CMS has approved two new topics for the DMEPOS RAC, Performant, to begin reviewing, effective March 1, 2020.
Hospital Beds: Medical Necessity and Documentation Requirements
Description: Hospital Beds must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined in Local Coverage Determination for Hospital Beds. Medical documentation will be reviewed to determine that services were reasonable and necessary.
Review Type: Complex
Affected Codes: E0250, E0260
Dates of Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020.
Description: Hospital Beds must meet basic coverage criteria whether at initial rental or at any point during a rental period, as outlined in Local Coverage Determination for Hospital Beds. Medical documentation will be reviewed to determine that services were reasonable and necessary.
Manual Wheelchairs: Medical Necessity and Documentation Requirements
Description: This review will determine if the Manual Wheelchairs are reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied
Review Type: Complex
Affected Codes: K0001, K0003
Dates of Service: Claims having a “claim paid date” that is more than 3 years prior to the ADR date will be excluded. Claims with dates of service on or after January 1, 2020 will be excluded.
Description: This review will determine if the Manual Wheelchairs are reasonable and necessary for the patient’s condition based on the documentation in the medical record. Claims that do not meet the indications of coverage and/or medical necessity will be denied.
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!