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Medicare Compliance & Reimbursement

Home Health:

CMN No Longer Required For DME Repairs

Published on Wed Jul 23, 2003

Good news on diagnosis coding trickles down to DMERCs as well.

Suppliers can cross at least a few paperwork tasks off their list of Medicare requirements - certificates of medical necessity and physician orders for durable medical equipment repairs.

The Centers for Medicare & Medicaid Services "shortly" will issue an instruction on requirements for DME repairs, said a CMS official in a June 25 special DME Open Door Forum. The instruction will clarify that neither CMNs nor physician orders will be necessary for Medicare to pay for repairs.

That will go for DME that Medicare paid for, or for beneficiary-owned items. For example, if a beneficiary purchased an item before he had Medicare coverage, then went on the program, Medicare will pay for repairs to the item without a CMN or order, the CMS source explained in the forum.

The forthcoming instruction also will clarify a repair versus replacement.

Diagnosis Coding 

CMS seems to be sending a message loud and clear on the issue of diagnosis coding, but some DME regional carriers still don't appear to be hearing it. If physicians fail to supply a valid ICD-9 diagnosis code for a patient, DME suppliers are free to use resources such as coding books and other professionals to assign a correct, updated code for a patient based on a physician's narrative description, CMS reiterated in the June 25 forum.

Further, DMERCs shouldn't deny claims when the diagnosis code on the claim doesn't exactly match the code on the original order or CMN, CMS said, as long as:

  • there's evidence in patient's medical record to justify use of the diagnosis code;

  • the diagnosis code on the claim justifies coverage for item or service; and

  • the diagnosis code on the claim is valid and to the highest level of specificity.

    But at least one DMERC posted an article intimating that the valid, correct diagnosis code, which will be required by HIPAA starting Oct. 16, must come from the physician, according to a caller participating in the July 2 Home Health Open Door Forum. CMS agreed to talk to the DMERC and tell it to remove the incorrect instruction.

    Appeals 

    Providers' fears surrounding the Administrative Law Judges' move from the Social Security Administration to the Department of Health and Human Services may be justified. A caller complained that her DMERC won't stop denying claims for the same item, even though an ALJ continually overturns the denials. In response, a CMS official said moving the ALJs to HHS may put a stop to those reversals.

    "The ALJs will be coming to CMS in the next couple years, and we're hoping we'll be able to concentrate more training for these ALJs," the source said, noting that the ALJs currently aren't held to local medical review policies. "They have not had some of that training in the past. So we hope that, over the next couple years, that situation will be corrected."

    CMS also doesn't have the funds to implement the appeals system changes required in the Benefits Improvement and Protection Act of 2000, another CMS official said in the June 25 forum.

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