Questions to Noridian/CEDI

Questions to Noridian/CEDI

Fall 2013

CEDI

Leader: Michele Hessler

Assistant: LeeAnn Ruber

EC Liaison: Sheila Roberson

66. How firm is the implementation date of ICD-10 looking? Rock solid! Any chance the deadline or dual use period will be extended? Do not think so, no. We are concerned about the readiness of many of the states.

The CEDI front end, including our edits, will be ready to process claims with ICD-10 codes with the current October 2014 implementation date. Any extensions or dual use periods will be decided and communicated by CMS. If and when we have any information to share from CMS for ICD-10, we’ll send this out via our listserv and the MACs will provide through their communication channels.

67. How is CEDI Medicare reverification coming?

CEDIs 2013 Trading Partner recertification is 41.72% complete as of 9/24/13. We are sending emails directly to the Trading Partners who still need to complete the Recertification Form. We’ll provide an updated percentage at the meeting.

No follow-up.

EDUCATION

Leader: Carolyn Koster

Assistant: Cindy Coy

EC Liaison: Mary Stoner

68. Providers are receiving complaints from beneficiaries that Competitive Bid, contract providers are refusing to service them.

a. Are contract suppliers « required » to service Medicare beneficairies ?

Contracted suppliers must accept beneficiaries who meet coverage criteria up to that supplier’s financial capabilities.

b. What is the beneficiary’s recourse when they are refused service by the contract suppliers?

Beneficiaries should call 1-800-Medicare.

69. It was mentioned during a recent Noridian Face to Face, San Diego, workshop that: If the POD is missing any information, e.g. pt did not date the POD, POD was missing the relationship of the person who signed for beneficiary etc., that the patient must get “re-qualified”.

a. Is this correct ? If so…Please clarify what is required to « re-qualify » the beneficiary?

If proof of delivery (POD) documents are not valid, upon review the claim will be denied. A supplier may choose to re-deliver new/like-new equipment if the original delivery is not valid. This will change the date of service (DOS) on the original delivery and future anniversary dates on rentals.

If a claim is denied because coverage criteria are not met, the supplier may choose to re-qualify a beneficiary. If a supplier re-qualifies a beneficiary all new documentation is required including proof of delivery of new/like-new equipment.

b. Can the beneficiary validate the delivery information? If so…Would they do so by signing and dating a newly created POD, acknowledging receipt of services?

Proof of delivery is created at the time the item is either directly delivered or shipped. If this question is asking if the beneficiary can attest to receiving the equipment after the fact to serve as proof of delivery the answer is “no”.

70. When changes are made to the supplier manual, what is the process for notifying suppliers?

Updates to the Noridian Supplier Manual are made as published changes or articles are announced through the Noridian email listserv. The date last update is indicated at the bottom of each chapter:

All previous versions going back to May of 2009 are available at the top of the supplier manual in PDF format:

A summary of updates are tracked at the bottom of the supplier manual:

71. December 2011 version of the Supplier Manual, Chapter 3, Detailed Written Orders states: Detailed written orders are required for all DMEPOS. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document. (Reference: CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3)

The elements required on all written orders include the following:

• Beneficiary name; and

• Detailed description of item (either a narrative description or a brand name/model number); and

• All options and accessories that will be billed separately or which require an upgraded code; and

• Signature of the treating physician and the date the order is signed; and

• Initial date of need or start date.

However, the June 2012, Supplier Manual, Chapter 3 versions through current all state:

A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and the start date, if start date is different from the date of the order

• Detailed description of the item(s) (see below for specific requirements for selected items)

• Physician signature and signature date

There is a notable difference with regards to the « date of the order ». Previously as shown in the Dec 2011 example it stated « initial date of need OR state date » the later versions all say « Date of the order AND the start date, if state date is different from the date of the order »

The PIM 5.2.3 merely states that « All orders must clearly specify the start date of the order ».

a. With no known changes to the PIM 5.2.3 since 03/01/2008, why would the documentation of the start date of the order be so drastically changed?

In June 2012 the supplier manual was updated to reflect the Standard Documentation Article published February 23, 2012. The four DME MAC Jurisdiction Medical Directors authored that article. This same language is being included in the Documentation section of all LCDs as they are updated. The change to the supplier manual was for consistency with that published article and other DME MACs.

b. When would the supplier community have been made aware that the dispensing orders would now need both the date of the order AND the start date ?

This has always been the case for the (relatively rare) situation where the start date was to follow the date of the order. The Standard Documentation Article was published as a clarification on February 23, 2012. Suppliers only need a start date if it’s different from the date of the order.

Changes such as these, and the lack of education provided regarding these changes, is causing providers problems when claims are audited. Most suppliers want to always be in compliance, but that is next to impossible when we are dealing with a moving target and a lack of communication that it has or is being moved !!

This was a clarification, not a new requirement, and was added to the Noridian Supplier Manual four months after notification was disseminated through the Noridian email listserv. Noridian education consistently announces and encourages suppliers to sign up for and read email notification during all educational events. In addition, this language has been included in all educational material since the publication date in February 2012.

Update from the meeting: Lelia Wilkerson asked Noridian to further explain.

Dr. Whitten further explained that this should only come into play when the physician specifically intends to have the order started on a specific date, rather than at the time the order is written. An example would be the physician orders a wheelchair today but asks that it not be provided until two weeks later. In that case two dates would have to be on the order. I specifically asked about an order that we receive via fax and the patient does not come in to the office until 1 or 2 days later and they said that was not what this was addressing. Their example was enteral that the provider wanted to start 7 days after the order date so they complete the supply they have before starting the new order.

72. We received a denial on a prepayment audit for urological supplies, that were provided in the supplier store front, referencing that we did not have “proof of exhaustion”. However, per the supplier manual, this information is only required if delivered or mailed or shipped to the beneficiary and does not apply for walk in patients. In this instance, the beneficiary picked up the supplies in person yet we were told when calling on the denial, that the Proof of Delivery POD shows as a “Delivery Ticket”. ALL of our PODs are labeled as such regardless of whether the item is shipped, picked up in the store front or delivered to the patient’s home. In June, Noridian published that a “delivery slip” is required but the folks who are processing the PPRs are denying when the POD is referenced as a “delivery ticket” when proof of exhaustion is not indicated.

a. How are providers expected to reference that a delivery was made in the store front in order to avoid an unwarranted denial and lengthy appeal/reconsideration process?

Noridian would need examples of unwarranted denials. The POD documents must indicate the delivery address, in these cases the retail store address. Recommend adding the supplier store front name when documenting the delivery address or ensuring that the POD indicates that item(s) were picked up at store front. Noridian will also accept an itemized sales receipt when items are picked up at a retail store.

b. Feeling this might be the result of misunderstanding or communication barrier, would Noridian consider providing additional education to the reviewer’s that what a provider names their « Delivery Tickets, Work Orders, Transaction Ticket, etc are all one in the same…that does not dictate how the beneficiary received their service ?
Review nurses and other review staff see many different formats for POD documents and itemized sales receipts. What is submitted for review must be clear and itemized so it is easily recognized to the reviewer that the item was picked up at a retail store. Noridian review staff are continuously educated and have breakout meetings regarding documentation concerns.

73. We received a denial on a prepayment audit for urological supplies that were provided in the branch referencing that we did not have “proof of exhaustion”. However, per the supplier manual, this information is only required if delivered or mailed or shipped to the beneficiary and does not apply for walk in patients. In this instance, the beneficiary picked up the supplies in person yet we were told when calling on the denial, that the Proof of Delivery POD shows as a “Delivery Ticket”. ALL of our PODs are labeled as such regardless of whether the item is shipped, picked up in the branch or delivered to the patient’s home. In June, Noridian published that a “delivery slip” is required but the folks who are processing the PPRs are denying when the POD is referenced as a “delivery ticket” when proof of exhaustion is not referenced. How are providers expected to reference that a delivery was made in the branch in order to avoid an unwarranted denial and lengthy appeal/reconsideration process?

Same as 72

74. Noridian has published audit results which often tend to include a certain percentage of “no response” in the mix. Last fall it was mentioned that Noridian would report no response providers to the NSC. Has that been implemented and if not, what does Noridian do with the providers who do not respond to audit requests?
Suppliers who routinely do not respond to documentation requests or other identified concerns may be reported to Benefit Integrity and/or the NSC. This is a requirement of the Program Integrity Manual, publication 100-8 Chapter 4.

a. To add to the question above, several providers have indicated that they have submitted a timely response on all audits received and have confirmation to prove submission. However, when looking at the results of the recent probe, there were several “No Response” items included in the mix causing the denial percentages to be overstated for this reason. When reporting denial statistics to providers, can Noridian provide us with the specific claim details and allow an opportunity to challenge the findings?

The denial statistics are updated to account for all documentation that is received within the time frame for MR review. We will consider your suggestion for including more information on the published review results.

75. Must a DME supplier obtain a revised Rx if, for instance, a doctor initially specifies a particular brand (e.g., “Coloplast catheters,”) and the patient later wants a different brand?
Yes. Any change in an order requires a revised detailed written order.

76. The new Face-to-Face Requirement that went into effect on 07/01/13, per the MLN MM8304 Revised (page 3) states the DWO needs to contain the elements of:

· The Beneficiary’s Name

· The item of DME ordered

· The prescribing practitioner’s National Provider Identifier (NPI)

· The signature of the ordering practitioner and

· The Date of Order

Problem 1: Again…it simply states the “Date of Order….not the Date of order AND start date of the order if different then the date of order.

MM8304 states “at a minimum” those are the requirement. Suppliers must continue to follow the standard documentation requirements as well.

Problem 2: The physician’s NPI is not shown as needed on a DWO in the Supplier Manual.
The supplier manual will be updated however notification has been disseminated. For items addressed in MM8304 the NPI is required.

Problem 3: The MLN does not indicate that the physician’s signature date is required.

MM8304 states “must follow the guidance in the CMS “Program Integrity Manual,” Chapter 5, Section 5.2.3”, which states the treating physician must “personally sign and date” .

Problem 4: The MLN does not state that it needs the physician’s name.

Same response as problem 3 above.

Problem 5: The MLN does not indicate that the item ordered needs a detailed description.