Identify potential problems at the source
by Sarah Hanna

Navigating the requirements of the Affordable Care Act (ACA) presents many challenges within our industry and the way we look at everyday sales activities is changing rapidly. Very few products face as many hurdles as portable oxygen units (E0431) in the wake of written order prior to delivery (WOPD) and face-to-face (F2F) requirements. In a second-quarter 2014 prepayment review conducted by National Government Services, 92 percent of the E0431 claims reviewed were denied. Key points that contributed to the high denial rate:

  • The detailed written order was not issued prior to delivery
  • The document does not support the beneficiary being mobile in the home
  • No evidence that the treating physician has determined the beneficiary has a severe lung disease or hypoxia-related symptoms that might improve with oxygen therapy
  • No evidence of blood gas results as reported on the certificate of medical necessity
  • Beneficiary was not in a chronic stable state during blood gas study

The coverage criteria aren’t new; reasons two through five have been around for many years. This information should be evidenced in the chart notes and test results that are to be reviewed by your staff. Denials resulting from these reasons are likely due to:

  • Lack of staff education regarding the coverage criteria
  • Deficiency in understanding the local coverage determination (LCD) by those responsible for the review of the medical record
  • Absence of documentation prior to setup/billing/audit

Providers need the F2F documentation prior to delivery in accordance with the ACA on portable oxygen. This allows the person reviewing the documentation to be aware of an absence of any qualifying information for the patient. Reason No. 1 relates to the WOPD. The certificate of medical necessity can act as the WOPD as long as it meets the requirements specified in the documentation section of the LCD for a written order. Providers should be keenly aware of the requirements covering errors on the WOPD and F2F that may occur prior to delivery, after delivery but before billing and after the claim has been billed to Medicare. If errors in the F2F documentation or WOPD are found prior to delivery, the supplier may request that the treating physician amend the visit notes or the WOPD following the guidance in the Program Integrity Manual, create a new WOPD or conduct a new F2F visit. After delivery, if errors in the WOPD are found or the face-to-face visit notes do not describe a medical condition for which the DME is being prescribed, the supplier has two options. Prior to claim submission, the original supplier may recover the delivered item, obtain a compliant WOPD or complete face-to-face visit notes that describe a medical condition for which the DME is being prescribed, and then redeliver the item to the beneficiary. If the error is discovered after submitting a claim, the original supplier can recover the items and a new supplier must complete the transaction after complying with all requirements. The ACA makes it particularly difficult to care for those who are discharged from the hospital and require portable oxygen to get home. Many times in these situations the documentation is not complete at the time of discharge. In addition, there are issues surrounding the documentation when the physician is a hospitalist. As providers in the DMEPOS industry, you have to be diligent in your efforts with referral sources and in operating within the confines of the ACA and LCD conditions. By supporting service organizations and your state, regional and national associations’ efforts at the government level, hopefully we can impact future legislation.