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On February 20, 2018, Performant Recovery, the National DMEPOS RAC, added Group 2 Support Surfaces to their approved issues list. According to their website, Performant Recovery will perform complex reviews on the Group 2 support surfaces to determine if coverage criteria and/or medical necessity requirements were met. Codes included in the audit: E0277, E0371, E0372, E0373 Applicable policy references:

• Social Security Act, Sections 1862(a)(1)(A) and 1833
• Medicare Benefit Policy Manual: CMS Publication 100-02; Chapter 15, § 110 - Durable Medical Equipment
• Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 34, § 10.61 and 10.62
• Medicare Program Integrity Manual: CMS Publication 100-08, Chapter 5, § 5.7, 5.8, and 5.9
• Medicare Program Integrity Manual: CMS Publication 100-08, Chapter 3, § 3.3.2 (Rev. 377, Effective 6/28/2011), §3.3.2.4 (Rev. 604, Effective 8/25/2015), and §3.4.1.1
• Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017
• MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017
• MAC Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017

On February 26, 2018, Performant also added Negative Pressure Wound Therapy Pumps to their approved issues list. According to their website, Performant Recovery will perform complex reviews on Negative Pressure Wound Therapy (NPWT) Pumps to determine if there is potential incorrect billing occuring when claims for NPWT pumps were billed without an indication supporting medical necessity as outlined in the LCD L33821 and related policy article A52511. Codes included in the audit: E2402, A6550, A7000 Applicable policy references:

• Social Security Act, Sections 1862(a)(1)(A) and 1833
• Medicare Benefit Policy Manual: CMS Publication 100-02; Chapter 15, § 110
• Medicare Claims Processing Manual: CMS Publication 100-04; Chapter 34, § 10.61 and 10.62
• Medicare Program Integrity Manual: CMS Publication 100-08, Chapter 5, § 5.7, 5.8, and 5.9
• Medicare Program Integrity Manual: CMS Publication 100-08, Chapter 3, § 3.3.2 (Rev. 377, Effective 6/28/2011), §3.3.2.4 (Rev. 604, Effective 8/25/2015), and §3.4.1.1
• Local Coverage Determination (LCD) L33821 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017
• MAC Policy Article A52511 - Negative Pressure Wound Therapy Pumps, Effective 10/01/2015; Revised 05/25/2017
• MAC Policy Article for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426), Effective 1/1/2017; Revised 12/21/2017

  Want some help? Come to the experts!  The van Halem Group offers proactive and reactive services to assist you. If you receive an audit request from the RAC our clinical team will review the claim file and respond to the audit on your behalf. If denied, we will work with you to obtain addendums and appeal the overpayment. Want to feel confident that the equipment you are providing meets coverage criteria? Sign up for our clinical prescreen review program. Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our  prescreen program. Contact us for more information!

*Claim must be submitted with same documentation provided at prescreen level. Any changes or alterations void free appeal.