Presentation - Freedom Innovations

2015 CMS Changes;
Written and Interpreted
PRESENTED BY:
Aaron Sorensen, MBA, CPO, LPO
O and P Billing Solutions, Inc.
2015 CMS
O 2014 brief review
O Code & definition changes in
2015
O Proof of Delivery/Delivery Ticket
O What is actually meant by the new
interpretation by CMS?
2015 Code Changes
O Every year is different with
O
O
O
O
code changes depending on
the message/direction the
medical directors and CMS
wants the
industry/reimbursements to
follow
i.e.: 24 new L-codes in 2014
vs 5 in 2015 (O and P)
63 existing L-codes with
descriptor modifications in
2014 vs 1 in 2015
3 discontinued in 2015 with
crosswalks to other codes
Are they trying to push more
items to different segment of
provider options?
O
Physician, PT, O and P
O Example – lets review 2014
changes in descriptors
2014 Code Changes Discussion
O 2015 still experiencing
important hangover
effect form 2014!
O Poor audit results from
these changes
O Region D –
experienced over 80%
denial rates for custom
fit and fabricated
orthoses
O L1960, L1970,
L0637, L4360,
L0631
O Lets review and discuss:
O 2014 – we saw new codes
with an emphasis on new
verbiage:
O …off-the-shelf ?!
O …prefabricated item that
has been trimmed, bent,
molded, assembled, or
otherwise customized to
fit a specific patient by an
individual with expertise
?!
2014 Code Changes Discussion
O 3 types of orthoses:
O Custom fabricated
O Prefabricated, Off-the-
shelf (OTS)
O Prefabricated,
customized to fit a
specific patient by an
individual with
expertise
O What happened to
verbiage
“…prefabricated, fitting
and adjustment”?
2014 Code Changes Discussion
O For a custom-fabricated
orthosis, there must be
documentation in the
supplier's records to support
the medical necessity of that
type device rather than a
prefabricated orthosis.
O LCDs describe the scenarios
that custom fabricated can be
dispensed BUT you can not go
by LCD only
O LCD uses verbiage “see
definitions in the related
Policy Article Coding
Guidelines”
***Custom fabricated orthoses,
must have detailed
documentation in the treating
physician’s records to support the
medical necessity of custom
fabricated rather than a
prefabricated orthosis.
O LCDs do not define or detail
custom fabricated
O
O
O
O
O
% assembled
% raw materials used
Fabricated over or to what:
mold/tracing/measurements?
Be careful as CMs likes to use
descriptors like….
O
Substantial and minimal for
modifications required
2014 Code Changes Discussion
O
Review - Custom fabricated:
O Items that are uniquely
made for an individual
beneficiary
O traditional casting
methodologies or using
CAD/CAM or similar
technology (not all-inclusive
O the item must be created
over an actual physical
model of the body part
O Requires the expertise of a
qualified practitioner to
custom-fabricate
O Assembly of
prefabricated
components does not
meet the definition of
custom fabricated
O CMS has issues with Kits
O Kits are (custom? Pre-fab?):
O components, materials
and parts that require
further assembly
O single source or may be
an assemblage of
separate components
from multiple sources
2014 Code Changes Discussion
O
Qualified Practitioners are:
O •Licensed physicians.
O •Licensed physical or
occupational therapists.
O •Licensed in orthotics or
prosthetics by the state in
which the item is delivered
O states that do not require
licensing of orthotics and
prosthetics must have
practitioners specifically
trained in O and P and
ABC/BOC or equivalent
2014 Code Changes Discussion
O Some individual codes still
describe the “detail” of
custom fabricated
i.e. spinal and inserts/shoes
L3020…MOLDED TO PATIENT
MODEL
O A5501 …MOLDED FROM
CAST(S) OF PATIENT’S FOOT
O L0480 …INCLUDES A
CARVED PLASTER OR CADCAM MODEL, CUSTOM
FABRICATED
O
O
O Why is this important?
O Audits and Appeals
2014 Code Changes Discussion
O Documentation
O Off-the shelf (thought
of as DME)
O No significant
changes or
modifications needed
O Out of the box and fit
O No “qualified”
provider required
2014 Code Changes Discussion
O Documentation
O prefabricated item
that has been
trimmed, bent,
molded, assembled,
or otherwise
customized to fit a
specific patient by an
individual with
expertise
O Why? 
O KEY***Has to have
medical necessity
emphasis:
O For proper function of
orthosis
O For reduction in
possibility of soft tissue
damage
O For added
control/protection
O For ……..
O Does the physician’s notes
support this required level
of fitting?
2015 Code Changes
O 2015 changes -
http://www.cgsmedicare.c
om/jc/pubs/news/2014/
1214/cope27960.html
O
O
O
O
Knee brace codes
K0901 - single upright…
K0902- double upright…
… thigh and calf, with adjustable
flexion and extension joint
(unicentric or polycentric), mediallateral and rotation control, with
or without varus/valgus
adjustment, prefabricated, offthe-shelf (Effective 10/1/2014)
O Upper orthotics
O L3981 fracture orthosis,
humeral, prefabricated,
includes shoulder cap
design, with or without
joints, forearm section, may
include soft interface,
straps, includes fitting and
adjustments
2015 Code Changes
O Prosthetics
O L6026 Transcarpal/metacarpal or partial
hand disarticulation prosthesis, external
power, self-suspended, inner socket with
removable forearm section, electrodes and
cables, two batteries, charger, myoelectric
control of terminal
O L7259 Electronic wrist rotator, any type
2015 Code Changes
O L6025 Transcarpal/metacarpal or partial hand
disarticulation prosthesis, external power, selfsuspended, inner socket with removable forearm
section, electrodes and cables, two batteries,
charger, myoelectric control of terminal device
O Cross walked to new code L6026
O L7260 Electronic wrist rotator, otto bock or equal
O Cross walked to new code L7259
O L7261 Electronic wrist rotator, any type
O Cross walked to new code L7259
2015 Code Changes
O L7367
O Old descriptor:
O Lithium ion battery,
replacement
O New descriptor
O Lithium ion battery,
rechargeable,
replacement
Delivery Ticket
O New delivery ticket interpretation February 12, 2015!
O Check your MAC interpretation
O
Region A:
O
//www.medicarenhic.com/dme/whatsnew.aspx
O
Region B:
O
//www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home
-lob/pages/policy-education/documentation
O
Region C:
O
//www.cgsmedicare.com/jc/pubs/news/2015/0215/cope28357.ht
ml
O
Region D:
O //www.noridianmedicare.com/dme/news/docs/2015/02_feb/proo
f_of_delivery_reminder.html
Delivery Ticket
O Region C
O “Recently during
claims review it was
noted that suppliers
have a
misunderstanding
about the purpose
of proof of delivery
(POD). “
O So for years,
Providers have a
misunderstanding!?
O Layer after layer of
audit and appeals,
years of Medicare
seminars….and WE
have a
misunderstanding!?
Delivery Ticket
O Region C continues:
O “In addition to
confirming receipt of
an item, POD also
serves other
functions in Medical
Review, specifically
the ability of
contractor's review
staff to determine
correct coding.”
O “Reviewers often see a
reiteration of the
HCPCS code narrative
on the POD form as the
detailed description of
the item, particularly
for orthotics and
prosthetics. This is NOT
adequate for POD
purposes.”
Delivery Ticket
O So if what was done for
years is no longer
acceptable, what is?
O “The preferred method
is:
O use of a brand name
and model number or
O brand name and serial
number or
O manufacturer name
and part number to
identify the product.”
O If this information is not
available, suppliers may
use a detailed narrative
description of the item
O However, it must contain
sufficient descriptive
information to allow a
proper coding
determination. This
"narrative description" of
the item is not the HCPCS
code narrative.
Delivery Ticket
O Proof of delivery
documents that fail to
properly identify
DMEPOS products
and allow reviewers
to make a correct
coding determination
will be denied for
insufficient delivery
information.
Delivery Ticket
O SO……. What do we
do?
O Play the
government’s game
again!
O Develop internal
SOPs to address the
interpretation ASAP!
Delivery Ticket
O Lets list what we
need:
 Must still meet all
the regulations
outlined in LCDs for
what information is
required on a
delivery ticket
• Beneficiary’s name
• Delivery address
• Sufficiently detailed
description to identify the
item(s) being delivered
(e.g., brand name, serial
number, narrative
description)
• Quantity delivered
• Date delivered
• Beneficiary (or designee)
signature
Delivery Ticket
 Dates and signatures?!
“When the supplier’s
delivery documents have
both a supplier-entered
date and a beneficiary or
beneficiary’s designee
signature date on the
POD document, the
beneficiary or
beneficiary’s designeeentered date is the date
of service.”
 SO what’s that mean?

 DO NOT type the date
on the POD
 Open to interpretation
again!
Delivery Ticket
 Descriptors of items
being delivered
 It does not say MAJOR
items being billed,
BUT ALL items being
billed.
 So if there is an Lcode being billed,
there needs to be
sufficient data for
reviewers to audit.
Delivery Ticket
O In-house fab
O Better control over
paperwork
O Document through fab
process what materials
and products/parts
O Outsourced
O Need to set
“paperwork” program
with your c-fab
O i.e. provide you with
itemized parts list
Delivery Ticket (sample)
Restorative Health Services, Inc.
Proof Of Items Delivery/Prosthetics
___ 1272 Garrison Dr., Ste 307, Murfreesboro TN 37129 ___ 506C W. Main St., Lebanon TN 37087
Components/alignable system
MFG
______________________
Part or Serial #
______________________
Socket materials
Carbon braid
___1816 N. Washington St, Ste 104, Tullahoma TN 37399 ___ 205 Oak Park, McMInnville TN 37110
Friddles Distribution
___1916 Patterson St., Ste 202, Nashville TN 37203 ___ 103 Forrest Crossing, Ste 101, Franklin TN 37064
__700-4CB-100 __700-6CB-100 __700-8CB-100
__700-CC-10
___ 204 Medical Dr., Lafayette TN 37083 ___ 1114 N. Main St., Ste B, Shelbyville TN 37160
Nyglass
SPS Distribution
Patient: ____________________________________________________
__ 0011000 7cm __0011100 9cm __0011200 12
__ 0011300 15 cm __0011400 20 cm
ID#: ___________________
Acrylic resin
SPS Distribution
The following list of items and materials are incorporated into the prosthetic device that was prescribed
and dispensed to me on the date acknowledged by my signature.
Flex socket
Friddles Distribution
__ CMRK
Test socket
Suspension
Vivak Plastic
Friddles Distribution
________________________
Mfg
_________________________
________________________
Qty/ Part or Serial #
___
Valve
Mfg and part#
________________________
Lock/lanyard
Mfg and part#
Vacuum
Mfg and part#
Knee
Liners
__________________
Suspension Sleeves
MFG
______________________
Part or Serial #
______________________
Mfg
_________________________
Qty/ Part or Serial #
___
__________________
Socks/shrinker
Foot
MFG
______________________
Mfg
Part or Serial #
______________________
Qty & Part #
Ankle
MFG
______________________
Part or Serial #
______________________
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_________________________
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_________________________
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_________________________
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_________________________
Patient Signature _____________________________________________ Date___________________
page 2 of 2
THANK YOU
O Freedom Innovations
thanks you for your
continued support and
hopes this series of
webinars helps you
make decisions to be
successful in today’s
unforgiven O and P
industry.
O Please provide
feedback to your
Freedom sales
representative of
future topics to cover
and if you find these
webinars helpful.

Aaron Sorensen, CPO, LPO


President , OPBS


asorensen@rhs-tn.com


Ph. 877-907-4180

Rob Cripe
VP Global Marketing
rcripe@freedominnovations.com
Ph. 949-544-7916