ACM Q and A - February 12, 2025 - 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.

Questions Received Prior to ACM

Q: Can braces be fit preoperatively with a prior authorization on file?
A: If the brace is for use postoperatively, it cannot be dispensed until medical need is established after surgery. Surgery may affect how the brace fits, so fitting and dispensing should be done postoperatively.

Q: Can the functional mobility deficit be sufficiently resolved by the prescription?
A: If the functional mobility deficit is listed on the prescription, it must also be addressed within the medical record. Medical necessity must be corroborated within the medical record to meet criteria.

Q: Are telehealth visit notes and testing still valid for oxygen qualifications?
A: An approved telehealth is allowed for oxygen; however, all oxygen qualification testing must be performed in person by a treating practitioner or other medical professional qualified to conduct oximetry testing.

• Noridian Medicare website > Browse by Topic > Documentation > Telehealth
• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > Oxygen and Oxygen Equipment

Q: How do we make sure we are prepared for and have all documents needed to pass a parenteral, enteral, or home infusion Recovery Audit Contractor (RAC) audit?
A: Performant, the RAC contractor reviews and ensures documentation complies with CMS guidelines and policies. Knowing and understanding the Standard Documentation Requirements Article for All Claims Billed to the DME MACs A55426, as well as the Local Coverage Determination (LCD) specific to the DME item in question, will help ensure suppliers are dispensing medically necessary items/services and are compliant with documentation requirements.
Medicare requires documentation such as a Standard Written Order (SWO) and medical records that support the necessity for the items provided (found in the related LCD and policy article) as well as proof of delivery. Other documentation that may be necessary may include a refill request and continued need/use documentation. Noridian also provides documentation checklists to help suppliers ensure all applicable documentation is readily available as part of Medicare claims payment and processing activities.

• Noridian Medicare website > Other Review Contractors > Recovery Auditor
• Noridian Medicare website > Policies > Documentation Checklists

Q: What should I do when using more than two modifiers?
A: The claim form can capture up to four modifiers. If more than four modifiers are needed, use modifier 99 (overflow) as the fourth modifier and enter the additional modifiers in the narrative field of the claim.

• Noridian Medicare website > Browse by Topic > Modifiers

Q: What are the required elements on a SWO when billing for walkers, canes, and crutches?
A: The required elements of the SWO are found in Standard Documentation Requirements Article A55426 and include:

• Beneficiary's name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number
  • For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
  • For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately)
• Quantity to be dispensed, if applicable
• Treating practitioner name or NPI
• Treating practitioner's signature

Q: Are there resources for compression items?
A: Noridian offers many educational tools for the understanding of lymphedema coverage.

• Webpage provides resources on billing, coverage, documentation, and enrollment, FAQs, and HCPCS associated with the policy. Noridian Medicare website > Browse by DMEPOS Category > Lymphedema Compression Treatment
• DME on Demand 16-minute tutorial reviewing coverage and billing guidelines. Noridian Medicare website > Education and Outreach > DME on Demand Tutorials
• Upcoming live webinar scheduled for March 4, 2025, at 1 pm CT. Register for this webinar. Noridian Medicare website > Education and Outreach > Schedule of Events

Q: Why am I getting CO261 denials again?
A: This denial indicates the procedure, or service is inconsistent with the patient's history. The procedure code billed is not correct/valid for the services billed or the date of service billed. In the event of a claim denied with no appeal rights, the education team would recommend evaluating the billed codes to make sure that they all make sense and go together and rebill based on that evaluation.

Q: What supporting documents from the doctor are required to qualify a patient for intermittent catheterizations (HCPCS code A4353)?
A: To qualify a patient for A4353, you'll need to ensure you have comprehensive documentation that supports the medical necessity of the procedure. Here are some additional supporting documents you might request from the doctor:

• Detailed medical history: information about the patient's underlying condition (e.g., neurogenic bladder, spinal cord injury, etc.) and any relevant past medical history.
• Diagnosis and Clinical Notes: Specific diagnosis codes and detailed clinical notes that explain why intermittent catheterization is necessary.
• Frequency of Catheterization: Documentation on how often the patient needs to catheterize (e.g., every four hours).
• Previous Treatment Attempts: Records of any previous treatments attempted and their outcomes.
• Immunosuppression Status: If applicable, documentation of the patient's immunosuppressed status (e.g., post-transplant, chemotherapy).
• Recurrent Infections: Evidence of recurrent urinary tract infections (UTIs) while using other catheterization methods.
• Consent and Education: Documentation that the patient (or caregiver) has been educated on the proper use of intermittent catheterization and has given informed consent.        

Q: Wyoming does not have any written policies regarding the length of validity of a prescription. How often do we need one for 99?
A: The Standard Documentation Requirements Article A55426 does not state a time frame for a Standard Written Order. It does however state that timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.

Q: Is a doctor able to hand sign his name and have the signature date typed, not an electronic signature, on a SWO/RX for DME?
A: The method used to sign, and date should be the same.

Q: Why can't dispensing fee codes be down coded in the portal anymore?
A: Self-service reopenings (SSROs) are available for most dispensing fees however, there are situations where a SSRO may not be appropriate. One situation would include a date of service overlap. When there is a date of service overlap, a SSRO is not appropriate, and the items will require an appeal. Likewise, in situations where the supplier initiates a SSRO and there is no base item on file, these items will require a telephone reopening.

• Noridian Medicare website > Billing, Claims, and Appeals > Reopening > Too Complex for Reopening

Q: Are alternative face-to-face charting methods such as Parachute and DMEscripts sufficient for coverage criteria and audits?
A: To determine what is considered medical records, please refer to the Program Integrity Manual, 100-08, Chapter 5, Section 5.9.

• For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable).
• The patient’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or HHA records and records from other health care professionals.

Q: For non-assigned claims, how long after the remittance advice date does it take for the beneficiary to receive payment?
A: While we cannot provide a specific timeline, Medicare Summary Notices (MSNs) with checks are mailed as they are processed.

Q: Are there any upcoming policy changes for ventilators?
A: The ventilator policy is not changing at this time. If changes arise, we will provide education.

Q: Respiratory Assist Device E0471 is ordered for a patient with a diagnosis of complex sleep apnea. The specific issue is tied to hypopneas during a CPAP (E0601) or BiLevel (E0470) titration. We have a sleep lab that currently does not categorize the hypopneas as "central" or "obstructive". The physician feels in the case where the hypopneas are not categorized as either obstructive or central, we should just ignore them altogether and not use them at all to factor into the CMS criteria. See below for two specific questions we were looking for answers to.

• 1. On a patient with a diagnosis of complex sleep apnea, how do we (as a supplier looking to qualify a patient) categorize hypopneas if the sleep study does not distinguish between central hypopnea and obstructive hypopnea?
• 2. If the sleep study does not categorize the hypopneas, can all hypopneas be removed from the qualifying criteria?

A: We cannot pre-approve medical documentation or how you as the supplier should distinguish hypopneas, as that would be a business practice. All hypopneas should not be removed from the qualifying criteria. Instead, the total number of hypopneas (both central and obstructive) should be included in the Apnea-Hypopnea Index (AHI) calculation.

Q: I am trying to locate any directional answer to the supplier of how we are supposed to operate in our event. Our facility has been totally destroyed, and files and products have been moved to storage. I've reached out to our accrediting body, and they have no clear answer, neither does the California Department of Public Health (CADPH). I've also reached out to Noridian, and they only gave me the links on the Noridian website to get my information. However, most of the information is regarding billing and beneficiaries getting their product, nothing about the supplier. Are we able to temporarily operate from home? What direction would be appropriate?
A: National Provider Enrollment (NPE) West states the supplier will need to submit a change of information to update the enrollment and include updated insurance, licensure, surety bond, etc., indicating the new address. A site visit will be ordered to ensure the location is compliant. There is a FAQ on the Palmetto website that provides information for home-based suppliers. https://palmettogba.com/palmetto/npewest.nsf/DID/CHEQ7G3182

Q: If a nocturnal oxygen patient later has suspected obstructive sleep apnea (OSA) and is qualified for positive airway pressure (PAP), do they need to requalify for nocturnal oxygen?
A: The beneficiary must meet the coverage requirements that are outlined in the PAP LCD along with meeting the coverage requirements in the oxygen LCD. In the case of OSA, it is required that the OSA be appropriately and sufficiently treated before oxygen saturation results obtained during sleep testing are considered qualifying for oxygen therapy and oxygen equipment.

Q: Why are A4222 GA supply lines being rejected with reason code CO-16, remark code M124 with base ambulatory infusion pump (E0781) on the same claim?
A: Claim specific questions must be directed to the Supplier Contact Center, Jurisdiction A – 866-419-9458 or Jurisdiction D - 877-320-0390.

Q: How should we be billing for services rendered to a beneficiary residing in our state, but shows an address on file in another state?
A: Please bill the jurisdiction where the beneficiary’s address is on file with the Social Security Administration. https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs

Q: Does sterile water/saline (A4217) require a modifier when dispensed for a tracheostomy patient?
A: HCPCS code A4217 does not fall into the tracheostomy policy and would not be covered under the tracheostomy benefit.

Q: For "inexpensive and routinely purchased items," can we, the supplier, gather ‘minor’ medical necessity information to supplement the providers records? Two examples:

• A bedside commode is prescribed, and the provider’s progress notes do not include, "the patient is confined to a single room of their home." Can we, during our intake, gather that information from the caretaker/family or patient and document it in our Electronic Health Records (EHR) system (that is, date, time, and user stamped and preserved)? This is especially when the progress notes describe the patient’s condition in such a way that being confined to a single room is a reasonable conclusion and there is nothing in the record to contradict it.
• A walker is prescribed, and the provider’s progress notes do not include the statement regarding "the patient can safely use the equipment and is willing to use the equipment." Can we, the supplier, during our thorough intake of the patient, gather and document this information within our EHR system?
• I’m asking because physicians rarely remember to include those statements, and when we ask for this ‘verbiage’ to be included in their chart note, the feedback is negative. Our local physicians have said it feels "robotic and routine" – much like the look, sound, and feel of a ‘form’ or ‘blanket statement’.

A: Payment is determined by Medicare based on the physician’s medical record and what is included in the record to substantiate the standard written order (SWO). The payment from Medicare will not be determined by supplier records when it comes to meeting medical necessity.

Verbal Questions During ACM

Q: For codes that require a prior authorization (PA), is the requirement the same if Medicare is secondary?
A: Yes. The PA process is the same if Medicare is secondary.

Q: We’re receiving a lot of same or similar denials recently and when we check the Noridian Medicare Portal (NMP), it’s not reflecting on there. Are there any glitches right now?
A: We are not aware of any at this time. Suppliers should check same and similar for all four DME MAC jurisdictions.

Written Questions Received During ACM

Q: Does sterile water/saline (A4217), when used with a nebulizer, require a modifier?
A: The Nebulizer LCD states the following modifiers are applicable: EY, GA, GZ, JW, JZ, KO, KP, KQ, and KX.

Q: If a beneficiary has been on therapy for many years and recently transitioned to Medicare Fee-for-Service (FFS), is it acceptable to use a sleep study scored using the 3% desaturation if we have notes dated after the Medicare eligibility date documenting use and benefits?
A: There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/Respiratory Disturbance Index (RDI) coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories. If the sleep study was scored at 3%, they can have it rescored if the raw data is available. If it's not, then a new sleep test is required.

Q: Did you change the format of the webinars? I am no longer able to copy and paste the questions, unable to screenshot the pre-submitted questions, etc. The Chat box is very different from previous webinars.
A: We updated the look of the slide deck but nothing else has changed in GoToWebinar that we are aware of.

Q: We had a beneficiary that qualified for an adaptive-servo ventilation (ASV) machine but then failed 90-day compliance. We then received a new prescription from their provider as they wanted to try using the machine again. When we researched the RAD policy, we could not determine the process of "requalifying" the beneficiary. Would they need to start over by obtaining a new diagnostic sleep study and go through the process all over again or maybe complete a new CPAP/BIPAP to ASV titration? They had continued using the machine but just didn't meet the 70% usage in the first 90 days.
A: Beneficiaries who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both: In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy; and repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.

Q: When will coverage criteria be established for the E0469? What should we look for in medical records currently for qualifying a beneficiary for the item?
A: At this time there is no established coverage criteria for this HCPCS code. If coverage criteria are established, we will provide education.

Q: For heavy duty walkers, the LCD states "if the supplier has documentation in their records that the beneficiary's weight (within one month of providing the walker) is greater than 300 pounds." Does this mean the weight can be documented by us as the supplier, or does it have to be in the medical record within 30 days?
A: For documentation to be considered, it must be included in the beneficiary’s medical record provided by the treating practitioner. We cannot use supplier records alone to consider payment from Medicare.

Q: Are you able to clarify what should be done when a beneficiary is living in one state, but their payee address is in another state? Are we required to have the address updated with Social Security Administration (SSA) to their residence state to bill our local jurisdiction? As a follow-up, will Noridian always have the most updated beneficiary residence address listed in the portal, even if they do have a payee in another?
A: If the beneficiary is traveling, they do not need to change their permanent address with the SSA. You should use the address on file with the SSA for billing, even if the beneficiary is temporarily living in another jurisdiction. The portal will contain the beneficiary’s address on file with the SSA. If the beneficiary has moved permanently, they should update their address by calling 1-800-MEDICARE. This ensures that all records are up to date and that any correspondence reaches the correct location.

Q: If we have a beneficiary with an actively renting standard manual wheelchair and we have now received a referral and begun the process of qualifying for a more complex power mobility device due to a change in condition, at what point in the process must we cease billing for the capped rental manual chair, or are we able to continue to bill until we deliver the new power mobility device if our original medical record indicates that the beneficiary has someone in the residence that can assist them in propelling the original chair?
A: You could continue billing a medically necessary manual wheelchair until the power wheelchair is delivered. Once that power chair has been delivered, you would begin billing for the power chair. If a same or similar denial is received, follow the appeals process and submit supporting documentation.

Q: If we have an oxygen beneficiary that switched from Medicare to an Advantage Plan, do we start the rental months over, or are we supposed to count the months billed to Medicare towards the Advantage Plan rental months?
A: If the beneficiary initially qualified with FFS Medicare, changed to an Advantage Plan, and then resumed FFS, as long as oxygen was used the entire time, billing would pick up where it left off from previous FFS billing.

Follow-up Question: If they switch from FFS to Advantage, do we count the billing months with FFS or start over on month one with the Advantage Plan?
A: We can only speak to the FFS billing. If they switched to an Advantage Plan, you need to contact that company for their requirements.

Q: A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests (ELRs) will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met. Does meeting only these criteria qualify a beneficiary for E1012, power elevating legrests?
A: Yes, meeting this coverage criteria listed in the LCD should meet for the E1012.

Q: Elevating legrests (E0990, K0046, K0047, K0053, K0195) are covered if:

• The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degree flexion at the knee; or
• The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or
• The beneficiary meets the criteria for and has a reclining back on the wheelchair.

If a beneficiary meets the criteria above and cannot operate manual ELRs and otherwise meets criteria for a power wheelchair, would this qualify the beneficiary for power ELRs?
A: If the beneficiary meets the criteria of the LCD, payment should be expected. Provider outreach and education cannot pre-approve claims or documentation.

Q: A power seating system – tilt only, recline only, or combination tilt and recline – with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met.
If a beneficiary meets only criteria 1, 2, 3, and 4, would they qualify for tilt/recline combo? For many beneficiaries, tilt alone allows him/her to perform functional weight shift. If the beneficiary only meets criteria 1, 2, 3, and 4 (and NOT 5 or 6) and a practitioner orders tilt/recline combo, does the practitioner have to justify why tilt alone would not be sufficient to allow the beneficiary to perform a functional weight shift in order to qualify for tilt/recline combo?A: If 1-3 are meet and only one of 4 - 6 are met then payment should be expected.

Q: For power mobility devices (PMDs), a SWO is required to be filled out by the treating practitioner. Is it acceptable for a treating practitioner to type part of the SWO and handwrite part of it? For example, could they type the detailed description of items, but handwrite the beneficiary name and date of birth or what if they typed the entire document, then hand-signed and dated?
A: This is acceptable if all the required elements of the SWO are present. However, the method used to sign, and date need to match.

Q: Per Policy Article A52498, if a PWC is a Group 3 chair and has only a power seat elevation system on it, is it considered a Single Power Option chair or No Power Option? The definitions seem contradictory. "No power options" definition says if a PWC can only accept power elevating legrests and/or seat elevation, it's a No Power Option. "Single Power Option" definition says for Group 3, 4, and 5, a power seat elevation system would make it a Single Power Option.
A: According to Policy Article A52498, a Group 3 power wheelchair (PWC) with only a power seat elevation system would be considered a Single Power Option chair, not a No Power Option chair.
The key distinction is that a Single Power Option chair can have one power feature (like a power seat elevation system) but not a combination of power tilt and recline. On the other hand, a No Power Option chair cannot have any power features like power tilt, recline, or standing systems.

Q: Is the L0120 (cervical orthotic) still covered by Medicare? Is it included in an LCD?
A: L0120 is still be covered by Medicare. There is not an LCD tied to L0120. Payment would be based on medical necessity documented in the beneficiary’s medical record and requirements from the Standard Documentation Policy Article A55426 being met.

Q: I am getting denials for the A7000 for modifier when used with a suction pump. This is not a wound suction pump. We never needed to add a KX. I have called prior on this and did not receive an answer, and it has been over a month. Please advise of this new CO-16 denial that started after January 1, 2025.
A: The claim will need to be billed with a KX, GA, GZ, or GY modifier to process correctly. If those modifiers are not added, the claim will deny for incorrect modifier/coding.

Follow-up Question: The KX modifier was never required for the suction pump, it was only required for the wound care suction. Are you saying that the policy has now changed that we need a KX modifier for the A7000 for a suction machine? If we add a KX modifier, will it then be assumed that it is being used for wound care and then subject to audits for wound care when we are not supplying it as wound care?
A: If an audit is received for this code, please provide all requested documentation for the review. The A7000 is listed under two different policies and if denials are being received for missing modifiers and you disagree with the denial, please follow the appeals process.

Q: Can you please talk a bit about custom orthoses that do not have a corollary off-the-shelf (OTS), like L1686 (prefabricated hip abduction orthosis). Can you explain the process of billing L1499 and L2999?
A: For custom fitted orthoses that do not have a corresponding off-the-shelf code, for example L1686, the supplier should bill the corresponding miscellaneous code (L1499 for spinal orthoses, L2999 for lower extremity orthoses, and L3999 for upper limb orthoses). Noridian's Off-the-Shelf or Custom-Fitted Orthotic Lookup Tool for Prefabricated Orthoses Only can assist and provide information on how to bill the miscellaneous codes. The tool can be found by selecting Tools in the upper right corner of the Noridian DME website.

Q: Can you please advise about billing hip orthosis without a policy?
A: When billing for an item that does not have a policy, follow requirements outlined in the Standard Documentation Requirements Policy Article A55426.

Q: If the beneficiary fails compliance, do they need to be set back up again within 90 days from the last bill date, or do we just need an RX dated within 90 days and then can set the beneficiary up anytime?
A: If the beneficiary fails compliance, they will need to reach compliance before billing the next month of rental.

Q: If a beneficiary can’t come off oxygen to be tested during exercise, for Part 2 of the test, can we use a result that qualifies while on oxygen, example during exercise, on 2LPM, 88%?
A: If all three parts of the exercise test are not met testing will not qualify the beneficiary for oxygen.

Q: Regarding high liter flow testing and trying to qualify during exercise, on the third phase of the test, does that have to show the improvement of a result in the 90s or would 88-89, which is an improvement over the second part of the test, be ok?
A: As long as the testing outlines (1) Testing at rest without oxygen; and, (2) Testing during exercise without oxygen; and, (3) Testing during exercise with oxygen applied (to demonstrate the improvement of the hypoxemia), this will meet compliance. This must be documented within the medical record.

Q: Is Medicare moving Monday’s calls to every two weeks instead of every Monday? I’ve noticed it’s not every Monday.
A: Monday Live Chat is an educational resource that Noridian provides to our supplier community. The 2025 Monday Live Chat schedule is approximately every other Monday.

Q: A beneficiary received a CPAP in 2018, paid for by Medicare, and now the physician is ordering a BIPAP. Since we don’t have use and benefit on the CPAP, what documentation is required to get the BIPAP covered? Would we be able to use the diagnostic study done in 2018?
A: To get the BiPAP covered by Medicare when there's no documented use and benefit for the CPAP, you'll need to provide updated documentation. Here are the key steps:

• New Sleep Study: Conduct a new sleep study to document the medical necessity for BiPAP therapy. The study should show that the beneficiary’s condition has changed or worsened since the last study.
• Medical Records: Ensure the medical records include symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headaches, cognitive dysfunction, and dyspnea.
• Physician Evaluation: Obtain a face-to-face clinical evaluation by the treating physician prior to the sleep test.
• Documentation of Conditions: Document any restrictive thoracic disorders or severe COPD that may necessitate BiPAP therapy.

The diagnostic study done in 2018 can be referenced, but it's important to have current and updated documentation to support the need for BiPAP therapy.

Follow-up Question: Regarding the CPAP in 2018, they are ordering the BIPAP for obstructive sleep apnea (OSA), not under the respiratory assist device (RAD) policy. Also, what type of studies would be required? Would a new titration suffice that showed CPAP ineffective?
A: There would need to be documentation to show an E0601 (PAP device) has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting. A titration study would be needed for the ineffective CPAP therapy.

Q: We are replacing a PAP and Medicare paid for the first machine. If we have notes that documented use, but not benefit, would a compliant download suffice in showing the patient is benefiting from therapy or would the benefit have to be documented in the medical record?
A: The download could be considered when evaluating the use and benefit. That information would have to be incorporated into the beneficiary’s medical record.

Q: Per the 2025 DME Jurisdiction List, A9270 is listed as a noncovered item or service. Can we use A9270 to bill for non-covered nursing (service) provided in the home?
A: Nursing services are not a DME benefit unless otherwise specified in the policy. This would not be appropriate.

Q: A beneficiary had Medicare FFS for a few years and then switched to a Medicare Advantage Plan for six months, for example, and then went back to Medicare FFS. Do we need a new order and notes stating the beneficiary is benefiting from PAP since re-entering Medicare FFS?
A: Yes, continued need would need to be established once the beneficiary comes back on FFS. This can be through the order and medical records.

Q: If Medicare is secondary, do we need to treat it as if it is a beneficiary entering Medicare FFS as their primary? Specifically, do we need new documents as far as needing a new order and notes regarding E0601 (PAP device) as we would if the beneficiary was entering Medicare FFS as their primary insurance?
A: For beneficiaries who are new to Medicare and already on PAP therapy, the following documentation is required.

• Sleep Study: Documentation of the most recent sleep study that meets Medicare's current criteria.
• Clinical Evaluation: A clinical evaluation on or after Medicare enrollment that documents a diagnosis of OSA and continued use of the PAP device.

If Medicare is the secondary payer, you still need to ensure that all Medicare coverage, coding, and documentation requirements are met for the DME items provided (including medical records and a valid order).

Q: For beneficiaries entering Medicare FFS, they are required to have a face-to-face (F2F) visit with their doctor after the enrollment in Medicare to discuss their diagnosis and that they are benefiting from PAP. We also must receive a new order for the machine that is still being rented and for the supplies. Does the order have to be dated on or after the F2F visit or can it be dated prior to the visit but after the enrollment in Medicare FFS?
A: The order needs to be dated on or after the visit once they become FFS eligible.

Q: For beneficiaries entering Medicare FFS, if we sent supplies after Medicare FFS became the primary insurance, must the F2F and order be dated prior to the date that we sent the supplies or is it ok that we later received the order?
A: For beneficiaries entering FFS, the F2F examination and the written order must be dated prior to the date that supplies are sent. The F2F examination must occur within six months prior to the date of the written order, and the written order must be dated on or before the date of delivery or the date shipped.

If the F2F and order are received after the supplies have already been sent, it may result in a denial of the claim. It's important to ensure that all documentation is in place before sending any supplies to avoid issues with claim processing.

Q: Would it ever be appropriate to qualify a beneficiary for a PAP with a titration sleep study instead of a diagnostic or split night?
A: A titration study would be used to qualify the beneficiary for oxygen with a diagnosis of OSA.

Q: Does an E0118 (crutch substitute) need to have the GY modifier for a patient responsibility (PR) denial?
A: When billing for HCPCS code E0118, the GY modifier should be used if the claim is expected to be denied as not covered. The GY modifier indicates that the item or service is statutorily excluded or does not meet the definition of any Medicare benefit

Q: Would it ever be appropriate to qualify a beneficiary for an E0601 (PA device) using a titration sleep study instead of a diagnostic or split night?
A: A titration study wouldn't be used to diagnose a beneficiary. The beneficiary would need a diagnostic or split night to diagnose OSA. The titration is used to identify the correct settings once OSA has been diagnosed.

Q: For an active nocturnal oxygen rental but years later has suspected OSA, does the beneficiary need to have a titration for their nocturnal oxygen to continue to be covered? If so, does the billing need to stop the date of the medical record that includes the suspected OSA?
A: You don’t need to stop billing oxygen for suspected OSA. A titration study or split night study would be required to diagnose OSA. Once confirmed then a titration study would be required to confirm the OSA is adequately controlled to confirm the medical need for oxygen.

Follow-up Question: If the sleep study does not include a titration to show their oxygen levels after treatment with the CPAP, does the beneficiary need a new study in order for their active oxygen to continue renting?
A: If oxygen is required with an OSA diagnosis, the beneficiary will need to complete the titration test and meet the requirements of the PAP and Oxygen LCD.

Follow-up Question: Would the stop date for the billing/coverage of the active nocturnal oxygen stop/end the date of the sleep study that confirms the OSA? It may not resume until they have another study that includes a titration to show they continue to require the oxygen even after the OSA is properly treated, correct?
A: With the change in beneficiary condition, the beneficiary would need to meet the criteria for the PAP and oxygen prior to billing both to Medicare.

Q: If a clinician provides wheelchair visit notes that are a "fill in the blank" template with only the diagnosis being unique to the beneficiary, would that be a valid medical record to meet the LCD/PA requirements?
A: Treating practitioners should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met.