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CBR201802 Spinal OrthosesReferring Providers

April 11, 2018

3:00 P.M. ET

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CBR201802 Spinal Orthoses

Referring Providers

April 11, 2018

3:00 P.M. ET

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Webinar Questions

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CBR201802 5


Webinar Outline

1. Introduction

2. Coverage & Documentation Overview

3. Data Sources & Results

4. References & Resources

5. Survey

CBR201802 6

Webinar Protocol

All attendee lines are muted

Submit questions via Q&A function throughout the webinar

Ask questions pertinent to webinar


Contact MAC for specific claims questions

CBR201802 7


Webinar Objective

Upon completion of this webinar, you should be able to:

Demonstrate a general understanding of CBR201802: Spinal Orthoses Referring Providers

Comprehend the results

Locate policy references and resources

CBR201802 8

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Webinar Materials

References and Resources

Webinar slides

Recording of webinar

Webinar Handout

Webinar Q&A

CBR201802 10

Acronyms Code Description

ABN Advance Beneficiary Notice

CMN Certificate of Medical Necessity

DMEPOS Durable Medical Equipment Prosthetics, Orthotics and Supplies

HCPCS Healthcare Common Procedure Coding System

IDR Integrated Data Repository

LCD Local Coverage Determination

LCA Local Coverage Article

NCD National Coverage Determination

OTS Off-the-Shelf

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Coverage & Documentation Overview


Topic Selection - OIG

Medicare Supplier Acquisition Costs for L0631 Back Orthoses:

2008-2011

Claims for L0631 back orthoses more than doubled

Medicare allowances increased from $36 million to more than $96 million

Medicare payment amounts were more than 4 times greater than supplier acquisition costs

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Billing Patterns

Billing may differ for many reasons:

Physician sub-specialties

Geographic location

Under-served urban areas

Rural areas

Patient acuity

More severe illnesses

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Definition

Medicare defines braces as rigid or semi-

rigid devices which are used for the purpose

of supporting a weak or deformed body

member or restricting or eliminating motion

in a diseased or injured part of the body.

CBR201802 15

HCPCS Codes

HCPCS Code Type

L0627 Custom-Fitted L0631 Custom-Fitted L0637 Custom-Fitted L0642 Off-the-Shelf L0648 Off-the-Shelf L0650 Off-the-Shelf

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Off-the-Shelf Orthoses vs Custom-Fitted Orthoses

Off-the-Shelf Custom-Fitted

Requires minimal self-adjustment for fitting Requires substantial modification

Prefabricated Prefabricated

May or may not be supplied as a kit May or may not be supplied as a kit

Does not require expert fitting Requires expert fitting at delivery Certified orthotist or someone with specialized training

CBR201802 17

Modifiers

Modifier Description

EY No physician or other licensed health care provider order for this item or service

GA Waiver of liability statement issued as required by payer policy, individual case

GZ Does not meet Medicares reasonable and necessary rules and no ABN was signed

KX Coverage criteria has been met

LT Left side

RT Right side

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Repairs and Replacements

Repairs: Covered to make item serviceable Billing should include HCPCS, purchase date, price, product name, model, justification of repair

Physicians order or Certificate of Medical Necessity (CMN) is not needed

Replacement: Refers to an identical or nearly identical item Replacement due to loss or irreparable damage (such as fire/flood) does not require physicians order

Need physicians order to replace item due to irreparable wear or change in patients condition (based on reasonable useful lifetime)

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Documentation

Documentation Requirements:

Medical necessity

Type of orthosis

Detailed written order (DWO)

Detailed description of modifications and fitting for custom fitted

Proof of delivery (POD)

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Local Coverage Determinations and Articles

Covers all DME Jurisdictions

LCD: L33790

LCAs: A52500, A55426

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Data Sources & Results


Report Data

Medicare Part B Referring Providers:

By National Provider Identifier (NPI)

Selected Spinal Orthoses HCPCS Codes L0627, L0631, L0637, L0642, L0648, L0650

Extracted: January 24, 2018 from Integrated Data Repository (IDR)

Dates of Service: October 1, 2016 September 30, 2017

CBR201802 23

Summary of Findings

Dates of Service: Oct. 1, 2016 Sept 30, 2017

67,000 Referring Providers

337,000 Beneficiaries

$358 Million

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Metrics and National Statistics

Percentage of Allowed Services Defined as Custom-Fitted

Nation: 17%

Percentage of Allowed Services Submitted Without a Visit to the Referring Provider within 90 Days of the DMEPOS Service Date

Nation: 51%

Average Allowed Charges per Beneficiary for the One-Year Period

Nation: $1,043.58

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http:1,043.58

Peer Groups

For comparison with the individual providers

State Medicare providers in the providers state referring spinal orthoses

National All Medicare providers in the nation referring spinal orthoses

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Comparison Outcomes

There are four possible outcomes:

1. Significantly Higher

2. Higher

3. Does Not Exceed

4. N/A

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Who Received a CBR?

Significantly Higher Than Peers

$5,000 Allowed Charges

10 Beneficiaries

2,166 providers received this CBR

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References & Resources

Comparative Billing Reports Comparative Billing Reports (CBRs) are ed ucational too ls administered by the Centers for Medicare & Medicaid Servk: es (CMS). They are developed and disseminated under contract by eGlobalTech, a womanowned Federal services firm based in Arlington , VA_

The CBRs are disseminated to the prov ider community to provide insight into bill ing trends ac ross regions and policy groups. AJB MACs have been produc ing and d isseminating limited numbers of CBRs to targeted providers for many years. CMS has now formalized and expanded the program to a national level. T he program also inc ludes a CBR Support Help Desk that providers can contact to ask questions regard ing ttle CBRs. Following the release of each CBR, eGT w ill hOld an educational teleconference or webinar to educate providers on tne substance of tne CBR and to provide an opportunity to r providers to asl< questions.

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About Us CBR Releases Education Recommended Links FAQs CBR Support Contact Us

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CBR201802 Web Page

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Webinar Sample CBR Statistical Debriefing Recommended Links FAQs

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Provider Self-audit

Providers and suppliers have an obligation to ensure claims are submitted correctlyto Medicare

Self-audits allow providers and suppliers to identify coverage and coding errors

Refer to the following CBR sections for assistance Documentation and Billing References

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CBR Support Help Desk

MondayFriday: 9:00a.m. to 5:00p.m. ET

Toll Free 18007714430


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Contacting MACs

Providers should contact the Medicare Administrative Contractor (MAC) for assistance with:

Claim Information

Documentation Requirements

Billing and Coding

CBR201802 34

PECOS and NPPES

Provider Enrollment, Chain, and Ownership System (PECOS) and National Plan and Provider Enumeration System (NPPES)

Sources for contact information used for the CBR

Correct your mailing information in PECOS at https://pecos.cms.hhs.gov/pecos/login.do

Correct your contact information in NPPES at https://nppes.cms.hhs.gov/

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Questions & Answers

We make every effort to address all questions submitted during our webinars. However, we cannot provide responses related to coding issues or to specific claims/scenarios. Since your Medicare Administrative Contractor (MAC) makes the determination to pay or deny a claim based on the CPT or HCPCS codes, medical documentation and description of the circumstances, and we do not have access to this documentation, we cannot respond to these types of questions. Please contact your MAC with questions that we do not address or if you identify any claims discrepancies while reviewing your CBR. The contact information for your MAC is located at http://go.cms.gov/IMap.

37

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Stay Tuned for WebinarCBR201802 Spinal Orthoses Referring ProvidersDisclaimer 2AnyMeeting Browser SupportWebinar QuestionsWebinar OutlineWebinar ProtocolWebinar ObjectiveSample CBRWebinar MaterialsAcronymsCoverage & Documentation Overview Topic Selection - OIGBilling PatternsDefinitionHCPCS CodesOff-the-Shelf Orthoses vs Custom-Fitted Orthoses ModifiersRepairs and ReplacementsDocumentationLocal Coverage Determinations and ArticlesData Sources & ResultsReport DataSummary of FindingsMetrics and National StatisticsPeer GroupsComparison OutcomesWho Received a CBR? References & ResourcesCBR WebsiteCBR201802 Web PageProvider Self-auditCBR Support Help DeskContacting MACsPECOS and NPPESQuestions & AnswersDisclaimer 3

cbr201802 webinar slides - spinal orthoses referring providers · macs have been producing and...

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