Breast Prostheses and Supplies Medicare Reference Guide
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Reimbursement Guidelines for Referral Sources
What’s inside? • External Breast Prosthesis and Supply Policy • Prescriptions • Medical Record Information • Proof of Delivery • Refill Documentation • ICD 10 Codes
For the “Date of the order” described above, use the dispensing order date i.e., the date the supplier was contacted by the prescribing physician (for verbal orders) or the date entered by the prescribing physician (for written dispensing orders).
In order to justify payment for DMEPOS items, suppliers must meet the following requirements: 1. Prescription (orders) 2. Medical Record Information 3. Proof of Delivery
Additional order date instructions: •If the prescriber creates the DWO, only a single date - the “order date” - is required. This order date may be the date that the prescriber signs the document.
Physician indicates on order number and frequency for bra refills –Should only bill three (3) month supply at one time • Example: If referral orders eight (8) bras to be dispensed for one year, you can only bill two (2)bras per three(3) months
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Before submitting a claim to Medicare, the supplier must have on file a dispensing order (if applicable), a DWO, information from the treating physician concerning the patient’s diagnosis, and any information required for the use of specific modifiers or attestation statements. The supplier should also obtain as much documentation from the patient’s medical record in order to assure themselves that coverage criteria for an item have been met. If the information in the patient’s medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice of Noncoverage (ABN) of possible denial has been obtained.
•If someone other than the prescriber (e.g., DME supplier) creates the DWO then the prescription must be reviewed and, “…personally signed and dated…” by the prescriber. In this scenario, two dates are required: an “order date” and a prescriber-entered “signature date”.
Medical Record Information
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Prescriptions
The beneficiary’s medical records include the treating practitioner’s records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request. It is expected that the beneficiary’s medical records will reflect the need for the care provided.
For the “Date of the order” described above, use the date the supplier is contacted by the prescribing physician for verbal orders or the date entered by the prescribing physician for written dispensing orders.
An external breast prosthesis garment, with mastectomy form (L8015) is covered for use in the postoperative period prior to a permanent breast prosthesis or as an alternative to a mastectomy bra and breast prosthesis.
DETAILED WRITTEN ORDERS (DWO) A DWO is required before billing. Someone other than the physician may complete the DWO of the item unless statute, manual instructions, the contractor’s LCD or policy articles specify otherwise. However, the prescribing physician must review the content and sign and date the document. It must contain:
Mastectomy bras cannot be billed as upgrade
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DISPENSING ORDERS Most equipment and supplies may be delivered upon receipt of a dispensing order. A dispensing order may be verbal or written. The dispensing order must contain: • Beneficiary’s name • Date of order • Description of item (s) • Prescribing physician’s printed name • Prescribing physician’s signature (if a written order) or supplier signature (if verbal order)
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Beneficiary’s name Prescribing physician’s name Date of the order Detailed description of the item(s) Prescribing physician’s signature Signature date, if applicable (see top of next page) Quantity to be dispensed Number of refills
A breast prosthesis is covered for a patient who has had a mastectomy. (See ICD-10 codes) A mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis.
EY – No physician or other licensed health care provider order for this item or service The RT/LT modifier are to be used with the prosthesis billing. LT - Left side RT - Right side GA - Properly executed ABN on file, and claim expected to deny
POLICY RERQUIREMENTS • PRESCRIPTIONS • MEDICAL RECORD INFORMATION
External Breast Prosthesis and Supplies Medical Policy Requirements
Proof of Delivery
Refill Documentation
There are three methods of delivery. Regardless of the method of delivery, the contractor must be able to determine that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) were received by a specific beneficiary: • Delivery directly to the beneficiary or authorized representative • Delivery via shipping or delivery service • Delivery of items to a nursing facility on behalf of the beneficiary
A routine prescription for refills is not needed. For items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.
METHOD 1—DIRECT DELIVERY TO THE BENEFICIARY BY THE SUPPLIER
METHOD 2—DELIVERY VIA SHIPPING OR DELIVERY SERVICE DIRECTLY TO A BENEFICIARY
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Beneficiary’s name or authorized representative if different from the beneficiary A description of each item that is being requested Date of refill request For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) the supplier must assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. • For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., mastectomy supplies) the supplier must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. The supplier must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill). • Cannot dispense more than a 3-month quantity at one time
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If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable POD would include both the supplier’s own detailed shipping invoice and the delivery service’s tracking information. The supplier’s record must be linked to the delivery service record by some clear method like the delivery service’s package identification number or supplier’s invoice number for the package sent to the beneficiary. The POD document must include: • Beneficiary’s name • Delivery address • Delivery service’s package identification number, supplier invoice number, or alternative method that links the supplier’s delivery documents with the delivery service’s records • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered • Quantity delivered • Date delivered • Evidence of delivery
THE REFILL RECORD MUST INCLUDE:
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Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery document. The POD document must include: • Beneficiary’s name • Delivery address • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description). The long description of the HCPCS code, may be used as a means to provide a detailed description of the item being delivered • Quantity delivered • Date delivered • Beneficiary (or designee) signature
If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service on the claim. Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This type of POD document must contain the information specified above. METHOD 3—DELIVERY TO NURSING FACILITY ON BEHALF OF A BENEFICIARY
For items directly delivered by the supplier to a nursing facility or when a delivery service or mail order is used to deliver the item(s) to a nursing facility, the supplier must have: • Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and, • Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.
REASONABLE USEFUL LIFETIME (RUL)
L8020 Fabric, foam or fiber filled = six (6) months L8030 Silicone breast prosthesis = two (2) years L8032 Nipple Prosthesis = three (3) months A new order is required for a new prosthesis at the time the RUL is reached. COMMON QUESTIONS: Q: If the RUL is 24 months for an L8030 silicone and six(6) months for L8020 foam, and beneficary gets
L8030 silicone today, she has to wait 2 years and at the time she could choose an L8020 foam? Then after six (6) months she would be eligible for L8030 again? A: Yes, that is correct. Q: Once reconstruction has been performed, external breast prosthesis will no longer be covered. Will
an external breast prosthesis still be covered in the event that the reconstruction does not provide for adequate symmetry? A: This is something that would be rare, but if medical necessity exists (diagnosis, etc.) showing that the bene still requires the external breast prosthesis even after reconstructive surgery, for symmetry, there would need to be good documentation in the medical records to justify why a prosthesis would still be needed.
PROOF OF DELIVERY • REFILL DOCUMENTATION
For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient.
ICD-10 CODE DESCRIPTION
C50.011
Malignant neoplasm of nipple and areola, right female breast
C50.912
Malignant neoplasm of unspecified site of left female breast
C50.012
Malignant neoplasm of nipple and areola, left female breast
C50.919
Malignant neoplasm of unspecified site of unspecified female breast
C50.019
Malignant neoplasm of nipple and areola, unspecified female breast
C79.81
Secondary malignant neoplasm of breast
C50.111
Malignant neoplasm of central portion of right female breast
D05.00
Lobular carcinoma in situ of unspecified breast
C50.112
Malignant neoplasm of central portion of left female breast
D05.01
Lobular carcinoma in situ of right breast
C50.119
Malignant neoplasm of central portion of unspecified female breast
D05.02
Lobular carcinoma in situ of left breast
C50.211
Malignant neoplasm of upper-inner quadrant of right female breast
D05.10
Intraductal carcinoma in situ of unspecified breast
C50.212
Malignant neoplasm of upper-inner quadrant of left female breast
C50.219
Malignant neoplasm of upper-inner quadrant of unspecified female breast
C50.311
Malignant neoplasm of lower-inner quadrant of right female breast
C50.312
Malignant neoplasm of lower-inner quadrant of left female breast
C50.319
Intraductal carcinoma in situ of right breast
D05.12
Intraductal carcinoma in situ of left breast
D05.80
Other specified type of carcinoma in situ of unspecified breast
D05.81
Other specified type of carcinoma in situ of right breast
Malignant neoplasm of lower-inner quadrant of unspecified female breast
D05.82
Other specified type of carcinoma in situ of left breast
C50.411
Malignant neoplasm of upper-outer quadrant of right female breast
D05.90
Unspecified type of carcinoma in situ of unspecified breast
C50.412
Malignant neoplasm of upper-outer quadrant of left female breast
D05.91
Unspecified type of carcinoma in situ of right breast
C50.419
Malignant neoplasm of upper-outer quadrant of unspecified female breast
D05.92
Unspecified type of carcinoma in situ of left breast
C50.511
Malignant neoplasm of lower-outer quadrant of right female breast
I97.2
Postmastectomy lymphedema syndrome
C50.512
Malignant neoplasm of lower-outer quadrant of left female breast
Z85.3
Personal history of malignant neoplasm of breast
C50.519
Malignant neoplasm of lower-outer quadrant of unspecified female breast
Z90.10
Acquired absence of unspecified breast and nipple
C50.611
Malignant neoplasm of axillary tail of right female breast
Z90.11
Acquired absence of right breast and nipple
C50.612
Malignant neoplasm of axillary tail of left female breast
Z90.12
Acquired absence of left breast and nipple
C50.619
Malignant neoplasm of axillary tail of unspecified female breast
Z90.13
Acquired absence of bilateral breasts and nipples
C50.811
Malignant neoplasm of overlapping sites of right female breast
C50.812
Malignant neoplasm of overlapping sites of left female breast
C50.819
Malignant neoplasm of overlapping sites of unspecified female breast
C50.911
Malignant neoplasm of unspecified site of right female breast
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D05.11
ICD-10 CODES
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ICD-10 CODE DESCRIPTION
NOTE ABOUT MEDICARE For any item to be considered for coverage by Medicare, the patient must meet the guidelines as outlined in the medical policies and associated articles as described on the Medicare websites, and the clinical records must prove the medical necessity. The information in this guide was compiled by Essentially Women, a division of VGM Group, Inc., a Member Service Organization of which we are a proud Member.
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The information provided herein is our judgment about interpretation of applicable policies and regulations and is believed to be current and substantially accurate as of the time of publication. Policies and regulations are subject to amendment or repeal, and the governing agency may issue official or informal interpretations, rulings or opinions at any time. The opinions and information expressed herein are subject to change based on such factors and should not be taken as legal advice or as binding on the authors.(Version 1.0 August 2017)