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Completing Durable Medical Equipment (DME)Forms, Certificates of Medical Necessity (CMN) and Statements of Ordering Physician (SOP). Thomas Cornwell, MD. Certificates of Medical Necessity (CMN). Medicare requires CMN filled out on majority of durable medical equipment (DME)
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Completing Durable Medical Equipment (DME)Forms, Certificates of Medical Necessity (CMN) and Statements of Ordering Physician (SOP) Thomas Cornwell, MD
Certificates of Medical Necessity (CMN) • Medicare requires CMN filled out on majority of durable medical equipment (DME) • Every CMN has same basic format and are divided into 4 sections A, B, C and D • Supplier can only fill out sections A & C • Section B can be filled out by physician’s office staff but they must include their name, title and employer at bottom of Section B • Prescribing physician must always sign and date (no signature or date stamp allowed)
CMN: Section A • Contains information on patient, prescribing physician, supplier and place of service (where the equipment is used: Home = 12) • Initial Date: Date the equipment was delivered • Revised Date: Examples where this would apply include change in supplier, needed to go from standard to heavy duty wheel chair because of weight gain, and the equipment is needed for longer period than initially expected • Re-certification date: This only applies to O2 where Medicare requires the need for O2 be reevaluated by the physician yearly • Charting the patient’s height and weight at the first visit helps with filling out any DME forms (for bed bound / wheelchair bound patients it can be approximated)
CMN: Section B • Estimated length of need: If short term give estimated number of months needed. If lifetime need put in “99.” • Diagnosis code: Must put in ICD-9 code and not narrative diagnosis. Only need one code but can put in up to four codes. • There may be anywhere from 5-10 other questions in Section B depending on the equipment • The last part of Section B asks for the information on the office staff filling out the form if other than the physician
CMN: Section C • Contains information about the equipment that was ordered, the supplier’s charge and Medicare allowable. The HCPCS codes should match the codes in Section A. • It is helpful to look at this section when filling out Section B (e.g. were wheelchair leg rests ordered, was portable oxygen ordered, was a trapeze ordered with the hospital bed, etc.)
CMN: Section D • Section D is the physician’s attestation and signature/date. By signing this form the physician is agreeing that everything is accurate. No signature stamps or date stamps are allowed.
Oxygen Certificate of Medical Necessity • Section A: Filled out by O2 supplier • Section B: Filled out by physician or his designate (if designate need to note name of person filling out form at the end of Section B (see next slide) • Section C: Filled out by supplier • Section D: Must be signed and dated by physician, no stamps allowed
Oxygen Certificate of Medical Necessity • Oxygen is a continuous rental item through Medicare. • Illinois Medicare allowable is $228.80/month for stationary system and $35.97/month for portable O2. Medicare pays 80% of allowable and the patient or their supplemental pays 20%. • There are many types of O2 systems and Medicare does not require one specific system to be used. It is up to the physician and patient to determine what would be best (with some helpful input at times from the supplier).
Oxygen CMN: Section B • Length of need: Usually 99 = lifetime • Common Diagnoses: COPD (496.0), Emphysema: 492.8, Asthma 493.90, Hypoxemia (799.0), Congestive heart failure (428.0), Obstructive sleep apnea (780.57) • Question 1: ABG PO2 must be <56% or O2 saturation must be <89% on room air. Certification is good for 1 year. If PO2 56-59 or O2 saturation 89% need to answer questions 8, 9 & 10 and one must be answered yes “Y.” Certification is then good for only 3 months. A physician, hospital or independent lab can do the testing to qualify a patient for O2. A home health nurse can do the testing if the home health agency is CLEO licensed.
Oxygen CMN: Section B • Question 2: self-explanatory • Question 3: Patient qualifies if PO2 < 56 at rest or if O2 saturation < 89% at rest, with exertion, or during sleep. There is not a specified time the patient needs to remain <89% with exertion. Testing should also show the O2 prevents the exertional drop in O2 saturation. For O2 saturation during sleep the patient needs to be < 89% for at least five minutes. • Question 4: self-explanatory. Test must be done within thirty days of setup. Make sure address is complete including the zip code.
Oxygen CMN: Section B • Question 5: Answer appropriately. Check Section C if portable O2 ordered. Circle “N” if patient bed bound. Most patients are given portable O2 as backup should the electricity fail. The O2 company can test if a conserving device would be appropriate for portable O2. • Question 6: self-explanatory • Question 7: self-explanatory • Re-certifying O2: Need to be seen by physician to re-certify need for O2. You do not need a PO2<56 or saturation<89% to re-certifying. The doctor just needs to fill out the form with the initial qualifying oxygen level and this shows s/he still feels the O2 is necessary.
Semi-Electric Hospital Bed Certificate of Medical Necessity • Section A: Filled out by supplier • Section B: Filled out by physician or his designate (if designate need to note name of person filling out form at the end of Section B (see next slide) • Section C: Filled out by supplier • Section D: Must be signed and dated by physician, no stamps allowed
Semi-Electric Hospital Bed CMN: Section B • Semi-Electric bed means an electric controller elevates the head and feet. A hand crank can adjust the height of the bed (to help patient with transfers—usually set at appropriate height by delivery person). • Length of need: Often 99 (lifetime). May be shorter if due to trauma or acute condition (amputation, Myocardial infarction). • Common qualifying diagnoses: Respiratory: COPD (496); Cardiac: CHF (428.); Neurologic: Acute CVA (436), Late effects of CVA (438.9), Alzheimer’s Disease (331.0), Parkinson’s Disease (332.0), Multiple sclerosis (340), ALS (335.20), Orthopedic: Fractures (829.0), Arthritis (715.90), spinal injuries; AIDS (042.9); Cancer (specify)
Semi-Electric Hospital Bed CMN: Section B • Question 1: Must be yes (“Y”) for patient to qualify • Questions 3-6: Answer appropriately. One must be answered “Y” for patient to qualify • Question 7: Must be “Y” for patient to qualify • Document person filling out form if not physician
Semi-Electric Hospital Bed • Medicare pays for hospital beds on a monthly rental basis. Medicare contributes 80% and patient/supplemental insurance 20%. Medicare allowable for first three months = $167.93 (Illinois). Months 4-10 allowable is dropped by 25% to $125.95. At 10th month patient chooses to continue rental or to purchase. If purchase option is chosen Medicare pays an additional three months (total of 13 months) of rental then the patient owns the bed. Any needed repairs are the patient’s responsibility. If rental option is chosen Medicare will pay an additional 5 months rent (total of 15 months) and then the bed goes on the maintenance program where the supplier bills Medicare $125.95 every six months. The supplier is responsible for any repairs or to replace the bed if needed. If the patient no longer needs the hospital bed, dies or moves to a skilled nursing facility, the bed is returned to the supplier.
Statement of Ordering Physician (SOP):Group 1 Support Surfaces • A SOP must have required information but the supplier can customize it as they like • Necessary information includes the supplier and patient demographic information; supplier charge and Medicare allowable; estimated length of need: usually lifetime = 99; appropriate ICD-9 codes; and seven standard questions (see next slide) • 7 standard Questions: Either question 1 must be yes (completely immobile) or question 2 or 3 must be yes (limited mobility / (+) pressure sore) plus one other “yes” from questions 4 though 7
Group 1 Support Surfaces: Part II Questions • Completely immobile – i.e. patient cannot make changes in body position without assistance. • Limited mobility – i.e. patient cannot independently make changes in body position significant enough to alleviate pressure. • Any pressure ulcer on the trunk or pelvis. • Impaired nutritional status. • Fecal or urinary incontinence. • Altered sensory perception. • Compromised circulatory status. To qualify either question 1 must be yes (completely immobile) or question 2 or 3 must be yes (limited mobility/(+) pressure ulcer) plus one other “yes” from questions 4 though 7
Group 1 Support Surfaces (G1SS) • A G1SS is for patients highly susceptible to pressure sores or for patients who have pressure sores that do not qualify for a Group 2 support surface • Examples of G1SS included gel pads, alternating pressure pad pumps and foam pads • G1SSs are a one time purchase for gel and foam products (Illinois Medicare allowable $271.88) with Medicare paying 80% and the patient / supplemental insurance paying 20%. The patient then owns the pad. Alternating pressure pad pumps are a monthly rental (Illinois Medicare allowable $21.73/month) with option to purchase or continuing to rent at 10 months similar to hospital beds.
Statement of Ordering Physician (SOP): Group 2 Support Surfaces • A SOP must have required information but the supplier can customize it as they like • Necessary information includes the supplier and patient demographic information; supplier charge and Medicare allowable; estimated length of need: usually lifetime = 99; appropriate ICD-9 codes; and six standard questions (see next 2 slides)
Group 2 Support Surfaces: Part II Questions • Does the patient have multiple stage II pressure ulcers on the trunk or pelvis? Yes (Y), No (N), Does not apply (D) • Has the patient been on a comprehensive ulcer treatment program for at least the past month which has included the use of an alternating pressure or low air loss overlay which is less than 3.5 inches, or a non-powered pressure reducing overlay or mattress? Y, N, D • Over the past month, the patient’s ulcer(s) have: 1) Improved 2) Remained the same 3) Worsened? • Does the patient have large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis? Y, N, D • Has the patient had a recent (within the past 60 days) myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis: Y, N, D: If yes, give date of surgery: • Was the patient on an alternating pressure or low air loss mattress or bed or an air fluidized bed immediately prior to a recent (within the past 30 days) discharge from a hospital or nursing facility? Y, N, D
Group 2 Support Surfaces Qualifications: Patient Must Have One of the Following: • One large or multiple stage III or stage IV pressure ulcers on the trunk or pelvis. • Multiple stage II pressures sores on the trunk or pelvis and patient has been on a comprehensive ulcer treatment program for at least the past month that has included the use of at least a group 1 support surface and the wound has worsened or remained the same. • A post-surgical flap/graft within the past 60 days and the patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).
Group 2 Support Surfaces (G2SS) • Medicare pays for G2SS on a monthly rental basis. Medicare contributes 80% and patient/supplemental insurance 20%. Medicare allowable for first three months = $759.36 (Illinois). Months 4-10 allowable is dropped by 25% to $569.52. At 10th month patient chooses to continue rental or to purchase similar to the hospital bed discussed above. If the patient does not have supplemental insurance the co-pay can be a significant financial burden. • Note: A stage III or IV pressure ulcer on a heel does not qualify a patient for a G2SS. The pressure ulcer must be on the trunk or pelvis.
Manual Wheelchairs Certificate of Medical Necessity • Section A: Filled out by supplier • Section B: Filled out by physician or his designate (if designate need to note name of person filling out form at the end of Section B (see next slide) • Section C: Filled out by supplier • Section D: Must be signed and dated by physician, no stamps allowed
Manual Wheelchairs CMN: Section B • Length of need: Often 99 (lifetime) unless self-limiting problem (e.g. trauma) • Common qualifying diagnoses: COPD 496, CHF: 428.0, Arthritis (715.90), Multiple Sclerosis (340), ALS (335.20), Cerebral Palsy (343.9), AIDS (042.9), Acute CVA (436), Late effects CVA 438.9), Cancer (specify) • >250 lbs need an extra-wide wheelchair
Manual Wheelchairs: Section B • Question 1: Must be “Y” to qualify • Questions 2-4: Answer appropriately. Looking at Section C can be helpful to see what was ordered. • Question 5: Needs to be a minimum of two hours • Question 8 and 9: Answer appropriately. To get a lightweight wheelchair patient must be incapable of self-propelling a standard wheelchair but capable of self-propelling a lightweight wheelchair.
Manual Wheelchairs • Medicare pays for wheelchairs on a monthly rental basis. Medicare contributes 80% and patient/supplemental insurance 20%. Medicare allowable for first three months = $54.62 (Illinois). Months 4-10 allowable is dropped by 25% to $40.97. At 10th month patient chooses to continue rental or to purchase. If purchase option is chosen Medicare pays an additional three months (total of 13 months) of rental then the patient owns the chair. If patient goes to a skilled nursing facility s/he can take the chair with them. Any needed repairs are the patient’s responsibility. If rental option is chosen Medicare will pay an additional 5 months rent (total of 15 months) and then the chair goes on the maintenance program where the supplier bills Medicare $40.97 every six months. The supplier is responsible for any repairs or to replace the chair if needed. If the patient no longer needs the wheelchair, dies or moves to a skilled nursing facility, the wheelchair is returned to the supplier.
Seat Lift Mechanism Certificate of Medical Necessity • Section A: Filled out by supplier • Section B: Filled out by physician or his designate (if designate need to note name of person filling out form at the end of Section B (see next slide) • Section C: Filled out by supplier • Section D: Must be signed and dated by physician, no stamps allowed
Seat Lift Mechanism CMN: Section B • Estimated length of need: Usually Lifetime = 99. • Diagnosis codes: Orthopedic: Hip Osteoarthritis (OA): 715.95; Knee OA: 715.96; Neurologic: CVA with hemiplegia: 438.20; Parkinson’s Disease (332.0) • Questions 1, 2 & 5: Self-explanatory • Questions 3 & 4: Self-explanatory: My experience has been that questions 3 & 4 are often mutually exclusive: it is rare that an ambulatory cannot get up from any chair or that a patient who cannot get up from any chair is capable of walking once up. There are rare circumstances when the answer is yes to both of these. • Medicare pays 80% of the lift mechanism only and the patient is responsible for the remainder of the cost.
