Ask the DMERC MDs

Tuesday, January 31, 2006

This month we continue with a variety of short topics.
Q. In January the new HCPCS codes are released. Sometimes there are codes that aren't in medical review policies. How are we supposed to handle them?
A. CMS releases the new HCPCS code list effective Jan. 1 each year. New codes are created, others are deleted or changed. How you handle them varies. Let's review a few common scenarios:
- An existing code is replaced with a new code. Most often no new action is needed other than to begin using the new code. You should always check the policy to be sure that there were no changes in either the coverage criteria or in the documentation requirements. If there are any changes, ensure that you are in compliance for any claims with dates of service on or after the effective date of the code.
- The narrative descriptor of a code has changed. Again, most often no action will be necessary. Be sure to review the narrative to ensure that the product you are providing is still appropriate for the code. Use the SADMERC resources, e.g. Web site, product category lists, hot line, etc., if you have any questions about correct coding.
- A new code for a new item is created. These items fall into two groups. First, the item fits into an existing policy. In this case review the LCD (local coverage determination), note any changes and follow the LCD requirements. Second, the code is for a new item that does not have any LCD associated with it. In this case, remember that the general coverage and documentation requirements for all Medicare reimbursed items still apply, i.e., the item is reasonable and necessary, the medical record contains sufficient information to justify the patient's need for the item, and the medical record information must be available to the DMERC upon request. Refer to your DMERC supplier manual for additional information on coverage and documentation.
Q. I have been receiving document requests from a variety of entities. Who are they and why are they asking for information?
A. There are multiple entities that may request information from a supplier. For several, the nature of the requests may overlap. The principal entities are:
- The National Supplier Clearinghouse will request information about your application for a supplier number and about your compliance with the supplier standards. Failure to comply may result in a supplier number not being assigned or suspension of an existing number.
- The DMERC Program Safeguard Contractor (PSC) performs both medical review activities and benefit integrity investigations. Thus you may be asked to provide a variety of information to demonstrate your compliance with national and local coverage and documentation requirements, as well as adherence to various technical requirements. Depending on the nature of the request, the consequences for failure to comply range from an educational intervention, overpayment recovery or a referral to law enforcement.
- The Comprehensive Error Rate (CERT) contractor also performs medical review activities. They will ask for information from the medical record in order to determine adherence to existing policies. This information is used to determine the contractor's error rate.
We strongly encourage all suppliers to comply with requests for information. Failure may have a significant impact. For additional information about documentation requirements, refer to your DMERC supplier manual.
Q. When Congress passes legislation it always seems to take the DMERCs a while to put it into practice. Why is that?
A. The DMERCs, as contractors, must wait for instructions from CMS before enacting any legislative requirements. CMS, after receiving the legislation, reviews it and develops implementing instructions that are provided to the contractors. Contractors, in turn, take the CMS instruction, make any needed changes to the LCD, instructional materials, system edits etc., and prepare guidance to suppliers. This work takes some time and creates the lag that you are seeing. We encourage suppliers to review their DMERC bulletins, policy articles and LCDs. All of this information is available on DMERC Web sites.