DMEevalumate launches new web-based documentation solution

Date Published: October 06 2013

When it comes to audits, respiratory providers can now rest easier when utilizing the first web-based solution that practitioners use for face-to-face documentation. has applied its functionality of correctly documenting medical justification for power mobility devices, to develop the first online questionnaire for respiratory equipment. 

“We are excited to be able to offer the first truly interactive electronic template that accurately documents and produces complete medical justification for oxygen, CPAPs and BiPAPS,” Jamie Loper, co-founder of said.

When using during a face-to-face evaluation, medical professionals select the equipment that the patient needs: home oxygen, PAP, or PAP with oxygen bleed. After answering a series of questions on the web-based template, the algorithmic program ensures all necessary information is documented. All mandatory questions must be answered before the user moves on to the next section. The program then applies coverage and coding criteria to the answers for instant determination and complete medical justification for that piece of equipment. 

“The question and answer process takes less than 10 minutes and DME providers and practitioners no longer have to spend hours researching and second-guessing what information is required,” Loper added. “ generates the Medicare-required outputs related to the piece of equipment a practitioner prescribes. Upon receiving this paperwork for vended equipment, DME providers can file accordingly in preparation for prepayment audits.”

According to Loper, DME providers can spend months trying to get complete paperwork for oxygen, CPAPs and BiPAPs.  Unlike power mobility documentation requiring face-to-face evaluation documentation and a seven-element order, different documentation is required for respiratory equipment, depending on a patient’s needs. These differing documentation requirements are a source of confusion for doctors and providers. 

Loper explains that the algorithms within automatically create the correct form required for each type of respiratory equipment. The first question in the program determines which type of equipment is needed – oxygen, CPAP or BiPAP, and whether it is an initial evaluation, recertification or a renewal. For example, if a patient has been identified as needing home oxygen, the initial evaluation in takes the practitioner through a series of questions which upon completion will produce sections A and B of the Certificate of Medical Necessity (or 484 CMN form) in addition to the face-to-face evaluation documentation and initial order. In the case of PAP therapy, the program creates an initial order and face-to-face evaluation document. “Once the required sections are completed and formatted appropriately the practitioner simply saves the face-to-face evaluation as a PDF, prints, and faxes it over to their preferred DME provider who will coordinate the next steps. They can also upload it into their electronic health records,” Loper said. “ ensures that the practitioner addresses all of the medical coverage criteria questions, eliminating the most frequent denial for PAP therapy which occurs in the 31 to 90 day recertification timeframe.”

As well as producing accurate and complete documentation, DMEevalumate now has a team of training and marketing managers and Medicare coverage criteria consultants; offering extensive customer support at no additional cost. Training managers assist subscribed providers in becoming familiar with DMEevalumate’s software and site, including going through the face-to-face evaluation questionnaire and reviewing the outputs with specific Medicare requirements for power mobility and respiratory. Marketing managers provide individualized referring physician communications including customized tactics and best practices for approaching physicians and presenting coverage experts review and provide assistance for resolution of documentation that has been denied, including assistance in writing an addendum or clarification and support for resubmittal.

“Our clients have unlimited utilization of the DMEevalumate’s electronic template online, and customized one-on-one training with an actual human,” Loper said. “We consider each client a partner and we want them to succeed, not only in utilizing the program but also at increasing physician referrals for respiratory and PMD. Our customers should feel empowered to be able to show physicians a proven solution for one of the industry’s toughest hurdles right now: accurate and compliant DME documentation.”

According to Loper, compliance is one of the biggest priorities in the HME industry. With the increase in audits, files must be compliant. In the case of pre-payment audits, if files are not compliant, the vended equipment will not be reimbursed until documentation is complete. In the case of post-payment audits, providers are expected to return payment if equipment was vended without sufficient paperwork from referring physicians. Receiving incomplete paperwork from practitioners that does not meet the Centers for Medicare and Medicaid Services (CMS) standards for an audit is not uncommon. Spending time reacting and preparing for audits means less time is spent being proactive and growing your business. Respiratory and PMD sales representative alike spend hours, sometimes days trying to obtain the correct information often with limited success.

“ enables accurate and complete respiratory orders to be obtained in a day. Oxygen and CPAP providers can now look forward to utilizing the time saved chasing missing paperwork with getting in front of more physicians and presenting a solution to produce the required respiratory documentation,” Loper said.

For years, the DME community has been asking for electronic templates to help take the guesswork out of the reimbursement process and instill confidence during audits. Since September of 2012, DMEevalumate’s online PMD electronic template has helped hundreds of PMD suppliers receive complete and accurate seven-element orders and face-to-face evaluation documentation from their referring practitioners. According to David Whitaker, director of provider relations for, the PMD program currently boasts a 99 percent prior authorization (PA) success rate in an industry experiencing an average of 50 percent denials in the seven PA states.

“We are pleased with the results our PMD module has generated for our partners so far,” Whitaker said. “If a patient qualifies for a PMD, successfully compiles the correct documentation that meets Medicare’s coverage criteria. The next obvious step for us was to provide the same solution for DME providers who focus on respiratory equipment.”

Whitaker added that the new face-to-face condition for payment, section 6407 of the Affordable Care Act, and an increase of pre- and post-payment audits across the nation prompted to provide a solution to help DME providers ensure compliant paperwork.

Effective July 1, 2013 (to be enforced in 2014), the new face-to-face requirement means that a patient can no longer simply call their primary care physician to request and receive a prescription for more than a hundred DME devices. Instead, they will need to schedule an appointment for a face-to-face evaluation with their physician, and that patient visit must have medical justification documentation for a piece of equipment.

“CMS will not reimburse a DME provider for any of the DME items listed in this new requirement without a detailed written order and the office visit note, otherwise known as a face-to-face evaluation. The date of the face-to-face evaluation must be before the date of the written order for the equipment.” Whitaker said.

Loper explains that this further impacts the DME provider because failure to obtain the required documentation will result in the denial of the claim, when reviewed in a pre-or post-payment audit. DME provider’s can expect more audits if their files do not pass inspection.

In August 2013, the medical review department of CGS, the Jurisdiction C DME MAC, shared a status report for quarter 2 – 2013 – HCPCS Code E0601 service-specific prepayment review, and reported that 67 percent of CPAP payments reviewed between April 1, 2013 and June 30, 2013, were denied.

 “CGS reported a 55 percent error rate the year prior, same quarter,” Loper said.

Simultaneously in another region, NHIC, Corp, the jurisdiction A DME MAC, has been performing a service-specific documentation compliance review (DCR) of HCPCS Code E1390 (Oxygen Concentrator) 5,401 claims from April 01, 2013 through June 30, 2013.

3,405 claims were denied resulting in a claim denial rate of 63%. An additional 85 claims were denied during this time frame because responses were not received for the Additional Documentation Requests (ADR).

“Based on review of the documentation received, NHIC Corp stated the primary reason for denial was insufficient documentation,” Loper said. “In most cases no documentation of the treating physician visit 30 days prior to the initial CMN was submitted. In addition no documentation of the beneficiary’s most recent blood gas study/oxygen saturation test was submitted. These are processes can help facilitate.”

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