For many providers, oxygen equipment is the No. 1 revenue-generating product category within their companies. Since the advent of the 36-month cap, relocation and travel requirements, not to mention the various audits that are being conducted, getting paid for oxygen is no easy task. Hence, the importance of a clean claim with proper documentation.
As a provider, your focus needs to be on training intake, medical documentation and billing personnel on the coverage criteria within your DME MAC's local coverage determination. A detailed understanding of the LCD can help your team in making informed decisions on admitting a patient into service and gaining the documentation that will assist in proving medical necessity for the oxygen that is being provided.
In addition, knowledge of the LCD is your only weapon when attempting to maneuver through the quagmire of challenges you might face in an audit. But let's not focus on audits; let's review the importance of training on the LCD.
A highly trained intake, medical documentation, billing and respiratory staff (if applicable) are needed to reduce the possibility of denials and understand medical necessity. If you have respiratory therapists on your staff, utilize them to train non-clinical staff members on verbiage within the LCD. The criteria listed for when a patient qualifies for Group 1 and Group 2 as well as testing requirements are difficult to understand and interpret without a clinical background.
If you have access to a respiratory therapist, whether on staff or through subcontract, it is a good idea to invite them to perform an in-service on how to interpret the test results to best match the LCD.
To a non-clinician biller, medical documentation assistant or intake employee, the language in the LCD is a foreign one. They need someone to explain "a decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least 5 minutes taken during sleep associated with symptoms (e.g., impairment of cognitive processes and [nocturnal restlessness or insomnia]) or signs (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis) reasonably attributable to hypoxemia," which is listed as the third option to meet Group 1 coverage criteria if the patient doesn't have "an arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake)."
Heck, just reading that back gets this old biller questioning herself. Everyone needs a sounding board to make sure what they are reading and seeing makes sense according to the mystical meaning of the LCD. Without training and a resource to go to, your company is at risk of denials and non-compliance.
Break It Down and Train, Train, Train
With regard to training, take the LCD apart and look at each section independently. Focus on the "little" words within the LCD like "and" and "or." Those words carry a lot of weight. They are so small that they are easy to miss, so pay particular attention to those little guys. "And" connects all of the criteria that must be met, and "or" gives you options about what is needed to meet coverage criteria.
Let's look at the first part of the LCD, which states that home oxygen therapy is covered only if all of the following conditions are met:
-
The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, "and"
-
The patient's blood gas study meets the criteria stated below, "and"
-
The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, "and"
-
The qualifying blood gas study was obtained under the following conditions:
-
If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than two days prior to the hospital discharge date, "or"
-
If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the patient is in a chronic stable state — i.e., not during a period of acute illness or an exacerbation of their underlying disease, "and"
-
-
Alternative treatment measures have been tried or considered and deemed clinically ineffective.
In addition to Section 1, Section 2 is very important, as it states that you must look at the patient's blood gas study to see if he or she meets the coverage criteria for Group 1 or 2. That means you have to move on to the next section in the LCD about Group 1 and 2 criteria before you can assess whether the patient meets the criteria in Sections 3, 4 and 5. Each part of the LCD builds upon the one before.
If your intake person misses an "and" or an "or," the oxygen patient you are about to admit may be denied. What does that mean to you as manager or owner of the company? Cost, cost and more cost, and at the end of the day, a big write-off. Yikes. No one likes write-offs. Write-offs do not bring cash in the door or keep the electricity running.
So training is truly the key to success. I often hear people say, "I don't have the money, time, or resources to train my staff." The truth is that providers will lose more money than they would spend on training if they don't invest in their team. In addition, a trained team leads to reduced employee turnover within the company because staff feel valued and have less stress due to increased knowledge. Like they say, "knowledge is power." Once your team is trained, you will reap the rewards through reduced denials, increased cash flow and increased compliance.
What kind of tools are you providing your employees to ensure they are asking the right questions at intake and reviewing the appropriate documents to assess medical necessity?
Noridian Administrative Services, the DME MAC for Jurisdiction D, and Cigna Government Services, the DME MAC for Jurisdiction C, provide nice training tools for oxygen under the "Documentation Checklist" option on their websites. These checklists offer a concise view of the LCD with checkboxes that can be used on a case-by-case basis for your intake and billing employees to follow when qualifying patients.
In addition, Noridian provides a decision tree for oxygen for employees to follow when determining coverage and to help them decide if an ABN needs to be issued.
National Government Services, the Jurisdiction B DME MAC, offers Medicare University, an easy and free online training tool that contains courses for any level biller on a variety of topics, including oxygen coverage criteria. Considering the plethora of training resources at your disposal, your staff should have no problem locating information to help guide them through the world of oxygen.
Time for the CMN
Once medical necessity is determined and the time to obtain a Certificate of Medical Necessity (CMN) comes around, navigating the rules of documentation can be just as tricky.
The medical documentation assistant is charged with the task of knowing the patient's oxygen treatment history and choosing the correct type of oxygen CMN to pursue. A wrong choice could result in denials and a lengthy appeals process. The question is, initial, revised or recertification? It seems simple enough, but the answer could change given a myriad of different factors.
The first to consider is the patient's oxygen treatment history. Has the patient rented oxygen equipment previously? If the answer is yes, you may have ruled out an initial CMN.
Another factor is the patient's past insurance history if he or she was receiving oxygen therapy. Depending on whether the patient was on a Medicare HMO or a private commercial insurance plan, that information could alter the requirements for the dates of the testing reported on the CMN.
Patients who were receiving oxygen therapy while covered under a Medicare HMO have an exception to the 30-day test requirement that is enforced for those who were started on oxygen while enrolled in fee-for-service Medicare. For Medicare HMO patients transitioning to fee-for-service Medicare, the blood gas study does not have to be obtained 30 days prior to the initial date but must be the most recent qualifying test obtained while in the Medicare HMO.
The LCDs from all DME MAC jurisdictions outline different scenarios for initial, revised and recertification CMNs. It is imperative that those team members involved in the medical documentation retrieval process are not only familiar with this section of the LCD but have the LCD available for reference. Having the website link to the LCD saved under their Internet browser 'Favorites' is a great way to get quick access to the LCD and also to make sure the version being reviewed contains the most up-to- date information.
Will Training Pay Off?
How do you determine if the effort that you've put into training is paying off? The answer comes down to effective reporting. The most visible evidence of improvement is your denial rate. Aggregate your denial data into meaningful reports using your software, then take a look at denial codes CO176 and CO173 as they relate to oxygen HCPC codes (E1390, E0431, K0738, etc.).
If you see these denial codes becoming major players in your denial rate, this indicates a problem with CMNs. Take all denials for those reason codes and drill down to individual patients. Get to the bottom of the problem and address the issue not only with the individual responsible for those claims but with the entire staff to ensure everyone is on the same page.
This can be a great learning tool because you can see an immediate cause and effect for poor documentation decisions. Plus, this information has the ability to turn future denials into payments.
Transitioning your staff from a position of uncertainty to a position of knowledge when it comes to oxygen may mean a period where you are still cleaning up the sins of the past. But during this time, your staff will have an opportunity to get ahead of the game for any CO176 and CO173 denials coming down the pike.
The reports that your billers pick up from CEDI contain information not only on claim rejections but also for CMN rejections (the RPT report). With this information, your billers can start the research process to determine the next step and get prepared for when the denial is received.
The training process outlined here is the basis for training on all the product categories your company provides. Take a small step by starting with oxygen and move forward with the other LCDs. Once you get going, you will gain momentum and your training program will build. When all is said and done, your hard work will, literally, pay off.
Documentation Checklist
Check out the Cigna and Noridian oxygen checklists that intake and billing employees can follow on their respective websites at:
Cigna: http://www.cignagovernmentservices.com/jc/coverage/MR/DocumentationChecklists.html
Noridian: https://www.noridianmedicare.com/dme/coverage/
Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.
