1. Transcutaneous Electrical Nerve Stimulators 1424_0213_TENS

2. 2 National Government Services, Inc. Today’s Presenters Charity Bright, Provider Outreach and Education Consultant Tamara Hall, Provider Outreach and Education Consultant

3. 3 National Government Services, Inc. Webinar Access All registrants received an E-mail from: Medicare Webinar by National Government Services [GoToWebinar.Notifications@citrixonline.com] –Click on the link within the e-mail to join the Web presentation –Using your telephone, dial into the conference call using the number and access code provided in the e-mail.

4. 4 National Government Services, Inc. Today’s PowerPoint Presentation PowerPoint provided in an e-mail PowerPoint available on events calendar –Go to the http://www.NGSMedicare.com Web sitehttp://www.NGSMedicare.com –Select DME Home Page –Click on the Training Events Calendar underneath Education and Training section –Select the Transcutaneous Electrical Nerve Stimulators (TENS) Webinar –Under attachments you will see the PowerPoint presentation link

5. 5 National Government Services, Inc. Audio Once you are connected to the audio, the PIN displays –Input the PIN on your screen into your telephone –Dial in number and PIN are unique for each attendee

6. 6 National Government Services, Inc. To Ask a Question Using the Question Box

7. 7 National Government Services, Inc. Disclaimer National Government Services, Inc. has produced this material as an informational reference for providers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each provider to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov. http://www.cms.gov

8. 8 National Government Services, Inc. No Recording Attendees/providers are never permitted to record (tape record or any other method) our educational events –This applies to our Webinars, teleconferences, live events, and any other type of National Government Services educational event

9. 9 National Government Services, Inc. Acronyms CLBP – Chronic low back pain CMN – Certificate of Medical Necessity CMS – Centers for Medicare & Medicaid Services CPT – Current procedural terminology DME – Durable medical equipment DMEPOS – Durable Medical Equipment Medicare Administrative Contractor HCPCS – Healthcare Common Procedure Coding System HICN – Health Insurance Claim Number PAP – Positive airway pressure (device) PHI – Protected health information HIPAA – Health Insurance Portability and Accountability Act LCD – Local coverage determination

10. 10 National Government Services, Inc. Acronyms MU – Medicare University TENS – Transcutaneous electrical nerve stimulators TMJ – Temporomandibular joint

11. 11 National Government Services, Inc. Objectives This Webinar is for all DMEPOS suppliers that bill Medicare for TENS units and supplies. During the presentation we will review Medicare’s basic coverage criteria, documentation and billing requirements.

12. 12 National Government Services, Inc. Agenda Coverage and Medical Necessity TENS Supplies Documentation Billing Information Resources

13. Coverage and Medical Necessity

14. 14 National Government Services, Inc. Basic Coverage Criteria The TENS is a type of electrical nerve stimulator that is employed to treat chronic intractable pain. This stimulator is attached to the surface of the patient’s skin over the peripheral nerve to be stimulated. It may be applied in a variety of settings (in the patient’s home, a physician’s office, or in an outpatient clinic). Payment for TENS may be made under the durable medical equipment benefit.

15. 15 National Government Services, Inc. Coverage Criteria #1 Acute postoperative pain –Coverage is limited to 30 days from the day of surgery. –Payment will only be made as a rental –A TENS unit will be denied as not reasonable and necessary for acute pain (less than three months duration) other than postoperative pain

16. 16 National Government Services, Inc. Coverage Criteria #2 Chronic pain other than low back pain –The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy. –Examples for which TENS therapy is not considered reasonable and necessary include (not all inclusive): Headache, Visceral abdominal pain Pelvic pain, TMJ pain –Pain present for at three months, other treatment modalities must have been tried and failed

17. 17 National Government Services, Inc. Trial and Purchase for Chronic, Intractable Pain Trial for a minimum of one month, not to exceed two months –Paid as a rental only –Monitored by physician to determine effectiveness Purchase requires physician’s determination of therapeutic benefit from continuous use –Documented reevaluation at end of trial period How often used Duration of use each time Results

18. 18 National Government Services, Inc. Coverage Criteria #3 Chronic low back pain –The patient has a qualifying diagnosis, and –The patient is enrolled in an approved clinical study Currently, no clinical studies involving TENS for treatment of CLBP have been approved by CMS –http://www.cms.gov/Medicare/Coverage/Coverage-with- Evidence-Development/index.htmlhttp://www.cms.gov/Medicare/Coverage/Coverage-with- Evidence-Development/index.html

19. 19 National Government Services, Inc. TENS Used for CLBP TENS eligible for purchase –Upon enrollment into an approved study –Trial rental period and physician reevaluation of effectiveness are not required

20. 20 National Government Services, Inc. Question #1 A TENS unit is covered for which of the following? a.Chronic pain b.Chronic low back pain c.Acute postoperative pain d.All of the above

21. 21 National Government Services, Inc. Question #2 A TENS trial period is limited to three rental months. a.True b.False

22. TENS Supplies

23. 23 National Government Services, Inc. Replacement Supplies for Purchased TENS TENS supply A4595 includes: –Electrodes, conductive paste or gel, tape or other adhesive, adhesive remover, skin preparation material, batteries, battery charger (if rechargeable batteries are used) One unit of service for E0720 Two units of service for E0730 –If the use of the TENS unit is less than daily, the frequency of billing for the TENS supply code should be reduced proportionally.

24. 24 National Government Services, Inc. Replacement Supplies for Purchased TENS Replacement lead wires A4557 –Rarely reasonable and necessary more than every 12 months One unit of service for E0720 Two units of service for E0730

25. 25 National Government Services, Inc. Conductive Garment A conductive garment (E0731) used with a TENS unit is rarely reasonable and necessary Covered only if all of the following conditions are met: –It has been prescribed by the treating physician for use in delivering covered TENS treatment; and

26. 26 National Government Services, Inc. Conductive Garment –Qualifying condition is documented The patient cannot manage without the conductive garment because –Large area or so many sites to be stimulated and –Stimulation would have to be delivered so frequently that it is not feasible to use conventional electrodes, adhesive tapes, and lead wires Area or sites to be stimulated are inaccessible with use of electrodes, tape, and wires Documented medical condition, such as skin problems Requires stimulation beneath a cast

27. 27 National Government Services, Inc. Conductive Garment and TENS Trial Period May be paid during the TENS trial period in the following situations: –The patient has a documented skin problem prior to the start of the trial period –The TENS is medically necessary for the patient

28. 28 National Government Services, Inc. Supplies and Accessories Used with TENS for Treatment of CLBP Date of service on or after June 8, 2012 –Supplies and accessories provided for use with a previously covered TENS used for CLBP (not as part of an approved study) are not eligible for reimbursement

29. Documentation

30. 30 National Government Services, Inc. Detailed Written Order Required prior to delivery of TENS unit and must include the following: –Beneficiary’s name –Physician’s name –Date of the order and the start date, if start date is different from the date of the order –Detailed description of the item(s) –Physician signature and date

31. 31 National Government Services, Inc. Detailed Written Order TENS Supplies Detailed written order must also include: –Items to be dispensed –Frequency of use –Quantity to be dispensed –Number of refills

32. 32 National Government Services, Inc. New Orders A new order is required when: –There is a change in supplier –There is a change in the item(s), frequency of use, or amount prescribed –There is a change in the length of need or a previously established length of need expires –State law requires a prescription renewal

33. 33 National Government Services, Inc. Question #3 A detailed written order is required prior to delivery of the TENS unit. a.True b.False

34. 34 National Government Services, Inc. Medical Record Documentation Patient’s medical record must contain sufficient documentation to substantiate the necessity of: –Type of equipment/supply –Quantity –Frequency of use Must include: –Patient’s diagnosis –Duration of patient’s condition –Clinical course (worsening or improvement) –Prognosis –Other therapeutic interventions, results

35. 35 National Government Services, Inc. Continued Use Continued use describes the ongoing utilization of supplies or a rental item by a beneficiary –Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary

36. 36 National Government Services, Inc. Continued Use Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary –Timely documentation in the beneficiary’s medical record showing usage of the item, related option/accessories and supplies –Supplier records documenting the request for refill/replacement of supplies Supplier records documenting beneficiary confirmation of continued use of a rental item

37. 37 National Government Services, Inc. Continued Need Initial justification for medical need is established at the time the item(s) is first ordered –Beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription

38. 38 National Government Services, Inc. Continued Need There must be information in the beneficiary’s medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary –A recent order by the treating physician for refills –A recent change in prescription –A properly completed CMN with an appropriate length of need specified –Timely documentation in the beneficiary’s medical record showing usage of the item

39. 39 National Government Services, Inc. Continued Use and Medical Need Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy –This applies to both continued use and continued medical need

40. 40 National Government Services, Inc. Question #4 Medical records must document other appropriate treatment modalities that have been tried and failed. a.True b.False

41. 41 National Government Services, Inc. Request for Refill Documentation Items provided on a recurring basis, contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to delivery/shipping date –Suppliers must not dispense a quantity of supplies exceeding a beneficiary’s expected utilization –No more than a three month quantity may be dispensed at one time –Not required if beneficiary picks supplies up in person

42. 42 National Government Services, Inc. Request for Refill Documentation The refill record must include: –Beneficiary’s name or authorized representative if different than the beneficiary –A description of each item that is being requested Must be detailed regarding each item being provided –Date of refill request –Information documenting that the beneficiary’s remaining supply is approaching exhaustion by the expected delivery date Must be a quantity of the amount remaining –Example: 1 week, 2 days

43. 43 National Government Services, Inc. Refills: Consumable Supplies Consumable supplies: supplies that get used up –Examples: surgical dressings, urological supplies, blood glucose testing supplies –Supplier should assess and document the quantity of the supply item the beneficiary still has remaining –Determine if the supply is nearly exhausted and/or compare to the last order filled

44. 44 National Government Services, Inc. Refills: Nonconsumable Supplies Nonconsumable supplies (supply items that are more durable in nature, but may require periodic replacement) –Examples: PAP supplies, nebulizer supplies, TENS supplies –The supplier should assess whether the supply item remains functional –Replacement should be provided only when the item is no longer functional –The supplier should document the condition of the item being replaced in sufficient detail to indicate why the replacement is necessary at that time

45. 45 National Government Services, Inc. Proof of Delivery Proof of delivery is Supplier Standard #12 –DMEPOS supplier records must be kept on file for seven years, available upon reque st For medical review purposes, the proof of delivery assists in coding verification and billing information If the service provided does not have appropriate proof of delivery from the DMEPOS supplier, the claim in question will be denied and/or overpayment will be requested

46. 46 National Government Services, Inc. Proof of Delivery Three methods: –Direct delivery to the beneficiary Date of service = date of delivery –Delivery via shipping service Date of service = ship date –Delivery to skilled nursing facility on behalf of beneficiary Date of service depends on method of delivery

47. 47 National Government Services, Inc. CMN for Purchased TENS Units TENS CMN – CMS-848 –Required for purchase of devices due to chronic pain after trial period – Four CMN Sections: A–D A and C completed by supplier B and D completed by ordering physician Signature/date stamps are not acceptable –Initial date reported must be on or after reevaluation date –A CMN is not required for the rental of a TENS unit

48. 48 National Government Services, Inc. Question #5 A Certificate of Medical Necessity is required for the rental of a TENS unit. a.True b.False

49. Billing Information

50. 50 National Government Services, Inc. Modifiers Primary pricing modifiers –RR, NU Informational modifiers –Documentation modifiers KX, EY –Liability modifiers GA, GZ –Clinical trial modifier Q0 (zero) –Approved clinical trial number must be submitted on the claim

51. 51 National Government Services, Inc. Not Separately Payable TENS rental allowed amount includes supplies –Supplies billed separately will be denied as not separately payable TENS purchase allowed amount includes one month of supplies –Supplies billed at the time of purchase will be denied as not separately payable

52. 52 National Government Services, Inc. Resources http://www.NGSMedicare.com –Jurisdiction B DME MAC Supplier Manual –TENS LCD (L27031) –TENS policy article (A47130) –Policy Education page –January 23, 2013 TENS Webinar question and answer document

53. 53 National Government Services, Inc. How to Participate Today

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58. 58 National Government Services, Inc. Medicare University http://www.MedicareUniversity.com Interactive online system available 24/7 Educational opportunities available –Computer-based training courses –Teleconferences, Webinars, live seminars/face-to- face training Self-report attendance

59. 59 National Government Services, Inc. Medicare University Self-Reporting Instructions Log on to the National Government Services Medicare University site at http://www.NGSMedicare.com http://www.NGSMedicare.com –Topic = Transcutaneous Electrical Nerve Stimulators (TENS) Webinar –Medicare University Credits (MUCs) = 1 –Catalog Number = AA-C-00954 –Course Code = 13072WDCTH1 –For step-by-step instructions on self-reporting please visit http://www.NGSMedicare.com > Medicare University > Accessing the Self-Reporting Toolhttp://www.NGSMedicare.com

60. 60 National Government Services, Inc. Thank You!