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~o PALMETTO GBA"' A CELERIAN GROUP COMPANY
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CBR201802 Spinal OrthosesReferring Providers
April 11, 2018
3:00 P.M. ET
mailto:[email protected]
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CBR201802 Spinal Orthoses
Referring Providers
April 11, 2018
3:00 P.M. ET
Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS).
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CBR materials are prepared as a service
to the public and are not intended to grant rights
or impose obligations. The information provided in
the CBR material is only intended to be a general
summary. The CBR project has made every
reasonable effort to ensure the accuracy of the
information and web links provided in the CBR
materials at the time of publication; however, the
information and links within the material may
change without further notice. It is the
responsibility of the provider to remain up-to-date
with program guidelines.
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Webinar Questions
All attendee lines are muted
Submit questions using the Q & A buttonthroughout the webinar
Ask questions pertinent to webinar
Email: [email protected]
CBR201802 5
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Webinar Outline
1. Introduction
2. Coverage & Documentation Overview
3. Data Sources & Results
4. References & Resources
5. Survey
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Webinar Protocol
All attendee lines are muted
Submit questions via Q&A function throughout the webinar
Ask questions pertinent to webinar
Email: [email protected]
Contact MAC for specific claims questions
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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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mp=m Billini: Rqort ,(CBR)-.ac,es are co~a-ed ibyM.edic.areRmB. Durab1eMS>11EcalEqwpl!!l.!l!.1 Pro5th!!cics. O:rt:lu,lic:s o:n.dS,q,;, s MEPOS) .m>a they ""'fumish~oo aphy-,icim's omer orin.ddmtto aphy;idm~semCJ!S. I!l!l!flsth.i!r do not~Medicm"sd-=fici1ioaof.a brirne are not cc\emi!. The l!!ll!Oics re\i.e,.ed in mis repori in.cmde:
i?eroanlage of illowed :il!El'ffi defuted as ,cu;rnm-fitted Pe:ro;,nrage of illowied :il!IVi= rubmitte~ v.mbom" vi..,it ,o tbe refemng jlroi.iJfer mrhm 90
da'y; c: the MEWS smicl! dilte A~ge clwges per b:ne,ilc:i.!.rr fur 11!.e one,-year period
The Office ofm,-pector ~Jal (OIG) i:ndudes onbose; in fue Work: Pim, Ffarol y.,..,. Wl report ,am.,! campo,re; M~c,e:rp,ymmt; fur braces to 11!.ose ofpri!l'ate im:-=oe rnmpanL, (noJt-Medicm payer,).. The orGm11de chese c.olllparisons in an effim to. :l!en.til) pocmtiailly v.S!Stafu! speoomg amt ro a.dj;u;i. ib.e fee sclJ.edJil.e for 11U!.()5e, to be m11re in lin.e v,,nn ooa, Me -care ~i1~!!13 . The, ;, u.rk PI.an al.so in.dlJdes m~ev.1'1! medi.
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Webinar Materials
References and Resources
Webinar slides
Recording of webinar
Webinar Handout
Webinar Q&A
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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
Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS).
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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.
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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
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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
Level II HCPCS codes are maintained and distributed by the Centers for Medicare & Medicaid Services (CMS).
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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
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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
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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
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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.
r.1ost Recent CBR
t 1AC Contact I nforrnat1on
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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
Email: [email protected]
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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
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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/
CBR201802 35
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Questions & Answers
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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.
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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