CMS has posted the list of review topics that have been proposed, but not yet approved, for RACs to review for November. These topics are listed, on a monthly basis, on the CMS RAC Provider Resources page. For the month of November there are two topics proposed for RAC review affecting DMEPOS suppliers, listed below.
Surgical Dressings: Medical Necessity and Documentation Requirements
Description: This review will determine if the Surgical Dressing is 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 review
Affected code(s): A6021, A6197, A6210, A6211, A6212
Applicable policy references:
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(a)- Payment for Durable Medical Equipment, (1)(E)(i)(ii)- Clinical Conditions for Coverage; (4)- Payment for Certain Customized Items; (7)(C)(i),(ii) and (iii)- Payment for Other Items of Durable Medical Equipment
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(i) - Payment for Surgical Dressings
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(5)- Medical and Other Health Services, Surgical Dressings
- 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
- 42 CFR §405.986- Good Cause for Reopening
- 42 CFR §410.36- Medical Supplies, Appliances, and Devices
- 42 CFR §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
- Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
- Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26- Supplier Proof of Delivery Documentation Requirements
- Medicare Program Integrity Manual, Chapter 5- Items and Services Having Special DME Review Considerations, §5.2.1- Physician Orders, §5.2.3- Detailed Written Orders, §5.2.4- Written Orders Prior to Delivery, §5.2.5- Face to Face Encounter Requirements, §5.2.6- Date and Timing Requirements, §5.2.7- Requirement of New Order, §5.2.8- Refills of DMEPOS Items Supplied on a Recurring Basis, §5.7- Documentation in the Patient’s Medical Record, §5.8- Supplier Documentation, and §5.9- Evidence of Medical Necessity
- Medicare Benefit Policy Manual, Chapter 15- Covered Medical and other Health Services, §100- Surgical Dressings, Splints, Casts, and Other Devices Used for Reductions of Fractures and Dislocations
- Medicare Claims Processing Manual, Chapter 7- - SNF Part B Billing (Including Inpatient Part B and Outpatient Fee Schedule), §60- Billing for Durable Medical Equipment (DME), Orthotic/Prosthetic Devices, and Supplies (including Surgical Dressings)
- CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33831: Surgical Dressings, Effective 10/01/2015; Revised 7/24/2017
- CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A54563: Surgical Dressings, Effective 10/01/2015; Revised 7/24/2017
- 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 01/01/2019
Cervical Orthoses within the Reasonable Useful Lifetime
Description: Claims for cervical orthoses with dates of service within the period of reasonable useful lifetime (RUL), i.e., five years, of a previously paid same cervical orthoses for the same beneficiary, will be denied as the reasonable useful lifetime (RUL) requirement has not been met.
Review type: Automated review
Affected code(s): L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0700, L0710, L0810, L0820, L0830, L1000, L1001, L1005, L1200, L1300, L1310, L1499
Applicable policy references:
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A) - Exclusions from Coverage and Medicare as a Secondary Payer
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e) - Payment of Benefits
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 - Special Payment Rules
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(j) - Requirements for Suppliers of Medical Equipment and Supplies
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1842(p)(4)- Provisions Relating to the Administration of Part B
- Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s) - Medical and Other Health Services Definitions
- 42 Code of Federal Regulations §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
- 42 Code of Federal Regulations §405.986- Good Cause for Reopening
- 42 Code of Federal Regulations §414.210- General Payment Rules
- 42 Code of Federal Regulations §424.57- Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges
- 42 Code of Federal Regulations §424.57(c)- Application Certification Standards
- Medicare Benefit Policy Manual, Chapter 15- Covered Medical and Other Health Services, §110- Durable Medical Equipment- General, §110.2.C- Repairs, Maintenance, Replacement, and Delivery
- Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §3.2.3.8- No Response or Insufficient Response to Additional Documentation Requests
- Medicare Program Integrity Manual, Chapter 4- Program Integrity, §4.26 Supplier Proof of Delivery Documentation Requirements
- Medicare Program Integrity Manual, Chapter 5, Section 5.2 - Rules Concerning Orders, Physician Orders
- Medicare Program Integrity Manual, Chapter 5, Section 5.2.7 - Requirements of New Orders
- Medicare Program Integrity Manual, Chapter 5, Section 5.2.8 - Refills of DMEPOS Items Provided on a Recurring Basis
- Medicare Program Integrity Manual, Chapter 5, Section 5.7- Documentation in the Patient’s Medical Record
- Medicare Program Integrity Manual, Chapter 5, Section 5.8- Supplier Documentation
- Medicare Program Integrity Manual, Chapter 5, Section 5.9- Evidence of Medical Necessity
- CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A55426: Standard Documentation Requirements for All Claims Submitted to DME MACs, Effective 01/01/2017, Revised 01/01/2019
Approved issues can be found on Performant Recovery’s website, here.
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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.
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