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On July 11, 2018, Performant Recovery, the National DMEPOS RAC, added Home Use of Oxygen to their approved issues list. According to their website, Performant Recovery will perform complex reviews on Home Oxygen to determine if the equipment provided meets coverage criteria and is medically reasonable and necessary. Code(s) included in the audit: E1390 Dates of service: Less than three years and after September 30, 2015 Applicable policy references:

1. Title XVIII, Social Security, §1833€
2. Title XVIII, Social Security, §1861(s)(6)
3. Title XVIII, Social Security, §1862(a)(1)(A)
4. 42 C.F.R. sections 405.980 (b) & (c) and section 405.986
5. 42 CFR 424.57(a)(12)
6. CMS, IOM Pub. 100-03, Chapter 1, Part 4, §240.2
7. CMS, IOM Publication 100-04, Chapter 20; 100.2.3
8. CMS, IOM Publication 100-04, Chapter 30.6; 130.6
9. CMS, IOM Publication 100-02, Chapter 15; 110
10. CMS, IOM Publication 100-08,Chapter 4, Section 4.26
11. CMS, IOM Publication 100-08, Chapter 5, Section 5.2.4 – 5.2.8, 5.7, 5.8, and 5.9.1
12. LCD L33797: Oxygen and Oxygen Equipment. Eff. Date: 10/01/2015
13. Local Coverage Article A52514: Oxygen and Oxygen Equipment. Effective Date: 10/01/2015
14. CMS Policy Article A55426 for Standard Documentation Requirements for All Claims Submitted to DME MACs: Effective date: 01/01/2017

On July 11, 2018, Performant also added Urological Supplies to their approved issues list. Note this audit does not become effective until 8/1/2018. According to their website, Performant Recovery will perform complex reviews on Urological Supplies to determine if the equipment provided meets coverage criteria and is medically reasonable and necessary. Codes included in the audit: Downloadable xls file of affected codes will be made available (presumably on or before the effective date of 8/1/2018) Dates of service: Less than three years and on or after October 1, 2015 Applicable policy references:

• Title VIII of the Social Security Act, Section 1862(a)(1)(A)
• Social Security Act, Section 1861(s)(8)- Prosthetic Device Benefit
• 42 CFR 424.57(c)(12)
• CMS, IOM 100-08, Chapter 3, Section 3.3.2.4
• CMS, IOM 100-08, Chapter 5, Section 5.2.1-8; 5.3; 5.8
• Local Coverage Determination (LCD) L33803- Urological Supplies: Effective date 10/01/2015; Revised 01/01/2017
• Local Coverage Article (LCA) A52521- Urological Supplies- Policy Article: Effective date 10/01/2015; Revised 01/01/2017
• Local Coverage Article (LCA) A55426- Standard Doc Requirements for All Claims Submitted to DME MACs: Effective date 01/01/2017; 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.