Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are two of the most important aspects of Medicare.
NCDs and LCDs are used by Medicare and their administrative contractors for coverage determination information and determining if the service is reasonable and necessary, as well as if it will be reimbursed by Medicare. Medicare and its contractors are not the only payers to follow these determinations. Additionally, many other payers have adopted Medicare's rules and policies, so ensure you are familiar with each payer's rules.
For the 2017 CERT report period, the improper payment rate for ventilators was 57.4 percent, with medical necessity errors for ventilators accounting for 58 percent of improper payments. For the purpose of the article in 2017, there were two HCPCS codes used to report home ventilators.
E0465 - Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466 - Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
The following is found in the NCD National Coverage Determination (NCD) for Durable Medical Equipment (DME) Reference List (280.1).
Medical necessity errors for ventilators accounted for 58 percent of improper payments. In other words, 58 percent of payment errors on ventilators were recovered due to providers' documentation failing to document treatment of beneficiaries with one of the following conditions or failed to indicate the ventilator was required to treat at least one of the three medical conditions listed.
Covered for treatment of neuromuscular diseases,
thoracic restrictive diseases,
and chronic respiratory failure consequent to chronic obstructive pulmonary disease.
Includes both positive and negative pressure types.
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There are several considerations to be aware of before assigning a code for lesions and soft tissue excisions.
The code selection will be determined upon the following:
Check the pathology reports, if any, to confirm Morphology (whether the neoplasm is benign, in-situ, malignant, or uncertain)
Topography (anatomic location)
Type of closure required
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
ICD-11 is officially released, but what does that mean for diagnosis coding in the United States? What's really different? This article discusses what has been happening with ICD-11, some interesting things to note about it, as well as links to other important information.
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.
hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.