Heritage Medical Equipment, LLC

L-0174 - The End is Near

 

It looks like the hornet's nest that is PDAC has been stirred up again.  Every manufacturer of cervical collars must re-submit their L-0174 products for coding re-verification, and the end date that practitioners will be able to use L-0174 for those products at their current level of reimbursement is August 31st, 2011.

An industry insider believes that most of the cervical collars you have been using (Aspen TX, Vista TX, Miami J, CSI, etc...) will be down-coded to L-0172.  What does this mean?  If we look at New York State for example L-0174 currently reimburses at $232.00  L-0172 reimburses at $123.00.  So New York State suppliers will be losing $109.00 in reimbursement whenever a cervical collar is applied.  Another way to look at it is if you apply a cervical collar with an approximate cost of $40, you will make about $83 instead of $192.  Why bother driving to the hospital and starting a chart?  

Why is this coding re-verification happening?  Our source blames Ossur. The rumor on the street is that Ossur recently submitted their new Miami J to PDAC and did not receive a favorable code.  Ossur contested PDAC in regards to this.  This appeal is what stirred up PDAC.  So thanks to Ossur it appears as if the entire industry is going to be stripped of L-0174.  

A June 10th 2011 NHIC newsletter reads, "HCPCS code L0174 (CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENTION) describes a cervical collar that is constructed of thermoplastic foam. It is a two piece system with posterior and anterior thoracic extensions. The thoracic extension must overlap the manubrium sternum anteriorly and to the thoracic vertebra T-1 posteriorly.

Products currently coded with L0174 which are listed on DMECS will be end dated as of August 31, 2011. A new coding application will need to be submitted for any product requesting this code. When the products are coded by the PDAC, those meeting the code specifications will be listed in the Product Classification Matrix on DMECS. Only those products listed may be billed using code L0174."

So what should you do?  Prepare for the inevitable.  It is likely that PDAC will mimic the same coding scenario they followed a few months back for L-0631.  So replace your L-0174 cervical collars with L-0180 collars.  In New York L-0180 reimburses at $343.00.  PDAC isn't looking at L-0180.

The Cyberspine Cervical Collar has PDAC approval for L-0180.  This collar is designed so practitioners can make adjustments to accommodate each patient's needs.  It is a much more substantial brace than the typical "slap and strap" type of L-0174 neck brace.  This Cyberspine has a higher reimbursement because you actually have the ability to mold the occipital component and adjust the multi-post yoke.  This cervical collar lets you be a practitioner again.   

The Medicare CERT Education Task Force

 
 

Comprehensive Error Rate Testing (CERT) Task Force

The Medicare CERT program was established by CMS so a national paid claims error rate could be calculated for all of the Medicare Fee-For-Service programs.  The error rate is computed for all Medicare Administrative Contractors, Carriers, and Fiscal Intermediaries.  CERT was implemented to comply with the Improper Payment Information Act of 2002.  The main objective of the program is to protect the Medicare Trust fund.

The CERT program uses random samples to select claims.  So reviewers cannot see provider billing patterns when making payment determinations.  This program cannot be considered a measure of fraud.  In an effort to reduce common CERT errors, DME MAC Jurisdictions A, B, C, and D have worked together and formed the DME MAC CERT Education Task Force.

Their primary purpose is to "centralize education specific to the CERT program and to present a single educational voice and message to suppliers throughout the United States".  The Task Force's goal is to improve knowledge and performance related to the Comprehensive Error Rate Testing program on a national level.

This task force released answers to pre-submitted questions regarding DME last January, though our industry didn't seem to take notice.  The upcoming series of blog posts will examine some of the questions and answers in an effort to bring some attention to how the CERT program is going to affect O&P.

Even though you use the correct L-Codes, PDAC approved products, and have all the proper documentation, your claims can still be denied by CERT for reasons out of your control.  Please comment on the posts, forward them to your colleagues, and help bring some attention to this!   

 

CMS Final Ruling - Section 424.57(d)

Section 424.57(d) adds a new paragraph to the regulations that if a DMEPOS supplier is convicted of a felony or involved in adverse legal actions that CMS or the NSC can establish an "overpayment" from the date of conviction.  

They believe this is necessary because some DMEPOS suppliers fail to report convictions to the NSC.  This new provision gives CMS the authority to assess and collect all overpayments from the time of the reportable event.

CMS DMEPOS Final Ruling - Rules and Regulations

 

CMS Final Ruling - Section 424.57(c)(31)

 

Effective September 27th, 2010 the final ruling from CMS will regulate DMEPOS suppliers and their ability to establish and maintain billing privileges.  

Section 424.57(c)(31) specifies that a DMEPOS supplier could not have IRS or state tax delinquencies.  Being convicted of tax evasion or the filing of a  tax lien can also mean a suspension or ban of privileges.

CMS DMEPOS Final Ruling - Rules and Regulations

 

CMS Final Ruling - Section 424.57(c)(30)

 

Section 424.57(c)(30) proposes a new standard that requires DMEPOS suppliers to be open a minimum of 30 hours per week.  

"Given that Medicare beneficiaries may not be able to find transportation during limited operating hours, the DMEPOS supplier must be open and available for periods long enough for beneficiaries to readily access their facility."   

CMS DMEPOS Final Ruling - Rules and Regulations

CMS Final Ruling - Section 424.57(c)(29)

The final ruling from CMS will become effective on September 27th, 2010.  This ruling regards DMEPOS suppliers' ability to establish and maintain billing privileges for Medicare.   

Section 424.57(c)(29) states that a, "supplier is prohibited from sharing a practice location with another Medicare supplier."

CMS believes that allowing a supplier to, "commingle its practice location with another DMEPOS supplier effectively limits the ability of CMS and NSC to ensure each DMEPOS supplier meets all of the supplier standards."

This is bad news for stock and bill companies.  Rumors state that Biomet (formerly EBI) is already making plans to stop billing for Medicare patients in the majority of their facilities.  Will Don Joy follow suit?  

CMS DMEPOS Final Ruling - Rules and Regulations

CMS Final Ruling - Section 424.57(c)(28)

On September 27, 2010 the final ruling from CMS will become effective regarding DMEPOS suppliers ability to establish and maintain Medicare billing privileges.

Section 424.57 (c)(28) explains that suppliers must maintain ordering and referring documentation for 7 years after a claim has been paid.  This is so suppliers can, "ensure themselves that coverage criterion for an item has been met".

The supplier will be responsible for the dollar amount involved if the information is not in the patient's record.

CMS DMEPOS Final Ruling - Rules and Regulations

CMS Final Ruling - Section 424.57(c)(27)

 

Section 424.57(c)(27) specifies that, "When a DMEPOS supplier is located in a state where licensure is required, then they must obtain their oxygen from a state-licensed oxygen supplier."  This standard is to ensure Medicare beneficiaries are protected and to promote quality in "the furnishing of oxygen".

CMS DMEPOS Final Ruling - Rules and Regulations

CMS Final Ruling - Section 424.57(c)(12)

 

Section 424.57(c)(12):  This section states that the supplier is responsible for instructing patients how to use the devices that are being supplied.  The section states, "a DMEPOS supplier is solely responsible for delivery of Medicare-covered items and for instruction on the use of those items."  

The DMEPOS supplier must:

 

1. be responsible for maintaining proof of delivery.
2. provide contact information to the beneficiary.
3. provide the beneficiary with instructions on how to use the equipment provided.
4. provide instruction to the beneficiary on how to use the equipment provided.
5. be responsible for documenting the instruction.

The segment concludes, "this section will help ensure that instructions for the safe and apropriate use of products will be given to beneficiaries."

CMS DMEPOS Final Ruling - Rules and Regulations

CMS FInal Ruling - Section 424.57(c)(11)

 

Section 424.57(c)(11) Suppliers cannot directly solicit patients.  

CMS or NSC may revoke a supplier's billing privileges if it is determined that a supplier has prohibited contacts with patients.

Sections 424.57(c)(11)(i) through 424.57(c)(11)(iii) explain the provisions of when a supplier may contact a Medicare beneficiary.

CMS DMEPOS Final Ruling - Rules and Regulations