BILLABLE SUPPLIES & Usual Maximum Quantities Wound – Gauze (sterile or non-sterile) - 186/mo Tape (waterproof or paper) - based on dressing size Foam/Film/Composite/Hydrocolloid/Collagen – 12/mo Alginate/Hydrogel Cover/Island Drsg/ABD Pad/Impreg Gauze – 1/day Wound Filler – 3 oz/mo Drugs/Powders/Topical Ointments – Not Billable *Most Commonly Used Supplies, Not A Complete List
BILLABLE SUPPLIES & Usual Maximum Quantities Enteral – Formula (>2500 calories/day addt’l doc) Pump (1/mo up to 15 months) IV Pole (1/mo with pump feeding) Syringe, gravity, or pump feeding supply kit (1/day) Tube –NG (1/month), G/J (1 per 3months)
Medical Necessity For All (Ostomy, Uro, Wound, TF, Trach) – Clinical Course that led to the conditiion Continued medical need documentation at least annually. Additional documentation is required for supplies that exceed usual maximum quantities. Medical need at inception and continued medical need for the duration. Permanent Condition (expected to exist for > or = to 3 months)
Medical Necessity Urological - Urological Supplies are only billable if permanent urinary incontinence or permanent urinary retention exists and is documented.
Medical Necessity For Trach - 1. An ICD-9 code of V44.0 Trach Status or V55.0 Attention to Tracheostomy or , , , For Ostomy - An ICD-9 DX of V code describing the type of ostomy must be documented (V44.2, V44.3, V44.6, V55.2, V55.3, V55.4, , )
Medical Necessity For Wound/Surgical Dressings - A wound caused by a surgical procedure A wound that has been debrided It is billable until healed Debridement – surgical, mechanical, chemical or autolytical
Medical Necessity For Enteral Nutrition (if dysphagia exists) – Modified Barium Swallow Study (MBSS) and/or Beside Evaluation by Speech, Language Pathologist (SLP) and/or Rehab Screen by SLP and/or Treatment/Therapy Notes of SLP
TF Medical Necessity (cont’d) Policy Article A25512 The beneficiary – 1) Must have “(a) permanent non-function or disease of the structures that normally permit food to reach the small bowel or (b) disease of the small bowel which impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength commensurate with the patients overall health status” 2) Must have a condition that is either anatomic or due to a motility disorder (dysphagia) 3) Must not be able to maintain adequate nutrition by dietary adjustment and/or oral supplements.
Pump Rental/Purchase Option Supplier Standard #5 Beneficiary must be notified of option to convert pump rental to purchase after 10 th rental month. If Beneficiary chooses purchase option they own equipment & Medicare pays 3 more months. Facility does not own pumps. They are leased by agreement with the pump manufacturer who has title to the pump. If beneficiary purchases pump the title is transferred to beneficiary.
Enteral Nutrition DME Information Form (DIF) required to support the medical necessity of the formula and pump
Specialty Nutrients Source: MLN Matters # & Nestle “Suggested Documentation Guide for Special Enteral Formulas” The documentation necessary to justify special formulas includes: Medical records documenting the medical condition requiring a HCPCS Code B4149, B4153-B4157, B4161, or B4162 formula as opposed to a B4150 formula and the severity of that condition as shown by history, physical exam and diagnostic/laboratory studies. The response of the medical condition to a B4150 formula as compared to the response to the prescribed B4149, B4153-B4157, B4161, or B4162 formula. If this comparison has not been made, the medical reason for its absence should be documented in the patient's medical record. The reason(s) should be individualized for the patient and not a generalized statement such as the diagnosis. DOCUMENTATION REMINDER: Pertinent Labs Progress notes from physician, specialist, dietitian, nursing on tolerance & outcomes (clinical course)
Advance Beneficiary Notice (ABN) of Non-Coverage Option 1 – I want the item. Bill Medicare, if they don’t pay I will. Option 2 – I want the item. Don’t bill Medicare and I will pay. I cannot appeal. Option 3 – I don’t want the item. I am not responsible for payment and can’t appeal to see if Medicare would pay.
Proof of Delivery Ch 3 Region C Medicare Supplier Manual, Pub Ch 4 & 5 Facility to Caregiver Caregiver to Resident Vendor to Facility
Detailed Written Order (DWO) The order must specify – “The type of supplies and the approximate quantity to be used per unit of time” (Policy Articles) And be signed & dated by the treating physician.
Detailed Written Order (DWO) Ch 3 Region C Medicare Supplier Manual 1) Beneficiary’s Name 2) Physician’s Name 3) Date of the order and the start date, if start date is different from the date of the order 4) Detailed description* of the item(s) 5) Physician signature and signature date *Detailed description may be a description or a brand name/model number. There must be sufficient detail to identify the items for coding. (LCD)
Wound Detailed Written Order A new order is required every 3 months even if the treatment has not changed. Order must specify – The type of dressing (hydrocolloid wound cover, hydrogel wound filler) or product name The size of the dressing (if it is available in different sizes) The number/amount to be used at one time (if more than one) The frequency of dressing change The expected duration of need
Enteral Nutrition Detailed Written Order 1) The formula name, formula amount, # of hours (pump), # of feedings (bolus or gravity) and method of feeding (via NG, J, G, PEG tube). 2) Routine orders to specify syringe, tubing, bag and feeding tube (G,NG, J) changes.
Monthly Billing Procedures Timeline 23 rd – C.S. & Wound Logs are sent to facilities 3 rd – C.S. & Wound Logs are due back 3-6 th – Outstanding Info Logs are sent to facilities and claims are submitted 10 th -17 th – Follow Up Calls on the OIL’s 18 th - 22 nd – Mid-Month Billing
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