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Performant Recovery posted one new complex issue and one new automated issue to their approved issues log this month.

Therapeutic Shoes and Inserts for Persons with Diabetes

On April 26, 2019, Performant Recovery, the National DMEPOS RAC, added Therapeutic Shoes and Inserts for Persons with Diabetes to their approved issues list. According to their website, Performant Recovery will perform complex reviews to determine if the documentation submitted for review meets Medicare’s coverage requirements for Diabetic Shoes and Inserts. Claims where the documentation submitted does not support the coverage requirements will be denied.

Code(s) included in the audit: A5500, A5501, A5512, A5513

Dates of service: Claims having a “claim paid date” which is less than 3 years prior to the ADR date.

Applicable policy references:

1. SSA 1861(s)(12)- Definitions of Services, Institutions, Etc.; Medical and Other Health Services
2. SSA 1861(qq)(1)- Definitions of Services, Institutions, Etc.; Diabetes Outpatient Self-Management Training Services
3. SSA 1833(o)- Payment Of Benefits
4. Medicare Benefit Policy Manual, Chapter 15, §140, Therapeutic Shoes for Individuals with Diabetes
5. Medicare Program Integrity Manual, Chapter 4, §4.26, Supplier Proof of Delivery Documentation Requirements
6. Medicare Program Integrity Manual, Chapter 5, Section 5.2- Rules Concerning Orders
7. Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient's Medical Record
8. Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation
9. Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity
10. Local Coverage Determination L33369: Therapeutic Shoes for Persons with Diabetes -Effective Date 10/1/2015 Revision 10/01/2015, Revision 07/01/2016; Revision 01/01/2017 and Revision 04/01/2018.
11. Local Coverage Article A52501: Therapeutic Shoes for Persons with Diabetes - Effective Date 10/1/2015, Revision 10/01/2015, Revision 07/01/2016; Revision 10/01/2016, Revision 01/01/2017 and Revision 04/01/2018.
12. CMS Policy Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs - Effective Date 01/01/2017, Revision 04/20/2017, Revision 05/25/2017, Revision 06/01/2017, Revision 11/20/2017, 12/21/2017, 05/07/2018 and 08/28/18th.

Knee Orthoses within the Reasonable Useful Lifetime (RUL)

On May 1, 2019, Performant Recovery, the National DMEPOS RAC, added Knee Orthoses within the Reasonable Useful Lifetime (RUL) to their approved issues list. According to their website, Performant Recovery will perform automated reviews on claims for knee orthoses with dates of service within the period of reasonable useful lifetime (RUL) of a previously paid knee orthoses for the same beneficiary, for the same anatomical site. These claims will be denied as the reasonable useful lifetime (RUL) requirement has not been met. 

Code(s) included in the audit: L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860

Dates of service: Claims that have a “paid claim date” which is less than 3 years prior to the Informational Letter date (automated review)

Applicable policy references:

1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
2. Social Security Act, Section 1834 (a) [42 U.S.C. 1395m], Payment for Durable Medical Equipment
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)(7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment
4. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
5. 42 CFR §405.986- Good Cause for Reopening
6. 42 CFR §414.210- General Payment Rules
7. CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.C
8. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- LCD L33318, Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 10/16/2017
9. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC- Local Coverage Article A52465 Knee Orthoses, Effective Date 10/01/2015; Revision Effective Date 01/01/201
10. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 08/28/2018

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.

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

Contact us for more information!