In last month's Payment Strategies column, we discussed the new standard written order (SWO) requirements that physicians and qualified healthcare professionals should follow when ordering durable medical equipment (DME) and supplies for use in the home by Medicare beneficiaries. Many readers have sent questions to this author about the requirements for face-to-face encounters and prior authorizations. Following are the frequently asked questions and answers about those topics:
Q: I heard there is a list of the equipment and supplies for which Medicare may require face-to-face encounters and/or prior authorizations. Is that true?
A: Yes. The Final Rule CMS-1713-F (84 Federal Register/Vol. 217) page 60756 released a "Master List" of DME prosthetics, orthotics, and supplies (DMEPOS) items that are potentially subject to face-to-face encounters and written orders prior to delivery and/or prior authorization requirements (Supplemental Table 1; http://links.lww.com/NSW/A29).
Q: Do any DMEPOS items currently require face-to-face encounters?
A: The CMS is expected to publish a list of equipment and supplies that will require face-to-face encounters and written orders prior to delivery. The list will be published in the Federal Register with no less than 60 days' notice. In addition, the list will be posted on the CMS website and the DME Medicare administrative contractors' (MACs') websites. Once DMEPOS items appear on the Required Face-to-Face and Written Order Prior to Delivery list, the treating practitioner must document and communicate to the DMEPOS supplier that he/she conducted a face-to-face encounter with the beneficiary within the 6 months preceding the date on the SWO. NOTE: If a specific CMS policy requires the face-to-face encounter to be performed within a shorter time period, the treating practitioner must abide by that policy.
Q: What qualifies as a face-to-face encounter?
A: An in-person or telehealth encounter between the treating practitioner and the beneficiary. Telehealth encounters must meet the requirements of 42 CFR [S][S] 410.78 and 414.65.
Q: Who submits the treating practitioner's documentation of the face-to-face encounter to the DME MAC?
A: The treating practitioner submits both the documentation of the face-to-face encounter and the SWO to the DMEPOS supplier, who must maintain both documents. If the CMS or the DME MAC requests the documents, the DMEPOS supplier submits them to the DME MAC.
Q: What information about the face-to-face encounter should be in the medical record to support coverage and payment for the item(s)?
A: The supporting documentation should include subjective and objective beneficiary-specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS item is ordered, such as patient history, physical examination, treatment plans, and so on.
Q: Has the CMS released a list of DMEPOS items that require prior authorization?
A: Yes, the Required Prior Authorization List is posted on the CMS website and the DME MACs' websites (Supplemental Table 2; http://links.lww.com/NSW/A30). The broad categories of DMEPOS items on the list are power wheelchairs, pressure reducing support surfaces, and lower limb prosthetics. See the list for the exact Healthcare Common Procedure Coding System (HCPCS) codes included. If the CMS decides to add more items to the list, they must announce it in the Federal Register with no less than 60 days' notice. That notice will also be posted on the CMS website and the DME MACs' websites.
For example, on February 11, 2020, the CMS selected six additional DMEPOS items to be subject to prior authorization and posted the announcement in the Federal Register. The announcement stated that the prior authorization for lower limb prosthetics will be implemented in two phases. Phase 1 will begin May 11, 2020 (90 days' notice), in one state from each DME MAC jurisdiction: California, Michigan, Pennsylvania, and Texas. Phase 2 will begin October 8, 2020, and will expand prior authorization of the selected codes to all the remaining states and territories.
Q: Is the prior authorization requirement for the support surface HCPCS codes implemented in all states?
A: Yes. The Federal Register announcement was on April 22, 2019. The implementation was in two phases: the first phase began in four states for all new support surface claims for five HCPCS codes (E0193, E0277, E0371, E0372, and E0373) with a date of service or delivery on or after July 22, 2019; the second phase was implemented nationally for dates of service or delivery beginning October 21, 2019.
Q: Did the CMS provide a reason for adding the support surface HCPCS codes to the prior authorization list?
A: Yes. The Comprehensive Error Rate Testing program estimated high rates of improper payment for support surface codes (59% from 2015 through 2017 and 75.2% in 2018 [over $18 million]). The prior authorization process for support surfaces was implemented to benefit all stakeholders:
* The DMEPOS suppliers know whether the DME MAC will likely pay for the support surfaces. If the DME MAC determines that a particular patient's medical condition does not meet the coverage requirements, but the Medicare beneficiary still wants the support surface and is willing to pay for it, the patient can sign an Advanced Beneficiary Notice of Noncoverage
* The Medicare beneficiaries know, prior to receipt of the support surfaces, whether Medicare will likely pay for them.
* The DME MACs can assess the medical information, prior to processing a claim, to provide provisional feedback on the support surface ordered.
Q: How does the prior authorization process work for support surfaces?
A: The process is the same for all DMEPOS items that require prior authorization. Prior to furnishing the item to the beneficiary or submitting the claim for processing, the DMEPOS supplier must submit a prior authorization request that includes evidence that the support surface complies with all applicable Medicare coverage, coding, and payment rules, including:
* a Prior Authorization Request Coversheet
* the beneficiary's name, Medicare Beneficiary Identifier, date of birth, and address
* the DMEPOS supplier's name, National Supplier Clearinghouse number, National Provider Identifier, address, and phone number
* the name of the medical professional who ordered the support surface, telephone number, National Provider Identifier (if applicable), and address
* submission date
* the HCPCS code of support surface ordered
* whether the request is an initial or resubmission review
* whether the request is expedited-if so, the reason why
* the SWO
* supporting documentation from the medical record
The prior authorization request can be mailed, faxed by adhering to Acceptable Risk Safeguards, submitted through the electronic submission of medical documentation system, or submitted through the MAC's provider portal (when available).
After the required documentation is received by the DME MAC, one of their reviewers will conduct a medical review and communicate a decision that provisionally affirms or nonaffirms the request. For initial requests, the DME MAC will ensure the written decision is faxed, postmarked, or delivered electronically within 5 business days. If the initial prior authorization request is not affirmed, the request can be submitted with additional documentation. The DME MAC will also ensure that the written decision is faxed, postmarked, or delivered electronically within 5 business days.
An expedited prior authorization can be requested if a delay in receipt of a prior authorization decision could jeopardize the life or health of the beneficiary. To avoid delays with mailing, the DMEPOS suppliers should use fax, electronic submission, or the MAC Portal for these requests. The DME MAC will communicate a decision within 2 business days of the expedited request. The DME MAC will send the detailed decision letter to the DMEPOS supplier who submitted the prior authorization request. A provisional affirmative decision is a preliminary finding that a future claim submitted to Medicare for the support surface likely meets Medicare's coverage, coding, and payment requirements. If the decision is nonaffirmed, the decision letter will provide a detailed explanation for the decision. The Medicare beneficiary and/or the medical professional who ordered the support surface may request a copy of the detailed decision letter.
The decision letters will contain a Unique Tracking Number that must be included on every claim submitted for that beneficiary's support surface. When a prior authorization request is affirmed, the DME MAC will pay the claim in full, if all of the appropriate documentation and relevant Medicare coverage and clinical documentation requirements are met, and the claim is billed and submitted correctly. When a prior authorization request is nonaffirmed, the requestor can resolve the nonaffirmative reasons described in the decision letter and resubmit the prior authorization request.
SUMMARY
If wound/ulcer management professionals and DMEPOS suppliers thoroughly document the patient's medical condition and show the medical necessity for all equipment and supplies ordered, they should not have difficulty complying with these requirements. Most important, Medicare beneficiaries can receive the equipment and supplies they need in a timely manner and do not have to worry about whether Medicare will pay for the item(s).