ACM Q and A - November 9, 2023 - JA DME

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for one supplier, Noridian addressed directly with the supplier. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.

Questions Received Prior to ACM

Q: For the E0651 (Pneumatic compressor, segmental home model without calibrated gradient pressure) four-week trial, we have beneficiaries developing swelling a few days after starting. How do we justify changing to the E0652 (Pneumatic compressor, segmental home model with calibrated gradient pressure)?
A: The coverage criteria for E0652 must be met, and the clinical documentation must support symptoms, objective findings (including measurements), what therapies or interventions have been tried and ruled out, as well as detailed documentation as to why the four-week trial was not completed. This information is imperative for establishing the medical necessity and severity of the condition. While this documentation does not necessarily guarantee coverage, it will be instrumental in the event of claim denial or review. All claim denials must follow the appeals process and include all pertinent records. Please refer to the Local Coverage Determination (LCD) L33829 for E0652 coverage criteria and documentation requirements.

Q: When are replacement continuous positive airway pressure (CPAP) devices covered by Medicare? Is replacement covered if a "motor hours exceeded" message appears on the machine?
A: Replacement CPAPs are covered by Medicare after the five-year reasonable useful lifetime (RUL). Equipment is expected to last the five-year RUL and replacement is only covered during the RUL in cases of loss, theft, or irreparable damage due to a specific incident (e.g., fire, flood, natural disaster). A machine message stating "motor hours exceeded" would not be a valid reason for coverage of a replacement during the RUL. Suppliers must provide functional equipment for the full five-year period.

Q: Where can I find information on coverage of oral appliances?
A: Coverage requirements for an oral appliance may be found in the LCD and Policy Article (PA) on the Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > Oral Appliances for Obstructive Sleep Apnea.

Q: For oxygen and oxygen equipment, can a new Standard Written Order (SWO) be obtained to start the rental period over and transition all beneficiaries to the N1, N2, N3 modifiers?
A: A new SWO would be needed to begin a new five-year RUL after the completion of the previous RUL, or in the case of replacement due to loss, theft, irreparable damage (specific incident). Obtaining a new SWO within the 60-month period for any other reason would not start a new rental period. The N modifiers were effective for dates of service on/after January 1, 2023, but required for initial dates of service on/after April 1, 2023. The KX modifier may be used for the entirety of the beneficiary’s RUL for initial dates of service prior to April 1, 2023. For a beneficiary with an initial date of service April 1, 2023, and after, the N modifier most appropriate for the beneficiary’s coverage would be appended to the claim(s). While you have the option of continuing to use the KX modifier for claims with initial dates of service prior to April 1, 2023, you also have the option to transition those claims to the most appropriate N modifier in place of the KX modifier.

Q: How do I determine pricing for the thoracic-lumbar-sacral orthosis code L0452?
A: When no pricing is available on the Pricing, Data Analysis and Coding (PDAC) website, pricing is determined by the supplier's cost. A detailed description of all parts used to customize the orthosis and the labor time should be documented by the supplier to be made available on request.

Q: A beneficiary has Medicare as the primary payer and Tricare as the supplemental payer. Tricare pays for the long-term care stay. Will Medicare cover DME?
A: Medicare does not pay for individual items furnished during a Part A inpatient stay. These items are paid to the Acute Care Hospitals, Long Term Care Facilities, Inpatient Psychiatric Facilities through the Inpatient Prospective Payment System (IPPS), under Medicare Part A. The facility must furnish all inpatient services and DMEPOS items during the stay or arrange for a supplier to furnish them. If necessary, the supplier will work out a payment arrangement with the facility as they are the ones receiving reimbursement from Medicare for items provided. Some items may be considered for DMEPOS in a skilled nursing facility (place of service 31) or a nursing facility (place of service 32) for beneficiaries not in a Part A covered stay. For additional guidance, visit our website at Billing, Claims, and Appeals > Billing Situations > Consolidated Billing.

Q: For Qualified Medicare Beneficiaries (QMBs), how do we ensure who pays the deductible from the first appointments of the year as well as cross-over claims?
A: QMBs are not liable for Medicare deductibles. Noridian recommends providers contact the beneficiary's state Medicaid agency for any questions about deductible billing. For more information, see the following:

• Noridian Medicare website > Browse by Topic > Remittance Advice (RA) > Qualified Medicare Beneficiary (QMB) Program
• MLN006977 – Beneficiaries Dually Eligible for Medicare & Medicaid
• Q: If a month during a capped rental period is denied for timely filing, can the rental period be extended to bill the final month past the 13-month cap in order to get the full 13 months of payment despite the clerical error?
  A: Yes, the month(s) denied can be added on at the end to allow the full 13 months rental.

Q: If the initial month with the KH modifier denied for timely filing, can we write this off and bill the second month with the KH modifier?
A: No, the second rental month would still be billed with the KI modifier. The supplier is able to add a rental month to the end of the capped rental period to request payment for all 13 rental months.

Q: If a month during a capped rental period denied for timely filing, can a month be added to the end to allow for the full 13 months so that supplies will be separately payable?
A: Yes, a month may be added at the end of the rental period to allow for the full 13 months so that supplies will be separately payable.

Questions Asked During ACM

Q: We have had several Medicare beneficiaries that have been dispensed a positive airway pressure (PAP) machine and then been referred for an oral appliance. After receiving the oral appliance (OA), they have found out that using both the PAP and oral appliance works best for them. Medicare will not pay for their PAP supplies since there is no documentation of the OA not working. How can we get Medicare to cover their supplies when they are using both and we have documentation from their Medical Provider stating they are using both PAP and OA?
A: Medicare will not cover both oral appliance and PAP with related accessories because they will deny for same or similar. The appeals process would need to be followed with documentation supporting why both devices would be being billed at the same time. This is unlikely to occur as both items would not be medically necessary at the same time.

Q: The Local Coverage Determination/ Policy Article (LCD/PA) for continuous glucose monitors (CGMs) states that the beneficiary must use the DME receiver to access their results, or the supplies are not covered. Can the supplier document the beneficiary's attestation that they do use it to meet this requirement, or must it be documented by the treating practitioner?
A: This information can be documented in either the supplier's or physician’s records.

Q: When will a Local Coverage Determination / Policy Article (LCD/PA) or other coding/coverage guidance be available for lymphedema garments under the new rule?
A: Additional lymphedema education will be coming shortly. Please watch our weekly emails, as well as our schedule of events for notification.

Q: Are gauze sponges around a suprapubic catheter tube opening in the skin covered under the Surgical Dressings Local Coverage Determination (LCD) with an appropriate wound evaluation?
A: At this time, gauze sponges are not listed in the surgical dressings LCD or Policy Article (PA) as being allowed for coverage.

Q: The Urological Supplies Local Coverage Determination/ Policy Article (LCD/PA) says that A6216, A6217, A6218 are not covered for "incontinence" but that other coverage remains under the surgical supplies LCD. Would these be covered for surrounding a suprapubic catheter with an appropriate wound evaluation? Would the documentation need to specify that they are not used for incontinence/urine leakage through the surgically caused tube opening?
A: This would be determined on a claim-by-claim basis. If the documentation supports and is specific that it is being used for the surgically created opening, it could be considered for payment upon review.

Q: Does Medicare provide reimbursement for oxygen for a beneficiary with obstructive sleep apnea (OSA) or is a positive airway pressure (PAP) device the recommended therapy for OSA?
A: For beneficiaries with OSA, the OSA must be sufficiently treated such that the underlying condition resulting in hypoxemia is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy and oxygen equipment. The question of which is the recommended therapy is at the discretion of the treating practitioner considering the beneficiary’s conditions and health needs and meeting coverage criteria in either/or both the positive airway pressure or oxygen and oxygen equipment policies, additionally, Medicare will not consider coverage of oxygen to treat OSA.

Q: Repair is needed to a beneficiary-owned positive airway pressure (PAP) device. Cost of repairs from the manufacturer before labor exceed the overall cost (13-month renal period) for the PAP device. The beneficiary is not eligible for a replacement item for another 12 months and we are not supposed to bill Medicare more than fee schedule. Do these repairs need to get billed to Medicare as non-assigned in this case or what other options does the beneficiary have?
A: No amount for repairs may be billed to Medicare or the beneficiary more than the cost of replacement. If the equipment is irreparably damaged due to a specific incident, a replacement may be provided and considered for coverage by Medicare.

Q: If the KH rental month gets denied for timely filing but 13 months of rental ultimately get billed and paid, what date of service date do we reference when billing supplies or replacement parts in the future: the actual delivery date (KH) month or the date of first paid rental month?
A: If Medicare paid all 13 rental months for the base item, supplies and repairs are separately payable and a narrative would not be needed to notify Medicare of the beneficiary-owned item. A narrative with a purchase date is only required when billing supplies for beneficiary-owned equipment that Medicare did not pay for.

Q: We have a beneficiary who resides in a skilled nursing facility (SNF), which Medicare does not cover. The secondary payer requires the items to be purchased versus rented. Some of these items are capped rental items with Medicare, for example E1161 (manual wheelchair). Since we must bill them as a purchase, we receive a CO-108 denial for failure to follow rental purchase guidelines. This causes issues with our secondary payer who then denies failure to follow primary payer guidelines. Is there a way to bill Medicare for the capped rental item as a purchase and get a patient responsibility (PR)-96 denial? Is there a modifier we should be using? We indicate POS 31 or 32 on the claim and all the accessories come back with the correct PR-96. It is just the capped rental items we have problems with. If we obtain an Advance Beneficiary Notice of Noncoverage (ABN) and bill the capped rental item as a purchase but with the GA modifier, will it then deny for PR or will Medicare automatically deny CO-109?
A: Medicare will not deny PR for a capped rental item billed when the beneficiary is in skilled nursing facility. Having a GA modifier on the claim will not automatically deny it. You cannot use an ABN to bill as a purchase.

Q: Regarding CMS Benefit Policy Manual, Chapter 9, Section 20.2.1.2, based on my understanding if the beneficiary gets a wheelchair from us that is currently renting as a capped rental item and Medicare retracts or denies a claim for the beneficiary being on hospice, if the diagnosis code we have on file for the chair is not related to the beneficiary's hospice diagnosis, we are able to bill with the GW modifier and Medicare will continue to pay for the item. Is this correct?
A: Yes, if the diagnosis is not hospice related, you would bill with the GW modifier stating it is not hospice related.

Q: If a beneficiary's old diagnostic study didn’t meet Medicare coverage criteria, and the doctor did a current titration study that qualifies, can he go back and do a home sleep study so there is a qualifying diagnostic study on file or is he ok with just the qualifying titration?
A: Payment for a respiratory assist device (RAD) for the treatment of the conditions specified in this policy may be contingent upon an evaluation for the diagnosis of sleep apnea (obstructive sleep apnea, central sleep apnea and/or complex sleep apnea). Diagnosis of sleep apnea is based upon a sleep test that meets the Medicare coverage criteria in effect for the date of service of the claim for the RAD. The sleep test must be either a polysomnogram performed in a facility-based laboratory (Type I study) or an inpatient hospital-based or home-based sleep test (HST) (Types II, III, IV, Other). If the titration meets current Medicare coverage guidelines and the guidelines above, it would be considered sufficient unless indicated in the policy that a facility-based study is required.

Q: Is Noridian planning to do a ventilator webinar that includes a few denial examples, similar the power mobility device (PMD) webinar that took place on November 7?
A: There is a ventilator webinar being developed. If you have examples of scenarios you would like to see included, please send them to dmewebinars@noridian.com. Continue to view the Schedule of Events on the Noridian Medicare website for a webinar date.