`
`IN THE COUNTY COURT, OF THE
`NINTH JUDICIAL CIRCUIT, IN AND
`FOR ORANGE COUNTY, FLORIDA
`
`CASE NO: 2019-SC-014080-O
`DIVISION: 70
`
`KISSIMMEE INJURY CLINIC, LLC a/a/o
`WILLIAM MALDONADO,
`
`Plaintiff,
`
`vs.
`
`STATE FARM MUTUAL AUTOMOBILE
`INSURANCE COMPANY,
`
`Defendant.
`
`/
`
`DEFENDANT’S NOTICE OF FILING AFFIDAVIT
`
`Defendant, STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY,
`
`hereby files this Notice of Filing of an Affidavit of Denisha M. Lich, MS, RHIA, HRM.
`
`CERTIFICATE OF SERVICE
`
`I HEREBY CERTIFY that on the 25th day of June, 2020, a true and correct copy of the
`
`foregoing was sent to Eduardo Rodriguez, Esq., Pardy & Rodriguez, P.A., PO Box 3747,
`
`Orlando, FL 32802 erodriguez@pardyrodriguezlaw.com; piplegal@pardyrodriguezlaw.com
`
`through the Florida Courts E-Filing Portal system.
`
`MIMI L. SMITH & ASSOCIATES
`
`BY:
`
`(Original signed electronically by Attorney.)
`SHALISA FRANCIS, ESQ.
`Florida Bar No. 58921
`390 N. Orange Avenue, Suite 1700
`Orlando, FL 32801
`Telephone: (407) 872-2498
`Facsimile: (855) 561-8864
`E-mail for service (FL R. Jud. Admin. 2.516):
`flor.law-pip.501o19@statefarm.com
`
`
`
`
`
`
`Attorneys and Staff of Mimi L. Smith & Associates
`are Employees of the Law Department of State
`Farm Mutual Automobile Insurance Company
`
`2
`
`
`
`IN THE COUNTY COURT, OF THE NINTH JUDICIAL CIRCUIT,
`INAND FOR ORANGE COUNTY, FLORIDA
`
`KISSIMMEE INJURY CLINIC, LLC a/a/o
`WILLIAM MALDONADO,
`
`Plaintiff,
`
`vs.
`
`STATE FARM MUTUAL AUTOMOBILE
`INSURANCE COMPANY,
`
`CASE NO: 2019-SC-014080-O
`DIVISION: 70
`
`Defendant.
`|__m=spt—“C—CCC
`
`AFFIDAVIT OF DENISHA M. LICH, MS, RHIA, HRM,
`
`STATE OF FLORIDA
`
`)
`
`COUNTY OF PINELLAS)
`
`the undersigned authority duly authorized to take oaths and
`Before me,
`acknowledgments, personally appeared Denisha M. Lich, who after being duly swom,
`states:/
`
`1.
`
`My nameis Denisha M. Lich and | am overthe age of eighteen and | am competent
`
`to testify.
`
`2.
`
`3.
`
`| have personal knowledge of the matters containedin this affidavit.
`
`My testimony is based upon sufficient facts and data. My testimony is the product
`
`of reliable principles and methods.
`
`| have applied the principles and methods
`
`reliably to the facts of this case.
`
`4.
`
`! am a Registered Health Information Administrator by the American Health
`
`Information ManagementAssociation.
`
`5)
`
`| possess specialized knowledge of coding based on AMA guidelines. A true and
`
`1
`
`
`
`correct copy of my current CV detailing my knowledge and experience is attached
`
`as Exhibit 1.
`
`| have reviewed the documentation received for date of loss 5/8/15, more
`
`specifically the KissimmeeInjury Clinic, LLC’s medical records, corresponding CMS
`
`1500 forms and Explanation of Reviews (EORs)pertaining to the electrodes supply
`
`submitted with electrical muscle stimulation services for 5/11/15 date of service and
`
`the modality service submitted for 5/27/15 date of service. Exhibit 2
`
`| have reviewed the Office of Inspector General’s Compliance Program for
`
`Individual and Small Group Physician Practices, 2015 HCPCS LevelI! Coding
`
`Manual, American Medical Association (AMA) 2015 CPT Manual, AMA CPT
`
`Assistant, Centers for Medicare and Medicaid website and the Medicare Physician
`
`Fee Schedule related to the coding andbilling of the following HCPCSLevelII and
`
`CPT codes:
`
`-
`
`A4556
`
`(Electrodes
`
`(eg.,
`
`Apnea
`
`monitor),
`
`per
`
`pair);
`
`G0283 (Electrical stimulation (unattended) to one or more areas for
`-
`indication(s) other than woundcare, as part of a therapy plan of care);
`
`-
`
`97010 (Application of a modality to 1 or more areas; hot/cold pack).
`
`The Office of Inspector General (OIG) Compliance Program for Individual and Small
`
`Group Physician Practices states the following,
`
`
`
`“... The OIG has developedalist of four potential risk areas affecting
`physician practices. These risk areas include: (a) Coding and billing; (b)
`reasonable and necessary services; (c) documentation... This list of risk
`areasis not exhaustive, or all encompassing...”
`
`In the area of Coding andbilling, the OIG notes,
`
`
`
`
`
`
`
`“The following risk areas associated with billing have been among the
`most frequent subjects of investigations and audits by the OIG...Billing for
`items or services not rendered or not provided as claimed; Submitting claims
`for equipment, medical supplies and services that are not reasonable and
`necessary,Billing for non-covered servicesas if covered; Unbundling(billing
`for each componentof the service instead ofbilling or using an all-inclusive
`code)...”
`
`The OIG also notesin the area of Medical Record Documentation,
`
`“In addition to facilitating high quality patient care, a properly
`documented medical record verifies and documents precisely what services
`were actually provided... (a) the site of the service; (b) the appropriateness
`of the services provided; (c) the accuracy ofthe billing; and (d) the identity
`of the care giver...” Exhibit 3
`
`KissimmeeInjury Clinic, LLC., inappropriately unbundled electrodes, submitted as
`
`HCPCS code A4556 when separately billing with electrical stimulation therapy,
`
`HCPCScode G0283 for 5/11/15 date of service.
`
`10.
`
`Review of the Patient's Progress and Treatment notes dated 5/11/15 underthe
`
`Plan/Recommendation section, shows that
`
`in addition to other services,
`
`the
`
`provider checkedthe line items representing the following,
`
`“G0283 — Electrical Stimulation and A4556 — Electrodes.” Please see
`Exhibit 2
`
`Electrodes are a necessary component in the delivery of the electrical
`
`stimulation services submitted as HCPCS Level Ii Code G0283 in this case. The
`
`electrode supplies were furnished as an integral part of the physician's course of
`
`treatmentof the injury performed in the physician'soffice.
`
`11.
`
`As noted in the above paragraph, the documentation shows that the provider
`
`performed electrical stimulation services, submitted as HCPCS Level
`
`Il code
`
`G0283, during the same encounter. There is no documentation to indicate that the
`
`3
`
`
`
`
`
`
`
`
`
`patient purchased a take-home TENSunit and that the electrodes were given to
`
`the patient as take-home and/or replacement supplies for the TENS unit that has
`
`been purchased. Rather, review of the documentation showsthat the electrodes
`
`were issued specifically for use with the electrical stimulation services performedin
`
`the office during the same and future encounters.
`
`12.
`
`Electrodes are a necessary componentin the delivery of the electrical stimulation
`
`services, in this case submitted as HCPCSLevelII Code G0283. The electrodes
`
`were furnished as an integral part of the physician's course of treatment,
`
`the
`
`electrical stimulation service, performed in the physician's office. Therefore, the
`
`electrodes supply would not be billed separately. The payment for the electrodes
`
`supply is already included within the payment of the Electrical Stimulation
`
`procedure, HCPCSLevelI! code G0283.
`
`Based on the guidelines and documentation received, the provider was not
`
`compliant with the coding and billing guidelines when submitting HCPCS Level Il
`
`code A4556for disposable/re-usable electrodes for 5/11/15 date of service.
`
`13.
`
`The Centers for Medicare and Medicaid Services (CMS) assists providers by
`
`defining the HCPCScoding system asseenin the following,
`
`
`
`“... HCPCSis divided into two principal subsystems, referred to as
`level | and levelII of the HCPCS. Level | of the HCPCSis comprised of CPT
`(Current Procedural Terminology), a numeric coding system maintained by
`the American Medical Association (AMA)... Level
`Il of the HCPCSis a
`standardized coding system that
`is used primarily to identify products,
`supplies, and services not included in the CPT codes, such as ambulance
`services and durable medical equipment, prosthetics, orthotics, and supplies
`(DMEPOS) whenusedoutside a physician's office. Because Medicare and
`other insurers covera variety of services, supplies, and equipmentthat are
`not identified by CPT codes, the level {I HCPCS codes were established for
`
`4
`
`
`
`
`
`
`
`
`
`
`
`submitting claims for these items.”
`
`The 2015 HCPCSLevel Il Coding Manual describes HCPCS code A4556
`
`as,
`
`“Electrodes (eg. Apnea monitor), per pair’.
`
`The Manualfurther states under the code description,
`
`“If “incident to” a physician’s service, do notbill.” Exhibit 4
`
`Therefore, when the electrodes are incidental to the physicians service,in
`
`this case the electrical stimulation service, they are not separately payable. The
`
`electrodes were furnished as an integral part of
`
`the physician's personal
`
`professional service in the course of treatment performed in the physician'soffice.
`
`14.
`
`A Review of the Medicare Physician Fee Schedule (MPFS) pertaining to HCPCS
`
`Level Il code A4556 was doneto assist with the determination of the Procedure
`
`Status Code/ Code Status of this code. The Procedure Status Code/ Code Status
`
`indicates whetherthe respective codeis in the physician fee schedule and whether
`
`it is separately payableif the service is covered.
`
`The detail information for the 2015 Medicare Physician Fee Schedule is no
`
`longer available for HCPCS Level II code A4556 therefore, a review of the 2016 fee
`
`schedule was reviewed to ascertain the detail information for the respective code.
`
`The 2016 MPFS showsthat the HCPCS code A4556 has a Procedure Status Code
`
`indicator of “P” which states,
`
`“Bundled/exciuded codes. There are no RVUs and no payment
`amounts for these services. No separate paymentis made for them under
`the fee schedule.If the item or service is covered asincident to a physician
`service and is provided on the samedayas a physician service, paymentfor
`
`5
`
`
`
`
`
`
`
`Bn
`
`it is bundled into the payment for the physician service to whichit is
`incident (an example is an elastic bandage furnished by a physician incident
`to a physician service).” Exhibit 5
`
`As noted above, the payment for the electrodes, submitted as A4556,is
`
`bundied into the payment for the electrical stimulation services, submitted as
`
`HCPCS Code G0283. The electrodes are a necessary componentin the delivery
`
`of the electrical stimulation services submitted as HCPCS LevelIl Code G0283for
`
`the respective date of service. The electrodes were furnished as an integral part of
`
`the physician's personal professional service in the course of treatmentof the injury
`
`performed in the physician's office. Therefore, no separate paymentis made.
`
`15.
`
`|The CMS’ website also contains the Medical Learning Network (MLN)to assist with
`
`the educational needs of the health care professional community. This Network
`
`provides free educational resources with the assistance from clinicians, billing
`
`experts and CMS subject matter experts to cover CMS programs,policies, and
`
`initiatives.
`
`CMS’ MLN Medicare Physician Fee Schedule Fact Sheet — ICN 006814-
`
`December 2014 shows how the payment
`
`rate for an individual service is
`
`determined. This documentfurther provides the description of each component
`
`within the formula. One of the componentsis the Relative Value Unit (RVU). There
`
`are three RVUs associated with the calculation of the allowed amount, one of which
`
`is the Practice Expense (PE) Relative Value Unit (RVU) as seen below.
`
`“PE RVUreflects the costs of maintaining a practice (for example,
`renting office space, buying supplies and equipment, and staff costs).”
`Exhibit 6
`
`
`
`
`
`The paymentof the electrical stimulation therapy represented in this case as
`
`HCPCS Level
`
`I! code G0283, already reflects and includes the cost of the
`
`electrodes used when performing the service. Therefore, separately billing for
`
`electrodes used when performing the electrical stimulation service would be
`
`considered unbundling resulting in duplicate payment.
`
`16.
`
`The is also seen upon review of the CMS website under the Physician Fee
`
`Schedule section- PFS Federal Regulation Notices Items - Details fortitle: CMS-
`
`1612-FC which provides a spreadsheetcontaining the descriptions of various items
`
`included in the calculation of the practice expense (PE) relative value units. Per
`
`CMS,the sourcesof these direct PE inputs are from oneofthe following:
`
`1. Clinical Practice Expert Panels (CPEPs) convenedin 1995 to develop
`estimates of the different types of resource inputs necessary to perform
`medical services;
`
`2. A crosswalk to a related service developed based upona clinical
`Opinion by CMS;
`
`3. The AMA’s Relative Value Update Committee (RUC)2;
`
`4. Refinement of the CPEP inputs by the AMA’s Practice Expense
`Advisory Committee (PEAC)or the Practice Expense Review
`Committee (PERC) (which replaced the PEAC in September2004) or
`the RUC Practice Expense Subcommittee (which took over the PERC’s
`role in September 2007).
`
`5. CMS; or
`
`6. A medical specialty society.” Exhibit 7
`
`Following are the items/inputs usedin the calculation of HCPCS code
`
`G0283.
`
`
`
`
`
`_hepes
`
`source
`
`category
`
`|
`cms_ |
`code s
`
`__ description
`
`unit
`
`Table 1 — Excerpt of CMS-1612-FC_PUF_SUPPLY
`
`
`io | satin
`| Of,
`|quanit! global_ireference
`ruc_
`ual
`code me
`
`
`
`G0281
`G0283
`
`G0283
`
`RUC
`RUC
`
`RuC
`
`Office Supply, Grocery
`Gown, Drape
`
`SKO68
`$B022
`
`Accessory,Procedure
`
`SDO055
`
`item
`pair
`
`item
`
`0.389
`0.084
`
`1312
`
`1
`1
`
`2
`
`xX
`OX
`
`mx
`
`razor
`gloves, non-sterile
`electrode, electical
`stimulation
`tape, surgical paper1in
`G0283
`OX
`6
`0.002
`inch
`(Mkropore)
`Wound Care, Dressings SGO79
`RUC
`G0283
`OX
`1
`0.016
`electrolyte coupling ge! mi
`Pharmacy, NonRx
`$J024
`RUC
`G0283
`XXX
`1
`0.013
`swab-pad, alcohol
`item
`Pharmacy, NonRx
`$J053
`RUC
`G0283
`OX
`1
`0.389
`razor
`tem
`Office Supply, Grocery
`SKO68
`RUC
`G0329
`
`
`
`RUC SB044ssunderpad 2ftx3h(Chux)Gown, Drape item 0.23 1 OX
`
`
`
`
`
`
`As noted in Table 1 above,electrodes, regardless of whether they are re-
`
`usable or not, are included within the calculation of the of the PE RVU for the
`
`electrical stimulation service performed in non-facility settings such as a physician
`
`office. Therefore, the paymentfor the electrodes is included within the paymentof
`
`the electrical stimulation service, submitted as HCPCS Level
`
`Il code G0283,
`
`performed during each encounter. Separate billing for the electrodes used during
`
`the performance of the electrical stimulation service would be considered
`
`unbundling resulting in duplicate payment.
`
`17.
`
`Per Medicare guidelines referenced above, the use of electrodes is considered an
`
`integral part of the physician professional services and therefore would not be
`
`separately payable.
`
`Furthermore, as referenced in paragraph #14, the Procedure Status Code
`
`for A4556 is “P” which signifies that no separate paymentis madefor this under the
`
`fee schedule andif the item or service is covered as incident to a physician service
`
`and is provided on the same day asa physician service, paymentforit is bundled
`
`into the payment for the physician service to whichit is incident. Therefore, the
`
`
`
`
`
`payment for the electrodes is included within the payment of the electrical
`
`stimulation services, HCPCS Level
`
`Il code G0283 for the respective dates of
`
`service.
`
`18.
`
`The Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician
`
`Practitioners 20.3 - Bundled Services/Supplies provides further clarification of
`
`bundled supplies as seen below,
`
`“There are a number of services/supplies that are covered under
`Medicare and that have HCPCS codes, but they are services for which
`Medicare bundles paymentinto the payment for other related services. If
`carriers receive a claim that is solely for a service or supply that must be
`mandatorily bundled, the claim for payment should be denied bythe carrier.
`Separate paymentis never made for routinely bundled services and
`supplies. The CMS has provided RVUs
`for many of the bundled
`services/supplies. However, the RVUs are not for Medicare payment use.
`Carriers may not establish their own relative values for these services.”
`Exhibit 8
`
`Therefore, when the electrodes were given to the patient for use with
`
`electrical stimulation services performedin the physician’soffice, they are incidental
`
`to the electrical stimulation procedure and are not separately payable. The payment
`
`of the electrical stimulation therapy represented in this case as HCPCS LevelIl
`
`code G0283, already reflects and includes the cost of the electrodes used when
`
`performing the service. Separately billing for electrodes used when performing the
`
`electrical stimulation service would be considered unbundling resulting in duplicate
`
`payment.
`
`19.
`
`Further
`
`review of
`
`the Medicare Claims Processing Manual Chapter 12 -
`
`Physicians/Nonphysician Section 20.4.4 — Supplies of the Manual showsthat there
`
`
`
`are specific circumstances where separate payment for supplies furnished in
`
`
`
`9
`
`
`
`
`
`
`
`connection with a procedure may occur. Per the Manual,
`
`for supplies furnished in
`“Carriers make a separate payment
`connection with a procedure only when oneof the two following conditions
`exists:
`
`A. HCPCS code A4300is billed in conjunction with the
`appropriate procedure in the Medicare Physician Fee Schedule Data
`Base (place of service is physician’s office). However, A4550,
`A4300, and A4263 are no longer separately payable as of 2002.
`Supplies have been incorporatedinto the practice expense
`RVU for 2002. Thus, no payment may be madefor these
`supplies for serviced provided on or after January 1, 2002.
`
`B. The supply is a pharmaceutical or radiopharmaceutical
`diagnostic imaging agent (including codes A4641 through A4647);
`pharmacologic
`stressing agent
`(code
`J1245); or
`therapeutic
`radionuclide (CPT code 79900). Other agents may be used which do
`not have an assigned HCPCScode...” Please see Exhibit 8
`
`Review of the documentation received does not support the conditions noted
`
`above. Rather, the documentation showsthat the electrodes were providedforin
`
`office use. The electrodes were an integral component in the delivery of the
`
`electrical stimulation service performed in the physician’s office for the respective
`
`dates of service. As referenced above,
`
`“Supplies have beenincorporatedinto the practice expense RVU
`for 2002. Thus, no payment may be made for these supplies for
`serviced provided on or after January 1, 2002.” Please see Exhibit 8
`
`Therefore, the paymentfor the electrodesis already included in the Practice
`
`Expense RVUusedin the calculation of the MPFS allowed amountfor the electrical
`
`stimulation service submitted as HCPCS Level I! code G0283 for 5/11/15 date of
`
`service.
`
`20.
`
`It is important to note that the documentation received does notindicate that the
`
`10
`
`
`
`
`
`
`
`patient purchased a take-home TENS unit and that electrodes were given to the
`
`patient as take-home and/or replacementsupplies for the TENS unit that has been
`
`purchased. Rather, the documentation shows that the electrodes were issued
`
`specifically for use with the electrical stimulation services performedin the office
`
`during the same and future encounter.
`
`Electrodes are a necessary component in the delivery of the electrical
`
`stimulation services submitted as HCPCS Level || Code G0283. The electrode
`
`supplies were furnished as an integral part of the physician's course of treatment,
`
`the electrical stimulation services, performed in the physician's office. Therefore,
`
`they are incidental to the services and are not separately payable.
`
`Again, the paymentof the electrical stimulation therapy represented in this
`
`case as HCPCSLevelIl code G0283, already reflects and includes the cost of the
`
`electrodes used when performing the service. Therefore, separately billing for
`
`electrodes used when performing the electrical stimulation service would be
`
`considered unbundling resulting in duplicate payment.
`
`21.
`
`Based on the medical record documentation and the guidelines referenced in the
`
`paragraphs above, the provider was not compliant when coding and separately
`
`billing HCPCS code A4556 for 5/11/15 date of service.
`
`Paymentfor the electrodes supply was already included within the PE RVU
`
`calculation for the paymentof the electrical stimulation procedure performed during
`
`the same encounter for which they were used. Additional payment would be
`
`considered unbundling and result in duplicate payment.
`
`11
`
`
`
`
`
`
`
`22.
`
`As previously mentioned, there is no evidence within the documentation received
`
`that the shows the patient was given the electrodes to take home as a Durable
`
`Medical Equipment (DME) supply for use with an at home TENS unit. Furthermore,
`
`there is no documentation to indicate that the patient has a DME TENS unit at
`
`home.
`
`Whencoding andbilling for DME supplies the following guidelines apply.
`
`23.
`
`The Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment,
`
`Prosthetics, Orthotics, and Supplies (DMEPOS) Durable - 10.1.1 - Durable Medical
`
`Equipment (DME) defines what is considered a Durable Medical Equipmentin the
`
`following.
`
`“DME is covered under Part B as a medical or other health service
`(§1861(s)(6) of the Social Security Act [the Act]) and is equipmentthat:
`a.
`Can withstand repeated use;
`b.
`Is primarily and customarily used to serve a medical purpose;
`c.
`Generally, is not useful to a person in the absenceof an
`illness or injury; and
`is appropriate for use in the home.
`
`d.
`
`All requirements of the definition must be met before an item can be
`considered to be durable medical equipment.” Exhibit 9
`
`Again, there is no documentation to support that the patient had a DME —
`
`TENS unit at home and that electrode supplies were needed for DME use. The
`
`provision of the electrodes in this case does not meet the requirements of a DME
`
`supply.
`
`24.
`
`The DME Jurisdiction C Provider Manual Chapter 9 does cover the Durable Medical
`
`Equipment benefit category when applicable as seenin the following.
`
`“All Medicare Part B covered services processed by the DME MAC
`
`12
`
`
`
`
`
`fall into one of the following benefit categories specified in the Social
`Security Act (§1861(s)):
`
`1. Durable medical equipment (DME)...” Exhibit 10
`
`The Manual also states that necessary supplies are covered underspecific
`
`circumstancesin the following.
`
`“Supplies and accessories that are necessary for the effective use of
`medically necessary DME are covered. Supplies may include drugs and
`biologicals that must be put directly into the equipment in order to achieve
`the therapeutic benefit of the DME or to assure the properfunctioning of the
`equipment.” Please see Exhibit 10
`
`Again, there is no documentation to support that the patient had a DME —
`
`TENSunit at home and that electrode supplies were needed for DME use. The
`
`provision of the electrodes in this case does not meet the requirements of a DME
`
`supply.
`
`25.
`
`Review of Chapter 5, DMEPOS Fee Schedule Categories, of the Manual also
`
`states,
`
`“Reimbursement for most durable medical equipment, prosthetics,
`orthotics, and supplies (DMEPOS)is established by fee schedules. Payment
`is limited to the lower of the actual charge or the fee schedule amount. See
`Chapter 10 of this manual for more information about fee schedules and
`pricing. The fee schedule classifies most DMEPOSinto one of the six
`categories explained below:
`
`¢ Inexpensive or other routinely purchased DME (IRP)
`* Items requiring frequent and substantial servicing
`* Customized items
`* Other prosthetic and orthotic devices
`* Cappedrental items
`¢ Oxygen and oxygen equipment” Exhibit 11
`
`In order to determine in which category a specific HCPCS codeis classified
`
`the Manualdirects the provider to see Appendix-A HCPCSlocated at the end of
`
`13
`
`
`
`
`
`
`
`the manual. Appendix - A, shows HCPCSLevelII code A4556 with a Payment
`
`category of “13” indicating supplies and that the codeis not valid for Medicare as of
`
`11/1/1996. Exhibit 12
`
`26.
`
`Although the review of the DME fee schedule showsan allowed amount for HCPCS
`
`LEVELli code A4556 as a DME supply,the provision of the electrodesin this case
`
`does not meet the requirements of a DME supply. Therefore, the DME allowed
`
`amountis not applicable in this case. Exhibit 13
`
`Furthermore, per the DME Manual referenced above in paragraphs #26,
`
`HCPCS LevelIl code A4556is not a valid code for DME MAC.
`
`27.
`
`The Manual also provides direction as to the appropriate method of submitting
`
`claims for DME supplies as seen below.
`
`beneficiary-owned
`and accessories used with
`supplies
`“For
`equipment (equipmentthat is owned by the beneficiary, but was not paid for
`by the DME MAC/fee-for-service Medicare), all of the following information
`must be submitted with the initial claim in Item 19 on the CMS-1500 claim
`form or in the NTE segmentfor electronic claims:
`
`* HCPCScodeof base equipment
`
`¢ A notation that this equipment is beneficiary-owned
`
`* Date the patient obtained the equipment
`
`Claims for supplies and accessories mustinclude all three pieces of
`information listed above. Claims lacking any one of the above elementswill
`be denied for missing information. Medicare requires that supplies and
`accessories only be provided for equipment that meets the existing coverage
`criteria for the base item.
`In addition,
`if the supply or accessory has
`additional, separate criteria, these must also be met.
`In the event of a
`documentation request from the DME MACor a redetermination request,
`you should provide information justifying the medical necessity for the base
`item and the supplies and/or accessories. Refer to the applicable Local
`Coverage Determination(s) and related Policy Article(s) for information on
`
`14
`
`
`
`
`
`
`
`
`
`the relevant coverage, documentation, and coding requirements at
`http:/Awww.cgsmedicare.com/jc/coverage/LCDinfo. html.”
`Please see
`Exhibit 11
`
`28.
`
`As directed in the above guideline, a review of the CMS Local Coverage Decision
`
`for
`
`(LCD)
`
`for Transcutaneous Electrical Nerve Stimulators (TENS)
`
`(L5031)
`
`guidelines, effective for services performed on or after 10/31/14 was performed.
`
`The LCD provides specifics as to the coverage, documentation and coding
`
`guidelines for supplies associated with the use of a DME TENS unit used at home.
`
`Per the LCD,
`
`“Supplies
`
`Separate allowance will be made for replacement supplies when
`they are reasonable and necessary and are used with a covered TENS.
`Usual maximum utilization is:
`
`2 TENS leads - a maximum of one unit of A4595 per month
`4 TENS leads - a maximum of two units of A4595 per month.
`
`If the use of the TENSunit is less than daily, the frequencyofbilling
`for the TENS supply code should be reduced proportionally.
`
`Replacementof lead wires (A4557) more often than every 12 months
`would rarely be reasonable and necessary.
`
`...Reimbursement for supplies is contingent upon use with a
`covered TENS unit. Claims for TENS supplies provided whenthere is
`no covered TENS unit will be denied as not reasonable and necessary.
`
`Effective for claims with dates of service on or after June 8, 2012
`supplies provided for use with a previously covered TENS unit used for
`CLBP (not as part of an approved study) are not eligible for reimbursement.
`These supply claims will be denied as not reasonable and necessary.”
`Exhibit 14
`
`
`
`
`
`Again, there is no documentation to support that the patient had a DME —
`
`TENS unit at home and that electrode supplies were needed for DME use. The
`
`15
`
`
`
`
`
`provision of the electrodesin this case does not meet the requirements of a DME
`
`supply.
`
`29.
`
`In addition,
`
`review of the LCD’s Article for Transcutaneous Electrical Nerve
`
`Stimulators (TENS)- Policy Article - Effective October 2014 (A37064) states,-
`
`“A TENS supply allowance (A4595) includes electrodes (any type),
`conductive paste or gel (if needed, depending onthe type of electrode), tape
`or other adhesive (if needed, depending on the type of electrode), adhesive
`remover, skin preparation materials, batteries (9 volt or AA, single use or
`rechargeable), and a battery charger(if rechargeable batteries are used).
`
`Codes A4556 (Electrodes, [e.g., apnea monitor], per pair), A4558
`(Conductive paste or gel), and A4630 (Replacement batteries, medically
`necessary TENS ownedby patient) are not valid for claim submission to
`the DME MAC. A4595 should be usedinstead.
`
`For code A4557, one unit of service is for lead wires going to two
`electrodes. If all the lead wires of a 4 lead TENS unit needed to be
`replaced, billing would be for two units of service.
`
`There should benobilling and there will be no separate
`allowancefor replacement electrodes (A4556), conductive paste orgel
`(A4558), replacementbatteries (A4630), or a battery charger used with a
`TENS unit.” Exhibit 15
`
`Again, although the review of the DME fee schedule shows an allowed
`
`amount for HCPCS LEVEL II code A4556 as a DME supply, the provision of the
`
`electrodes in this case does not meet
`
`the requirements of a DME supply.
`
`Therefore, the DME allowed amountis not applicable in this case.
`
`Furthermore, per the DME Manual referenced in the paragraphs above,
`
`HCPCS Level Il code A4556is not a valid code for DME MAC.
`
`30.
`
`Lastly, the 2015 DME MACJurisdiction List for DMEPOS HCPCS Codestates for
`
`HCPCScode A4555 — A4558 Electrodes; Lead Wires; Conductive Paste, shows,
`
`16
`
`
`
`
`
`
`
`
`
`“Local Carrier if incident to a physician’s service (not separately
`payable).
`If other DME MAC’Exhibit 16
`
`The electrode supplies were furnished as an integral part of the physician's
`
`course of treatment, the electrical stimulation services, performed in the physician's
`
`office. Therefore, they are incidentalto the services and are not separately payable.
`
`31.
`
`As previously mentioned, review of the Initial Evaluation notes dated 5/11/15 shows
`
`that there is no documentation to indicate that the patient purchased a take-home
`
`TENS unit and electrodes were given to the patient as take-home and/or
`
`replacement supplies for the TENS unit that has been purchased. Rather, the
`
`electrodes were issued specifically for use with the electrical stimulation services
`
`performedin the office during the same encounter.
`
`Electrodes are a necessary component in the delivery of the electrical
`
`stimulation services submitted as HCPCS Level Il Code G0283.
`
`In this case, the
`
`electrodes were furnished as an integral part of the physician's course of treatment,
`
`the electrical stimulation services, performed in the physician's office. Therefore,
`
`the electrodes supply would not be billed separately. The payment for the
`
`electrodes supply is already included within the payment of the Electrical
`
`Stimulation procedure, HCPCSLevelIl code G0283.
`
`As noted abovein paragraph #13,
`
`“If “incident to” a physician’s service, do notbill.” Please see
`Exhibit 4
`
`Again, the paymentof the electrical stimulation therapy represented in this
`
`case as HCPCSLevelII code G0283, already reflects and includes the cost of the
`
`17
`
`
`
`
`
`electrodes used when performing the service. Therefore, separately billing for
`
`electrodes used when performing the electrical stimulation service would be
`
`considered unbundling resulting in duplicate payment.
`
`32.
`
`As referenced above in paragraph #8, one of the potential risk areas affecting
`
`physician practices under Coding and Billing is Unbundling. The OIG further
`
`defines Unbundling as,
`
`“,..the practice of a physician billing for multiple components of a
`service that must be includedin a single fee...”
`
`The payment for the electrodes is included within the payment of the
`
`electrical stimulation service, submitted as HCPCS Code G0283, performed during
`
`each encounter. Again, separate billing for the electrodes used during the
`
`performance of the electrical stimulation service would be considered unbundling
`
`resulting in duplicate payment.
`
`33.
`
`Based on the guidelines and documentation received,
`
`the provider was not
`
`compliant with the coding and billing guidelines when submitting HCPCS LevelI!
`
`code A4556for disposable/re-usable electrodes for 5/11/15 date of service.
`
`There is no documentation to indicate that the patient purchased a take-
`
`home TENSunit and electrodes were given to the patient as take-home and/or
`
`replacement supplies for the TENS unit that has been purchased. Rather, the
`
`electrodes were issued specifically for use with the electrical stimulation service
`
`performedin the office during the same encounter.
`
`Electrodes are a necessary componentin the delivery of the electrical
`
`stimulation services submitted as HCPCSLevelII Code G0283. The electrodesin
`
`18
`
`
`
`
`
`this case, were furnished as an integral part of the physician's course of treatment,
`
`the electrical stimulation services, performed in the physician's office. Therefore,
`
`the electrodes supply would not be billed separately.
`
`Electrodes provided for sanitary reasons does not negate the fact that they
`
`are still a necessary componentto the electrical stimulation procedure performed
`
`during the encounter. For example, manyphysician practices use various supplies
`
`for sanitary reasons suchasthe use of thermometercovers on thermometer probes
`
`when taking patients temperature, new syringes used for injections,
`
`individual
`
`specimen cups,disposable paper c