaches reasonable useful lifetime• Lost, stolen, or irreparable damage due to specific

incidentS li l i• State licensure or regulations


DME Information Form

F l t d i d• Form completed, signedand dated by supplier

• Initial claim must include• Initial claim must includeelectronic DIF

• Revised DIF required if • Revised DIF required if drug changes or another drug addedg


Relevant Medical Records

E l f l t di l d i l d• Examples of relevant medical records include:– Physician notes– Non-physician clinical notes– Non-physician clinical evaluations


Supplementary Documentation

Oth t f i f ti t ffi i t b • Other types of information not sufficient by themselves to document coverage criteria – Even if signed or initialed by treating physicianEven if signed or initialed by treating physician– Not considered part of patient’s medical record

• Will be given consideration if corroborated by Will be given consideration if corroborated by medical record– Applies to documents created before delivery of item(s)y ( )


Examples of Supplementary DocumentationDocumentation

F ( ith ti h k ff) d i d b • Forms (either narrative or check-off) devised by supplier and completed by physician

• Summaries of patient’s medical condition prepared • Summaries of patient s medical condition prepared by supplier or physician

• Forms (either narrative or check-off) developed by • Forms (either narrative or check-off) developed by suppliers and completed by patient or caregiver


Refills

• No automatic dispensing on predetermined basisNo automatic dispensing on predetermined basis• Must contact beneficiary to determine:

– Consumable supplies: quantities that remain from previous pp q pdelivery

– Non-consumable supplies: supplier should assess if items remain functionalremain functional

• Document functional condition of item being refilled

• Contact no sooner than 14 days prior to d l / h ddelivery/ship date

• Deliver no sooner than 10 days prior to end of usage of current productusage of current product


Refill Documentation

R fill t t b d t d b f hi t • Refill request must be documented before shipment • Retrospective attestation statement not sufficient

D i i l d• Documentation must include:– Beneficiary’s name or authorized representative

Description of each item being requested – Description of each item being requested – Date of refill request– Consumables: quantity of each item remaining Consumables: quantity of each item remaining – Non-comsumables: functional condition of item being

refilled


Proof of Delivery

S li St d d 12• Supplier Standard 12• Required to verify beneficiary received item

M b il bl • Must be available upon request• Maintain documentation for seven years• Signature

– Can be signed by beneficiary or designeeC t b i d b li l f li – Cannot be signed by suppliers, employees of suppliers or anyone with financial interest in delivery of item


Delivery Methods

Directly to beneficiary Delivery/shipping service• Have signed delivery slip

– Items recommended to be included on slip:

P i ’

• Proof of delivery recommendations:– Delivery service’s tracking

li f i• Patient’s name• Quantity delivered• Detailed description of item

deliveredB d

slip referencing:• Each individual package• Delivery address• Corresponding package

• Brand name• Serial number

• Date of signature must be date beneficiary or

p g p gidentification number

• If possible, date delivered– Supplier’s own shipping

invoicedate beneficiary or designee received item

• Date of service = date of delivery

• Including delivery service’s package identification number

• Date of service = shipping datedelivery date


Delivery Methods (2)

Return postage-paid Directly to nursing facilityp g p• Invoice must list

– Patient’s name– Quantity

y g y• Obtain copies of

documentation from nursing facility to prove Quantity

– Detailed description of item(s)

– Brand name

nursing facility to prove usage and delivery– Nursing notes for usages– Signature for proof of Brand name

– Serial number– Beneficiary or designee

signature and date

Signature for proof of delivery

• Date of service = date of delivery or ship dateg delivery or ship date


Authorization to Bill Medicare

B fi i t th i li t bill M di • Beneficiary must authorize supplier to bill Medicare • Sign and date Item 12 on CMS-1500 claim form; or

Si O Fil (SOF) • Signature On File (SOF) – One-time authorization

Statement from beneficiary authorizing Medicare benefits – Statement from beneficiary authorizing Medicare benefits to be paid to themselves or supplier


SOF & Future Claims

L t l i f i b fil d ith t • Later claims for same services can be filed without obtaining additional signature

• Claims may be assigned or non assigned• Claims may be assigned or non-assigned– Exception non-assigned DME rentals


What is an ABN?

W itt ti f • Written notice of noncoverage– Informs beneficiary that Medicare may not pay for item

• Allows beneficiary to make informed decision • Allows beneficiary to make informed decision • Protects supplier from liability if properly executed

IOM P bli ti 100 04• IOM Publication 100-04– Chapter 30 – Financial Liability Protections– http://www cms gov/manuals/downloads/clm104c30 pdf– http://www.cms.gov/manuals/downloads/clm104c30.pdf

• ABN form and instructions – https://www.noridianmedicare.com/dme/forms/https://www.no idian edica e.co /d e/fo s/


GLUCOSE MONITOR AND GLUCOSE MONITOR AND GLUCOSE MONITOR AND GLUCOSE MONITOR AND TESTING SUPPLIES TESTING SUPPLIES

Local Coverage Determination (LCD) - L196Policy Article (PA) - A33673

Basic Coverage CriteriaMonitor E0607Monitor E0607

P ti t t t ll th f ll i it i• Patient must meet all the following criteria:1. Diabetic (diagnosis code 249.00 – 250.93)2. Monitor and supplies ordered by a physician 3. Beneficiary or caregiver completed training on

f i use of equipment 4. Capable of using results 5. For use in the home


Special Feature Monitors –E2100 E2101E2100, E2101

I i d i l it• Impaired visual acuity– Integrated voice synthesizer (E2100)

• Covered when basic criteria is met, andCovered when basic criteria is met, and• Physician certifies severe impairment

– Best corrected visual acuity of 20/200 or worse

I i d l d i• Impaired manual dexterity– Integrated lancing (E2101 only)

• Covered when basic criteria is met and• Covered when basic criteria is met, and• Physician certifies impairment of manual dexterity

– Physician’s narrative statement on file


Accessories and Supplies

L t (A4259)• Lancets (A4259)– 1 unit = 100 Lancets

• Blood glucose test strips (A4253)• Blood glucose test strips (A4253)– 1 unit = 50 strips

• Glucose control solutions (A4256)• Glucose control solutions (A4256)• Spring powered device (A4258)

1 per six month– 1 per six month


Non-covered Supplies

N d• Non-covered– Alcohol or peroxide (A4244, A4245)– Betadine or phisoHex (A4246 A4247)– Betadine or phisoHex (A4246, A4247)– Urine reagent strips or tablets (A4250)– Home glucose disposable monitor (A9275)g p ( )– Continuous glucose monitor

• Considered precautionary

– Reflectance colorimeter devices• Frequent professional re-calibration makes them unsuitable for

home use


Not Reasonable and Necessary

L ki i i d i (E0620)• Laser skin piercing device (E0620)• Replacement lens shield cartridges (A4257)


Utilization Guidelines

• Patient not treated ith ins lin• Patient not treated with insulin– 100 test strips and 100 lancets or one lens

shield every three monthsshield every three months• Patient being treated with insulin

– 100 test strips and 100 lancets or one lens– 100 test strips and 100 lancets or one lensshield every month

• Oral medication is not insulin-treated Oral medication is not insulin treated


Over-Utilization Guidelines

• Patient who exceeds guidelines must meet all the • Patient who exceeds guidelines must meet all the following criteria:a) Coverage criteria 1 – 5 are met) gb) Supplier of test strips, lens shield and lancets maintains

in records the order from treating physician c) Beneficiary has nearly exhausted supply of test strips and c) Beneficiary has nearly exhausted supply of test strips and

lancets, or useful life of one lens shieldd) Treating physician ordered frequency of testing that

d ili i id li exceeds utilization guidelines • Documented in patient’s medical record with specific reason for

additional materials


Over-Utilization Guidelines (cont)(cont)

e) Treating physician has seen patient and has evaluated e) Treating physician has seen patient and has evaluated their diabetes control e) Within six months of ordering strips and lancets, or lens shield

that exceed guidelines

f) If refills of quantities of supplies that exceed guidelines are dispenseda e dispensed• Must be documented in physician’s or supplier’s records

– Patient actually testing the frequency that corroborates the quantity dispensed quantity dispensed » Narrative statement or beneficiary’s log

• For patients that regularly use quantities exceeding guidelines – New documentation at least every six months – New documentation at least every six months


Refills

• No automatic dispensing on predetermined basisNo automatic dispensing on predetermined basis• Must contact beneficiary to determine:

– Consumable supplies: quantities that remain from previous pp q pdelivery

– Non-consumable supplies: supplier should assess if items remain functionalremain functional

• Document functional condition of item being refilled

• Contact no sooner than 14 days prior to d l / h ddelivery/ship date

• Deliver no sooner than 10 days prior to end of usage of current productusage of current product


KX, KS Modifiers

O f th f ll i difi t b d d i • One of the following modifiers must be used during claim submission:– KXKX– KS


THERAPEUTIC SHOES FOR THERAPEUTIC SHOES FOR PERSONS WITH DIABETESPERSONS WITH DIABETESPERSONS WITH DIABETESPERSONS WITH DIABETES

Local Coverage Criteria – L157P li A ti l A37076Policy Article – A37076

Coverage Criteria

1 Patient has diabetes mellitus1. Patient has diabetes mellitus– Diagnosis 249.00 – 250.93

2. Patient has one or more following conditions:2. Patient has one or more following conditions:a. Previous amputation of other foot, or part of either foot,

orb Hi f i f l i f i h f b. History of previous foot ulceration of either foot, orc. History of pre-ulcerative calluses of either foot, ord. Peripheral neuropathy with evidence of callus formation d. Peripheral neuropathy with evidence of callus formation

of either foot, ore. Foot deformity of either foot, orf P i l ti i ith f t df. Poor circulation in either foot; and


Coverage Criteria (2)

3 Si d tif i t t t f h i i3. Signed certifying statement from physician– Certified criteria 1 and 2 are met– Treating patient under a – Treating patient under a

comprehensive plan of care for diabetes

• In-person visit within 6 months prior to delivery of shoes/inserts; and

• Sign statement on or after date of S g st te e t te d te in-person visit and within 3 months prior to delivery of shoes/inserts

Shoes are needed– Shoes are needed


Coverage Criteria (3)

4 P i t l ti it li t d t d 4. Prior to selecting items, supplier must conduct and document in-person evaluation

5 At time of delivery supplier must conduct and 5. At time of delivery supplier must conduct and document in-person visit with patient


Allowance Per Calendar Year

• One pair of custom molded shoes (A5501) and two • One pair of custom molded shoes (A5501) and two additional pairs of inserts (A5512 or A5513)

OR

• One pair of depth shoes (A5500) and three pairs of inserts (A5512 or A5513)– Not including non customized removable inserts provided – Not including non-customized removable inserts provided

with shoes


KX, GY Modifiers

O f th f ll i difi t b d d i • One of the following modifiers must be used during claim submission:– KX modifier must be used if coverage criteria metKX modifier must be used if coverage criteria met– GY coverage criteria not met and properly executed

Advance Beneficiary Notice of Noncoverage is on file

• Claim will reject for missing information without a KX, GY modifier


EXTERNAL INFUSION EXTERNAL INFUSION PUMPPUMPPUMPPUMP

Local Coverage Determination – L11570Policy Article – A19834 y

Insulin Infusion Pump – E0784I J1817Insulin – J1817

IV S b t i li f di b t llitIV. Subcutaneous insulin for diabetes mellitus– ICD-9 249.00 – 250.93– Criterion A or B AND criterion C or D– Criterion A or B AND criterion C or Da. C-peptide testing requirement

1. < 110% of the lower limit of normal of the laboratory’s measurement method; OR

2. Patients with renal insufficiency and creatinine clearance < 50 ml/minutes, a fasting C-peptide < 200% of lower limit of normal of the laboratory’s measurement method; AND

3. Fasting blood sugar obtained same time as C-peptide is < 225 mg/dl

b. Beta cell autoantibody test is positive


Insulin Infusion Pump – E0784Insulin J1817 ( )Insulin – J1817 (cont)

IV Continued criterion C or DIV. Continued criterion C or Dc. Completed comprehensive diabetes education program,

multiple daily injections of insulin with frequent self-adjustments at least 6 month prior to insulin pump adjustments at least 6 month prior to insulin pump, documented self-testing at least 4 X per day 2 months prior to insulin pump and one or more of the following1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 1. Glycosylated hemoglobin level (HbA1C) greater than 7 percent 2. History of recurring hypoglycemia 3. Wide fluctuations in blood glucose before mealtime 4. Dawn phenomenon with fasting blood sugars frequently p g g y

exceeding 200 mg/dL 5. History of severe glycemic excursions

d. On external insulin pump prior to Medicare enrollment d t ti t l t 4 X d th th i t and testing at least 4 X per day the month prior to

Medicare enrollment September 2012 NAS, LLC Proprietary 66

Continued Coverage for Insulin PumpInsulin Pump

P ti t t b d l t d b t ti • Patient must be seen and evaluated by treating physician at least every 3 months

• Physician who orders and follows up must manage • Physician who orders and follows up must manage multiple patients on continuous subcutaneous insulin infusion therapys o t e apy

• Physician works closely with a knowledgeable team – Nurses– Diabetic educators– Dieticians


KX, GA, GZ Modifiers

• O f th f ll i difi t b d d i • One of the following modifiers must be used during claim submission:– KX modifier must be used if coverage criteria met, apply:g , pp y

• Insulin infusion pump (E0784)• Insulin (J1817)

GA coverage criteria not met and properly executed Advance – GA coverage criteria not met and properly executed Advance Beneficiary Notice of Noncoverage is on file

– GZ coverage criteria not met and valid ABN not obtained• All claim line(s) items submitted with a GZ modifier shall be denied

automatically and will not be subject to complex medical review

• Claim will reject for missing information without a KX, j g ,GA or GZ modifier


RESOURCES AND RESOURCES AND REMINDERSREMINDERS

CERT Review Program

C h i E R t T ti (CERT) t • Comprehensive Error Rate Testing (CERT) post audit random sampling program for Medicare claims– Measures and improves quality/accuracy Measures and improves quality/accuracy – Send CERT requested documentation timely – Quarterly NAS CERT web presentations availableQ y p– Watch signature requirements/documentation

• CMS Claims Review Programs booklet g– November 2011– Includes MR, NCCI, MUEs, CERT, and RAC


Signature Requirements

• Rendering/ordering i i l lpractitioner clearly

identified in records– First name/last

/ d i l /d

ACCEPTABLE

H d itt El t i name/credentials/date• If illegible, must also

type/print name

Handwritten Electronic

NOT ACCEPTABLE • Dictated notes must be verified or read by physician/practitionerI O l M l

NOT ACCEPTABLE

Signature stamps

Verbiage stating signed, but not

• Internet Only Manual (IOM) Publication 100-08, Chapter 3, Section 3.4.1.1

p g ,read


National Coverage Decision (NCD) Policies

NCD Title NCD #

Blood Glucose Testing 190 20

http://www.cms.gov/mcd/index_list.asp?list_type=ncd

Blood Glucose Testing 190.20Diabetics Outpatient Self-Management Training & Medical Nutrition Treatment (MNT)

40.1

Diagnosis/Treatment of Diabetic Sensory Neuropathy with Loss of Protective Sensation (LOPS)

70.2.1

Glyclated Hemoglobins/Proteins 190 21y g / 190.21Home Health Visits to a Blind Diabetic 290.1HBO Therapy 20.29y

Surgery for Diabetes 100.14Home Blood Glucose Monitors 40.2Infusion Pumps 280.14September 2012 NAS, LLC Proprietary 72

Miscellaneous Coverage

P di t• Podiatry– One exam every 6 months

With di b t l t d d t ith f t• With diabetes-related nerve damage to either foot

• Hemoglobin A1c TestsM bl d l l l t 3 th– Measures blood glucose levels over past 3 months

• Ordered by physician for diabetic patients


Benefits Integrity

Ph i i B f “ il d ” li f i • Physicians: Be aware of “mail order” suppliers faxing orders to your office for signature– When not ordered or authorizedWhen not ordered or authorized

• Check with patient – E g non-diabetic patient receives direct diabetic supplies E.g., non diabetic patient receives direct diabetic supplies

• Patient / physician may call to report fraud – 1-800-MEDICARE (1-800-633-4227)1 800 MEDICARE (1 800 633 4227)

• Write to Benefits Protection:– Medicare Part B, PO Box 6710, Fargo ND 58108-6710, , g


Provider Compliance Webpage

• CMS MLN compliance products• CMS MLN compliance products– How to avoid common billing errors and other improper

activities

• Fact sheets/educational tools, such as:– Quarterly Provider Compliance Letter

F d/Ab P i D i d R i – Fraud/Abuse Prevention, Detection and Reporting – Overpayment Collection Process

• http://www cms gov/Outreach-and-http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedQtrlyCompNL_Archive.pdf


OIG Roadmap Booklet

• OIG Booklet (31 pages) ( p g )• Fraud/Abuse Laws• Physician’s/Payer y y

Relationship• Tips for Medical Directors• Other valuable information• http://oig.hhs.gov/compliance

/ph i i/physician-education/roadmap_web_version.pdf


p f

Medicare Learning Network (MLN)(MLN)

• MLN Product and Resource Guide• MLN Product and Resource Guide– http://www.cms.hhs.gov/MLNproducts– Guides– Articles– Educational Tools

Booklets / Brochures– Booklets / Brochures– Fact Sheets– Training Presentations– Web-Based Training– Special Initiatives– Web Resources

September 2012 NAS, LLC Proprietary 77Jurisdiction D DME MAC 77

CMS Resource

I t t O l M l (IOM) P bli ti 100 02 • Internet Only Manual (IOM), Publication 100-02 Chapter 15, Section 300 (Diabetes Outpatient Self-Management Training Services)Management Training Services)– 110 (Durable Medical Equipment)– 140 (Therapeutic Shoes for Individuals with Diabetes)( p )– 300.1 (Coverage Requirements)– 300.2 (Who Can Provide DSMT?)– 300.3 (Training Frequency)– 300.4 (Outpatient Diabetes Self-Management Training)

h // / l / li /b df• http://www.cms.gov/manuals/102_policy/bp102c15.pdf


Join NAS E-mail Lists!

• What’s New/Latest Updates• What s New/Latest Updates– Emails sent Tuesday/Friday– Simple, quick sign upp , q g p

• Benefits:– Latest news/information from NAS

d CMS and CMS – Up-to-date Medicare regulations – Workshop and educational event notices Workshop and educational event notices – Medical policy updates – Payment/reimbursement updates – NAS hours of availability and related notifications


WHAT QUESTIONS DO YOU WHAT QUESTIONS DO YOU HAVE?HAVE?

Thank you for attending Thank you for attending Thank you for attending Thank you for attending today’s workshop!today’s workshop!

Documents

Diabetes Billing