A Guide to Getting O&P Repairs and Replacement Coverage, Part I

O&P practices provide thousands of dollars in uncompensated repairs each year because of insufficient chart documentation to allow coverage. This article series will provide a summary of documentation requirements for repairs and replacement, proper coding for repairs and replacement, and sources of guidance that dictate the requirements The table of contents provides a guide to the three parts of the series to help enable you to navigate to the information you are searching for. Table of Contents Part I: General Document Guidance History of the Device Clinician Evaluation Documentation Assessment of Needs When Is a New Physician Order Required? Documentation for Continued Medical Need (Policy Article A55426) Part II: Definitions of Coverage Criteria What Is a Repair and When Is It Covered? What Is a Replacement and When Is It Covered? Summary of Medical Documentation Required for Coverage of Repair/Replacement Part III: Repairs and Replacement Coding Coding and Documenting Labor Involved to Perform Repairs How to Code for Replacement Parts Replacement Documentation Required for Prosthetic Replacement Documentation Required for Orthotic Replacement Pricing/Billing and Reimbursement Issues Modifiers Allowable Amounts Not Otherwise Specified Codes Payment Methodologies for Minor Parts/NOS Codes Medicare Medicare Gap Filling Explained Co mmercial Insurers Regulatory Mandates Conclusion Part I of the series covers general documentation requirements. History of the Device The multiplicity of sources of guidance and the specificity of their scope can be confusing and seemingly contradictory. We begin with the applicable general documentation requirements described in Policy Article A55426 and offer suggestions as to best practices for O&P. There are numerous Centers for Medicare & Medicaid (CMS) manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met for payment to be justified. In the event of a claim review, a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) supplier must provide sufficient information to demonstrate that the applicable criteria have been met to justify payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file a standard written order (SWO), a certificate of medical necessity (CMN) if applicable, information from the treating practitioner concerning the patient’s diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain Durable Medical Equipment Medicare Administrative Contractors (DME MAC) policies. The supplier should also obtain as much documentation from the patient’s medical record to assure that coverage criteria for an item have been met. It is likely you will need to submit your documentation for payer review before being reimbursed for repairs or replacements. To easily accommodate these documentation requests, it is useful to restate in the repair note the following key pieces of information regarding the device you are assessing: Device type and side Initial delivery date of service Name of the provider who supplied the original device Whether the device was initially covered by insurance and which plan (If a device was not covered initially, its repairs will also not be covered.) Whether the device is still under warranty Whether there was any similar device provided on a later date of service for the same limb, which superseded this device as the primary covered device (This also could result in noncoverage of repairs.) Whether the patient is in a hospital or Medicare Part A stay (In this situation, the facility becomes the payer unless the two-day rule will apply.) Clinician Evaluation Documentation Next, the clinician must evaluate the patient’s current needs and the status of the device and record the following: The issue with the device The cause of the issue The impact on the patient If the original device still meets the patient’s needs Whether the device can be restored to optimal function to meet the patient’s needs Assessment of Needs In the clinician assessment of what will be required to restore the device to optimal function, it is important to distinguish what needs to be repaired from what needs to be replaced. It is critical to separate these activities and to correctly use the terminology regarding whether the correction is: a repair (labor portion or the clinician/technician time to restore the device); a repair that will require the replacement of parts of a component (without established Healthcare Common Procedure Coding System (HCPCS)); or a replacement of a major component (with established HCPCS). Explain what needs to be done to return the device to optimal function Document the actual labor time involved with the repair, detailing exactly what covered activity was performed and how long it took. (See Part II, “Definitions of Coverage Criteria,” about what is covered as labor.) Document the minor parts without HCPCS codes that are replaced as part of the repair. Some payers will require an invoice to determine the reimbursement for purchased parts, so be sure there is a mechanism in the documentation to link the part to a parts order or purchase order that can be provided with an invoice for the part. Document the replacement of any major component (a part with a HCPCS code) that will be necessary and whether the cost of repair to the device is less than 60 percent of the cost of a new device. Code the service appropriately, considering the original prescription, codes that describe what needs to be provided, and the payer’s claims processing procedures (individual payer’s claims processing treatment of the minor parts codes, L-7510 and L-4210, when predetermined allowables are established may preclude use of these codes when billing that payer). When Is a New Physician Order Required? Review the original SWO to determine if a new CMN and/or treating practitioner’s order is needed for repairs. If you have documentation of continued medical need, a new SWO/CMN is not required for a repair. If you do not have an SWO with the length of need specified that includes the time period within which you are performing the repair, or if you were not the original provider and do not have the original SWO, you will need to obtain a new SWO or other physician documentation to satisfy the requirement of continued medical need. The Claims Processing Manual , Chapter 20, Section 50 states: “Replacement of equipment which the beneficiary owns or is purchasing or is a capped rental item is covered in cases of loss, or irreparable damage or wear, and when required because of a change in the patient’s condition subject to the following provisions: Expenses for replacement required because of loss or irreparable damage may be reimbursed without a physician’s order when, in the DME MAC’s judgment, the equipment as originally ordered, considering the age of the order, still fills the patient’s medical needs.” However, claims involving replacement equipment necessitated because of wear or a change in the patient’s condition must be supported by a current physician’s order. (For more detail about payment for equipment replaced under a warranty, see the Medicare Benefit Policy Manual, Chapter 16, Section 40.4. ) DME MACs investigate and deny cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment as discussed in the Benefit Policy Manual , Chapter 15 , where it is determined that it is unreasonable to make program payment under the circumstances. They refer such cases to the program integrity specialist in the Medicare Regional Office ( Claims Processing Manual , Chapter 20, Section 50).” Documentation for Continued Medical Need (Policy Article A55426) For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from that time frame. Entries in the beneficiary’s medical record must have been created prior to, or at the time of, the initial date of service (DOS) to establish whether the initial reimbursement was justified based upon the applicable coverage policy. For ongoing supplies and rented DME items, in addition to the information described above justifying the initial provision of the item(s) and/or supplies, there must be information in the beneficiary’s medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Any of the following may serve as documentation justifying continued medical need: A recent order/prescription by the treating practitioner for refills A recent change in an order/prescription A properly completed CMN or DME information form (DIF) with an appropriate length of need specified Timely documentation in the beneficiary’s medical record showing usage of the item Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy. For some items, the initial justification for medical need establishes that the condition necessitating the item is permanent. As a result, once the benefit category is met (or continues to be met), ongoing documentation of medical need is not required. Be sure your SWOs contain appropriately completed information for expected length of need. Refer to the Local Coverage Determination (LCD)-related policy articles for clarification regarding exceptions to ongoing justification for continued medical need. Susi Ebersbach, MT (ASCP), MBA, provides independent consulting and has over twenty years of experience in O&P reimbursement topics, working with both providers and manufacturers. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.

A Guide to Getting O&P Repairs and Replacement Coverage, Part I

General Document Guidance

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A Guide to Getting O&P Repairs and Replacement Coverage, Part I

General Document Guidance

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