october 2008 medical equipment updates presented by eds provider field consultants

October 2008

Medical Equipment UpdatesPresented by EDS Provider Field Consultants

MEDICAL EQUIPMENT UPDATES2 / OCTOBER 2008

Agenda

• 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

Welcome and Announcements


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


Date of Service

•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)

Reminder


Provider Code Sets

•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

Effective August 1, 2006


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


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


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


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


Capped RentalClaims 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


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


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


Mail Order Incontinence, Ostomy, and Urological SuppliesContracted 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

1-888-217-9610www.binsons.com

– Healthcare Products Delivery, Inc (HPD)1-800-291-8011www.hpdinc.net

– J & B Medical1-866-674-5850www.jandbmedical.com


•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

Mail Order Incontinence, Ostomy, and Urological Supplies


Mail Order Incontinence, Ostomy, and Urological Supplies

•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)

Program Exclusions


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

Mail Order Incontinence, Ostomy and Urological Supplies


Billing Guidelines

•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

Diabetic Test Strips


Billing GuidelinesHumidifiers

•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


Billing GuidelinesCPAP

•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


Billing Guidelines

•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 end-stage renal disease dialysis services

•See IHCP provider bulletin BT200031 and banner page BR200139 for more billing information for sterile or non-sterile gloves

Gloves


Billing Guidelines

•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

Codes Added to Bypass Table


Billing Guidelines

•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

Sterile Saline and Water


Billing Guidelines

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

Power Wheelchair Codes


Billing Guidelines

• 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

Rolling 12-Month Period


•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

Common DenialsBilling Guidelines


•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

Billing GuidelinesCommon 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



•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



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


Spend-down UpdatePolicy 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


•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

Spend-down UpdatePolicy Effective January 1, 2006


Helpful ToolsWeb interChange

•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

interChange HomeIndiana MedicaidCheck InquiryClaim InquiryClaim SubmissionEligibility InquiryPA InquiryPA SubmissionProvider ProfileHelpFAQHow to Obtain an IDContact UsLogonLogoffChange Password


Helpful ToolsAvenues 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 7263Indianapolis, IN 46207-7263

• Provider Relations Field Consultant

– View a current territory map and contact information online at HCP Web site at www.indianamedicaid.com


Questions


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october 2008 medical equipment updates presented by eds provider field consultants

Documents

medical equipment updates

purchase equipment

purchased equipment

home medical equipment

hme provider

capped rental policy

capped rental period

rental repair