By: Ronda Buhrmester, Reimbursement Specialist
Results have been released for the NIV (E0464) prepayment review with Jurisdiction A (NHIC). Even though these results are from Jurisdiction A, it’s important for all suppliers in all areas to review these results because the error rate is 90 percent! Jurisdiction C and D are performing reviews on the NIVs as well. Be prepared suppliers in Jurisdiction B, because it may come your way, too.
Use these results as a learning tool for your team and for your referral sources. As will see, the area with the highest error rate is in the clinical documentation.
The reviews have been initiated because of the increase in claims submitted for this code. It’s important for all DME suppliers that provide this product to be prepared in all Jurisdictions. Here are helpful tips abolut ventilator coverage:
- Generally covered for treatment of neuromuscular disorders, thoracic restrictive diseases, or chronic respiratory failure secondary to COPD.
- Make sure the least costly alternative has been considered or tried and ruled out. Why is a BiPAP insufficient? This is very important information that must be documented in the patient’s medical record.
- The E0464 is one of the HCPCS codes under the ACA 6407 Face to Face ruling that was implemented July 1, 2013.
There are two elements to the F2F ruling:
- Detailed Written Order
- The detailed written order needs to be completed and obtained by the supplier prior to delivery.
- Make sure the order has been date stamped in a method that it’s clear it was “received by ABC supplier.”
- Make sure the order was written within 6 months of the F2F encounter.
- Face to Face Encounter
- Needs to be obtained prior to delivery with a date stamp received.
- The medical record needs to include why this item is medically necessary.
4. The detailed written order needs to include the following elements:
- Patient’s name
- Treating practitioner’s name (printed or typed)
- Start date of order – if start date is different than order date
- Order for ventilator with description/brand/model/ and settings
- Practitioner signature
- Practitioner signature date and NPI
- Length of need
- Frequency of use
It’s very important to be proactive by reviewing patients files to make the necessary information has been obtained. Does the medical record state that BiPAP has been tried or considered and ruled out? If the medical record states something like, “patient is on BiPAP and seems to be doing well” and then an NIV is ordered, you will get a denial. The medical record must rule out BiPAP therapy!
It’s important to be prepared and organized when submitting requested documentation by including a table of contents, numbering all the pages, and underline or asterisk important information. Make sure to track these reviews and copy all the information that has been submitted.
Documentation is KEY when dealing with any equipment, especially ventilators. A diagnosis alone is not enough information to support the need. You’ve heard the phrase before, “paint a picture.”
Paint the picture so it’s clear why the ventilator is being ordered versus the least costly alternative.
Some resources are included for your reference. Included in the resources is a more recent article, SE1513, about accreditation for ventilator equipment. Make sure to review this article and follow up with your accreditation organization about the ventilator policy group.
Results of Widespread Prepayment Probe Review of Claims for E0464
Correct Billing of Non-Invasive Interfaces Used in Conjunction with HCPCS Code E0472
Correct Coding and Coverage of Ventilators
Pressure Support Ventilators (HCPCS E0464) Notification of Service Specific Prepayment Probe Review
MLN Matters: SE1513
For further questions, please contact:
Ronda Buhrmester, CRT
Respiratory equipment, face to face ruling, and general DME
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Article: NIV Prepayment Review in Jurisdiction A and D, Now Jurisdiction C! Helpful Tips Regarding Ventilator Coverage
Article: Detail Written Order – What is Needed