Archive for the ‘Important Industry Information’ Category

Medicare DMEPOS Supplier Standards

Tuesday, February 17th, 2015

Note: This is an abbreviated version of the supplier standards every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges.These standards, in their entirety, are listed in 42 C.F.R. 424.57(c).

  1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.
  2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days.
  3. A supplier must have an authorized individual (whose signature is binding) sign the enrollment application for billing privileges.
  4. A supplier must fill orders from its own inventory, or contract with other companies for the purchase of items necessary to fill orders.  A supplier may not contract with any entity that is currently excluded from the Medicare program, any State’ health care programs, or any other Federal procurement or non-procurement programs.
  5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
  6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
  7. A supplier must maintain a physical facility on an appropriate site and must maintain a visible sign with posted hours of operation. The location must be accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
  8. A supplier must permit CMS or its agents, to conduct on-site inspections to ascertain the supplier’s compliance with these standards.
  9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance.The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited.
  10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business, and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.
  11. A supplier is prohibited from direct solicitation to Medicare beneficiaries. For complete details on this prohibition see 42 CFR § 424.57 (c) (11).
  12. A supplier is responsible for delivery of and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery and beneficiary instruction.
  13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
  14. A supplier must maintain and replace at no charge or repair cost either directly, or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.
  15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
  16. A supplier must disclose these standards to each beneficiary it supplies a Medicare-covered item.
  17. A supplier must disclose any person having ownership, financial, or control interest in the supplier.
  18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
  19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
  20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
  21. A supplier must agree to furnish CMS any information required by the Medicare statute and regulations.
  22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive’ and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment for those specific products and services (except for certain exempt pharmaceuticals).
  23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
  24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
  25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
  26. A supplier must meet the surety bond requirements specified in 42 CFR § 424.57 (d).
  27. A supplier must obtain oxygen from a state-licensed oxygen supplier.
  28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f).
  29. A supplier is prohibited from sharing a practice location with other Medicare providers and suppliers.
  30. A supplier must remain open to the public for a minimum of 30 hours per week except physicians (as defined in section 1848(j) (3) of the Act) or physical and occupational therapists or a DMEPOS supplier working with custom made orthotics and prosthetics.

DMEPOS suppliers have the option to disclose the following statement to satisfy the requirement outlined in Supplier Standard 16 in lieu of providing a copy of the standards to the Beneficiary.

The products and/or services provided to you by ( supplier legal business name or DBA) are subject to the supplier standards contained in the Federal regulations shown at 42 Code of Federal Regulations Section 424.57(c). These standards concern business professional and operational matters (e.g. honoring warranties and hours of operation). The full text of these standards can be obtained at ecfr.gpoaccess.gov. Upon request we will furnish you a written copy of the standards.

What Does Medicare Cover in Wound Supplies?

Thursday, June 12th, 2014

wound_careMedicare is offered in a variety of forms, so it is important to find the right coverage for yourself, your financial situation and your condition. If you are looking into wound care options, here are a few details to consider:

Dressings

Medicare win cover all surgical dressings that are deemed medically necessary for your treatment. You will only be responsible for the co-payment amount for these dressings (each of which is set for the type of dressing). Dressings are covered under Medicare Part B, and so the standard deductible applies.

Home Care

Medicare Part A can cover the costs for at-home-care that is deemed medically necessary. This can include, but is not limited to: changing and applying sterile dressings to a surgical wound site, the cleaning or washing of the wound site and/or the administering of certain medicines.

Follow-Up Care

Interestingly, Medicare requires that clinicians provide documentation of the presence of a wound to continue treatment and coverage. Medicare does not want to pay for services that are not being used, so it requires evidence that demonstrates a condition. Paperwork that has been completed or at least signed by your clinician that may be required for your wound includes:

  • Evidence of the wound
  • Wound size
  • Wound extent
  • Drainage needs

Overall Costs

If you qualify for coverage, Medicare will cover 80 percent of the approved amount of your costs. W.L. SCHNEIDER ASSOCIATES will bill & collect the remaining 20% for the cost of these supplies. However, all costs that are submitted must be deemed medically necessary to receive this cost breakdown. Costs for other conditions that are submitted, such as additional unrelated ulcer wounds or the like, must be documented by your clinician.

If you are covered under a plan other than Original Medicare, such as a MediGap or Medicare Advantage Plan, get in touch with your plan provider to discuss chronic wound coverage, as the rates may be different.

Things to Consider

Before choosing your clinician, be sure that they accept Medicare. If they are not enrolled, Medicare will not pay the claim. As with most services, you must pay your annual deductible for services and supplies to be delivered; so these costs should be factored into your decision as to what type and level of care is best for you.

Medicare Coverage of Catheters

Thursday, June 12th, 2014

urological1Intermittent catheterization (IC) is a covered benefit of Medicare and most private insurance plans.  A doctor’s order or prescription is required and should reflect the actual number of times an individual catheterizes per day.  The prescription must be individualized for each patient.

In 2008, the Centers for Medicare and Medicaid Services opened its coverage policy for up to 200 single-use, disposable catheters per month.  Now any Medicare beneficiary who meets the basic coverage criteria of permanent urinary incontinence or urinary retention can receive one (1) sterile urological catheter and one (1) packet of lubricant for each episode of covered catheterization.

Always keep in mind that regular visits to your healthcare provider are required to maintain the integrity and usefulness of the catheter regimen.

Catherization Information for Men

Wednesday, June 11th, 2014

HOW DO I CATHETERIZE MYSELF ?

  • Try to urinate before you catheterize yourself.
  • Gather all the items you will need and ask your caregiver where to get the supplies to catheterize yourself.
    • A clean catheter
    • Water-based lubricating jelly
    • Container to collect urine
    • A Bowl of warm water, soap, washcloth, and hand towel
    • Waterproof pad or bath towel
  • Wash your hands with warm water and soap.
  • Get into position for inserting your catheter. Lie or sit down with your knees bent. Put a towel or waterproof pad under your penis. You may also stand in front of the toilet. Make sure the other end of the catheter is pointed into a container or down toward the toilet.
  • Clean yourself. Wash your penis with soap, warm water and a washcloth. If you are not circumcised, pull back the foreskin. Wash the head and the urinary meatus (the opening where urine comes out). Rinse and dry your penis. Put the container close to you to collect the urine.
  • Put water-based lubricating jelly on the first 7 to 10 inches of the catheter. This will help decrease discomfort during the procedure.
  • Insert the catheter:
    • With one hand, hold your penis straight out from your body. With your other hand, slowly put the catheter into the urinary meatus.
    • Gently push the catheter about 7 to 10 inches into your penis until urine begins to come out. Once urine starts to flow, push the catheter up 1 inch more and hold it in place until the urine stops
  • Remove the catheter when you are finished. When urine no longer comes out of the catheter, pinch it closed with the hand that was holding your penis. Gently and slowly pull the catheter out. Keep the end of the catheter up to prevent dribbling of urine. If you are not circumcised, pull the foreskin down over the head of the penis.
  • Clean the catheter: If your catheter is reusable, follow your caregiver’s instructions to clean it. If your catheter is a single-use catheter, throw it away.

 

WHEN SHOULD I CATHETERIZE MYSELF ?

Catheterize yourself at least 4 times each day and at bedtime.

How can I help prevent an infection? 

  • Wash your hands. Always wash your hands with soap and water before you catheterize yourself.
  • Clean and dry reusable catheters. Clean all reusable catheters with soap and warm water after every use. Sterilize all reusable catheters in a pan of boiling water for 20 minutes. Set the catheters on a clean paper towel to dry.
  • Store catheters correctly. Store dry catheters in a clean plastic bag. Throw away torn, hardened or cracked catheters.
  • Wear cotton boxers or underwear. These allow air-flow and keep your genital area dry.
  • Drink plenty of liquids. Ask your caregiver how much liquid to drink each day and which liquids are best for you. This helps to keep you from getting a urinary infection.

WHAT CATHETER PROBLEMS COULD I HAVE ?

  • No urine comes out of the catheter. Gently rotate the catheter in case it’s blocked. Try gently pushing the catheter a little further up into the penis or pulling it back. Check also that the catheter opening is not blocked by lubricant or mucus.
  • Urine leakage between catheterizations. You may have some urine leakage if you have been drinking more liquids than usual, especially those containing caffeine or alcohol. It could also mean that you have a bladder infection. If you are having a problem with urine leakage, try catheterizing yourself more often. If you think you have an infection, contact your caregiver.
  • Difficulty inserting or removing the catheter. If you have pain or discomfort when you insert your catheter, use more lubricant. It is common to meet some resistance when you are pushing the catheter past your prostate. The prostate is the gland that makes semen. Take a deep breath and try to relax before you push the catheter in further. Breathe in, then continue pushing the catheter in as you slowly let your breath out.
  • Blood on the catheter or in your urine. This may happen if your meatus or urethra is too dry. Try using more lubricating jelly to prevent irritating your meatus and urethra. Make sure you drink enough liquids. Blood in the urine could also mean you have an infection.

WHEN SHOULD I CONTACT MY CAREGIVER ?

  • Contact your caregiver if:
    • You have a fever.
    • Your urine is thick, cloudy or has mucus in it.
    • You have red specks in your urine or your urine looks pink or red.
    • Your urine has a strong smell.
    • You have pain or burning in your urethra, bladder or abdomen.
    • It’s , too painful, difficult or uncomfortable to insert your catheter far enough to start your urine flow.
    • You have questions or concerns about your condition or care.

HIPAA POLICY

Tuesday, June 10th, 2014

(HIPPA:  Computer Systems & Equipment)

  1. W. L. SCHNEIDER ASSOCIATES is committed to protecting staff and clients from illegal or damaging actions by individuals, the improper release of patient heath information and other confidential or proprietary information.
  2. The purpose of this policy is to outline the acceptable use of computer equipment by W. L. SCHNEIDER ASSOCIATES employees with regards to patient health information.  Inappropriate use exposes W. L. SCHNEIDER ASSOCIATES to risks, compromise of network systems and services and breach of patient confidentiality and other legal claims.
  3. This policy applies to employees, volunteers, contractors, consultants, temporary employees, students and others authorized by W. L. SCHNEIDER ASSOCIATES that have access to computer equipment and other equipment which stores patient data, including all personnel affiliated with third parties. This policy applies to all equipment owned or leased by W. L. SCHNEIDER ASSOCIATES.
  4. Confidential information shall be protected at all times regardless of the medium by which it is stored. Examples of confidential information include, but are not limited to: individually identifiable health information concerning patients, patient lists and reports, research data, billing information and patient treatment information.  Employees should take all necessary steps to prevent unauthorized access to this information.

Notice to Clients of Privacy Practices

This notice describes how medical information about you may be used and distributed.  W. L. SCHNEIDER ASSOCIATES is required by law to protect the privacy of a patient’s health information.

The general consent for release of medical records a patient signs authorizes W. L. SCHNEIDER ASSOCIATES to disclose the information in their medical record for treatment, payment and other health care operations.  For the purpose of providing, coordinating or managing a patient’s order, their information may be shared with employees and contractors of this provider.  For the purpose of arranging payment for the patient’s supplies, their information may be shared with their insurer or other third party payors who are responsible for paying all or part of the cost of their care.  For the purpose of providing services, W. L. SCHNEIDER ASSOCIATES may use and disclose information that is necessary for business operations (e.g. – internal quality assessment, contacting other health care providers about treatment or claim payment).

W. L. SCHNEIDER ASSOCIATES may send information about a patient to remind them by telephone, letter, e-mail or postcard of information regarding their order.

W. L. SCHNEIDER ASSOCIATES is required by law to maintain the privacy of a patient’s health information.  If a patient believes their privacy rights have been violated they may contact the Secretary of the U. S. Department of Health and Human Services.

Negative Pressure Wound Therapy (NPWT) and Medicare Coverage

Sunday, June 1st, 2014

Negative Pressure Wound TherapyA negative pressure wound therapy (NPWT) pump is a portable or stationary device used for the treatment of ulcers or wounds that have not responded to traditional wound treatment methods.

Utilization of the pump has increased dramatically in recent years.

Medicare covers the pumps under PART B as durable medical equipment (DME) and can be billed on a monthly basis for up to four (4) months or longer if a physician requests an extension.

Medicare also covers specialized dressing sets and drainage canisters.

W. L. SCHNEIDER ASSOCIATES will work with your physician on planning an appropriate course of therapy.

W. L. SCHNEIDER ASSOCIATES will also deliver and set-up the pump, conduct training on how to properly use the pump and follow-up as part of their excellent Customer Service Program.

Last, but certainly not least, W. L. SCHNEIDER ASSOCIATES bills Medicare directly; thus creating a worry-free, hassle-free one-stop-shopping environment.

For more information on this state-of-the-art program that can greatly benefit you, please contact:  Joe Sullivan at 215-624-7201…or…by e-mail at:  jsullivan@wlschneider.com

Prospective Billing for Parenteral and Enteral Nutrition

Thursday, December 1st, 2011

The following article has been reposted from NHIC, Corp.

This article serves as clarification for the proper billing of Enteral and Parenteral Nutrition claims prospectively to ensure proper claim payments. Per Change Request 7452:

“For DMEPOS items and supplies that are provided on a recurring basis, billing must be based on prospective, not retrospective use. The following scenarios are illustrative of this concept:

Scenario 1: The treating physician writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order, delivers 100 units and bills the claim with a date of service as the date of delivery indicating 100 units. This is an example of prospective billing and is acceptable.

Scenario 2: The treating physician writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order and delivers 100 units. A claim is not billed. At the end of the month, the supplier determines that the beneficiary used 90 units for the month and delivers 90 units to replace the nutrient used. A claim is then submitted with a date of service as the date of delivery indicating 90 units of enteral nutrition. This is an example of retrospective billing and is not acceptable.”

The following instructions apply to enteral and parenteral nutrition claims:

No more than one month’s supply of parenteral/enteral nutrients (PEN), equipment, or supplies may be dispensed at one time. Therefore, the maximum supply that can be billed at one time is a 31-day supply.

Suppliers must not automatically dispense a quantity of items on a predetermined regular basis, even if the beneficiary has “authorized” this in advance. It is the supplier’s responsibility to assess how much nutrition and supplies the beneficiary is actually using by contacting the beneficiary or caregiver prior to dispensing the items. The supplier must determine the quantities that remain from the previous delivery and modify the quantity delivered or the delivery date accordingly. If the beneficiary has not used all of their previously delivered nutrients/supplies, the supplier should either delay delivery of the next shipment or should reduce the quantity delivered so that there is no more than one month’s supply on hand at any one time. This may occur in situations in which the beneficiary was admitted to the hospital, or in which the beneficiary did not receive their usual nutrient intake because of an acute illness, etc.

Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 14 days prior to the delivery/shipping date. For subsequent refill deliveries, the supplier should deliver the product no sooner than 10 days prior to the end of usage for the current product. The Medicare system will allow up to a 10-day overlap in dates of service for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply. Reminder: Claims should not be consistently 10 days earlier each month as this would allow for additional payments.

The supplier itself may deliver the parenteral/enteral nutrition and supplies directly to the beneficiary or the supplier may use a shipping service to ship the items. If the supplier delivers the items directly to the beneficiary, the “From” date of service on the claim will be the actual date the items were delivered. If the supplier ships the items to the beneficiary using a shipping service, the “From” date of service will be the date the items were shipped. To determine the “To” date of service, the supplier counts the number of days the nutrients are expected to last (example: supplier ships a 28-day supply) and adds that number of days to the “From” date on the claim. Span dates on the claim will not usually match the dates of expected use of the nutrients.

Example: Supplier used a shipping service

Month 1

• 08/04/2011: 28-day supply shipped

• 08/06/2011: Beneficiary receives supply of nutrients

• 08/07/2011: Beneficiary starts using nutrients

• 09/04/2011: Beneficiary finishes supply of nutrients in this shipment

• Dates of service on claim:

o From date = 08/04/2011 (date the nutrients were shipped)

o To date = 08/31/2011 (28 days after the from date since a 28-day supply was shipped)

Note: The span dates (“From” and “To” dates) are determined by the date the nutrients were shipped and the number of days for which the quantity shipped is expected to last. The span dates do not coincide with the dates the beneficiary actually used the nutrients.

Month 2

• 08/26/2011: Supplier calls beneficiary to determine beneficiary’s usage during the previous month and determines quantity of next shipment

• 08/30/2011: 28-day supply of nutrients shipped to beneficiary (expected dates of use 09/05/2011 – 10/02/2011)

• 09/02/2011: Beneficiary receives shipment

• 09/05/2011: Beneficiary begins using nutrients shipped

• 09/13/2011 – 09/20/2011: Beneficiary admitted to inpatient hospital stay

• 10/09/2011: Beneficiary exhausts supply

• Dates of service on claim:

o From date = 08/30/2011 (date the nutrients were shipped)

o To date = 09/26/2011 (28 days after the “From” date since a 28-day supply was shipped)

Note: The next month’s shipment should be delayed to account for the additional supplies on hand due to the inpatient hospital stay.

Shipping Supply Kits

Supply kits consist of multiple items which are sometimes shipped separately. As with nutrients, the span dates on the claim usually will not match the dates of expected use of the supplies.

Example: Supplier uses a shipping service

• 08/01/2011: 28-day supply of infusion pump bags and tubing shipped

• 08/08/2011: 28-day supply of irrigation syringes shipped

• 08/26/2011: 28-day supply of infusion pump bags and tubing shipped

Claim submission based upon above shipping example:

Month 1

• HCPCS = B4035

• Units of service = 28 UOS

• From date = 08/01/2011

• To date = 08/28/2011

Month 2

• HCPCS = B4035

• Units of service = 28 UOS

• From date = 08/26/2011

• To date = 09/23/2011

In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the “From” date on the claim.

If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the “From” date on the claim.

Please see the following Self-Service Tools that will assist in filing PEN claims:

• Supply Refill and Contact Calculator

• Enteral Nutrition Units of Service Calculator