Have You Received Your Audit Request?
If you have not received an audit request from AdvanceMed
already, it is likely that you will.
AdvanceMed is an independent auditor hired to perform audits for
the Centers for Medicare and Medicaid Services. The Comprehensive
Error Rate Testing program, or CERT, allows CMS to monitor claims
to ensure that they are accurate, and therefore, should be
reimbursed.
Let's review to make sure your documentation meets the
requirements to pass these audits — and so that your claims
will be reimbursed.
Physician Orders
Physician orders must be complete and accurate. A 3"×5"
prescription slip that reads “bedside commode, diagnosis: CVA
(cerebrovascular accident),” even if it contains the
patient's name and the doctor's signature, is not an acceptable
order.
What does constitute a compliant physician order? Check your
orders for the following:
Patient's name, address and Health Insurance Claim (HIC)
number
Physician's name, address and UPIN
Quantity of the item to be dispensed
Frequency of use
ICD-9 code or narrative diagnosis
Specific type of equipment or supply ordered
Date of the order
Length of need
Physician's signature and date
Medical necessity of the item
Certificates of Medical Necessity
CMNs must comply to Medicare guidelines; providers can face
large fines if they are not. Check your CMNs for accuracy and
completion. As a provider, you must complete Sections A and C of
any CMN before it is delivered to the physician's office for his or
her signature and date.
In Section A, make sure to include:
Patient demographics
Place of service
Provider's information
Physician's information, including UPIN
Patient's date of birth, sex, height and weight
Section B must be completed by the physician or an employee of
the physician. If someone other than the physician completes
Section B, that person's name, title and employer must be stated.
Section B also gives the medical necessity qualifications for the
equipment being ordered.
Section C, to be completed by the provider, must state the
equipment, supplies and accessories being ordered, as well as the
Medicare allowable and supplier's charge.
Section D includes the treating physician's signature and the
date of the physician's signature.
Remember to make sure the CMN retains its back section, which
includes printed instructions for the physician on how to complete
the CMN. Any changes made on the CMN must have the physician's
initials and date. Any electronic CMN that is transmitted to the
DMERC must be a mirror image of the paper CMN.
Go through your CMNs thoroughly. If you find any that are not in
complete compliance, obtain revised CMNs so that you will be
prepared for auditing.
Written Order Prior to Delivery
For items requiring a written order prior to delivery (WOPD),
verify that you have a signed, written order in your hands before
the equipment is delivered or leaves your showroom floor. A WOPD is
required for:
Support surfaces
Transcutaneous electrical nerve stimulator (TENS) units
Seat lift mechanisms
Negative pressure wound therapy (NPWT)
Power-operated vehicles (POVs)
Before sending any audit to AdvanceMed or directly to your
DMERC, it may be wise to have an outside review of the
documentation to avoid an overpayment, or a possible denial of a
pre-payment review. The saying “pay now or pay later”
comes true all too often for many providers.
Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A
reimbursement specialist, Bunch delivers educational seminars
worldwide, helps develop corporate compliance plans, and serves as
a consultant for fraud and abuse cases. She can be reached at
678/445-1221 or via e-mail at
target="_blank">BILLHME@aol.com.
