ACM Q and A - February 8, 2024 - JD 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 Meeting

Q: What is the maximum allowable for collagen dressings under the Surgical Dressings Local Coverage Determination (LCD) (L33831)?
A: While CMS publishes the majority of medically unlikely edit (MUE) values on its website, other MUE values are kept confidential and used solely by CMS and CMS Contractors. Collagen dressings can remain in place for up to seven days, depending on the type of dressing. The medical documentation would need to support why additional changes were made within those seven days.

Q: Is there a timeframe for the next round of competitive bid? Have products for the next competitive bid round been identified?
A: CMS has not disclosed any information regarding the next round of competitive bid. For the most up-to-date information please visit the Noridian Medicare website > Browse by Topic > Competitive Bidding or the Competitive Bidding Implementation Contractor (CBIC) website.

Q: Can braces be fit at a pre-operative visit with an authorization on file?
A: Once a prior authorization has been completed by a supplier and approved, a brace can be fitted. For more information on prior authorization see the Noridian Medicare website > Medical Review > Pre-Claim Review > Required Prior Authorization Programs.

Q: Can you please provide the Recovery Audit Contractor (RAC) process for parenteral nutrition, enteral nutrition, and home infusion claims? How can we best be sure we are prepared and have all documents needed to pass an audit?
A: The DME MAC can only answer general questions on this topic. The RAC is Performant Recovery and questions related to this topic should be directed to them. However, the RAC reviews post-payment claims based on CMS approved audit issues. The RAC will review a claim after it has been paid, and if identified as improperly paid, a letter will be sent to the supplier indicating what information is needed to complete the review and reverse the claim (if appropriate). Be sure to pay attention to the information in the letter from the RAC. The letter will detail what documentation is required in your response. Documentation requirements are detailed in the Standard Documentation Requirements Policy Article A55426. For the nutrition and infusion policies, there are detailed documentation checklists on the Noridian Medicare website that will walk you through these requirements. See the paths below for applicable resources.

RAC contact information:

• Email: info@performantrac.com
• Toll Free Telephone 1 (866) 201-0580

Noridian website paths:

• Medical Review > Other Review Contractors > Recovery Auditor
• Policies > Documentation Checklists > Enteral Nutrition
• Policies > Documentation Checklists > Parenteral Nutrition
• Policies > Documentation Checklists > External Infusion Pumps

Q: Can you provide knowledge on submitting prior authorization requests (PAR)?
A: Suppliers can submit a PAR through fax, mail, or electronic submission of medical documentation (esMD) with a coversheet. Suppliers can also submit through the Noridian Medicare Portal (NMP). A coversheet is not required when submitting through the NMP. For more information on PAR submission and documentation requirements, please see the Noridian Medicare website > Medical Review > Pre-Claim Review > Required Prior Authorization Programs.

Q: What documentation from treating practitioner's or therapists is required to be in the medical record for lymphedema compression treatment items?
A: There is not a published list of required documentation specifically for lymphedema compression treatment items. The Standard Documentation Requirements Policy Article A55426 should be followed. We would encourage suppliers to maintain a comprehensive record including treating practitioner progress notes, therapist notes, hospital records, nursing facility records, and home health records that demonstrate medical necessity. Payment for lymphedema compression treatment items is limited to the ICD-10-CM codes of lymphedema listed below. The presence of an ICD-10-CM code listed in this section is not sufficient by itself to assure coverage.

A Standard Written Order (SWO) is not part of the medical record but is required to be signed by the treating practitioner prior to claim submission. Information regarding the SWO and Standard Documentation Requirements required for all policies can be found on: Noridian Medicare website > Browse by Topic > Documentation.

Q: Are there additional requirements for billing portable oxygen equipment that differ from stationary equipment?
A: Portable oxygen is separately payable for beneficiaries who are mobile within their home and meet coverage criteria for Group I, II, or III. If the only testing done was during sleep, portable oxygen would be denied as not reasonable and necessary.

Q: Can a beneficiary qualify for oxygen coverage with telehealth visit notes and testing?
A: With the COVID-19 expiration on May 11, 2023, testing flexibilities are no longer in place. Any beneficiary qualifying for initial coverage must meet current guidelines listed in the testing requirements in the LCD (L33797) which state "All oxygen qualification testing must be performed in-person by a treating practitioner or other medical professional qualified to conduct oximetry testing." There is an exception for overnight testing in the LCD. There is not a face-to-face requirement in this policy, a telehealth visit, and documentation could be considered for substantiating medical necessity if it meets telehealth requirements set forth by CMS.

Q: When speaking in terms of the Knee Orthoses Local Coverage Determination (LCD) coverage criteria for medical necessity, there are two pathways for coverage of an L1833. For example, the first pathway being "recent injury or surgical procedure." The question at hand is what timeframe does Medicare consider as "recent injury?" Is it 30 days? Is it 90 days?
A: Medicare does not specify any timeframe. Therefore, the medical record should indicate the reason and substantiate the timeframe from when the injury/procedure occurred when the beneficiary is fitted with an orthotic.

Q: I am seeking clarification on the procedures related to same-day billable office visit in light of the suspension of the Competitive Bidding Agreement. Specifically, with the suspension of the KV modifier, does this also impact the requirement for DMEPOS to be dispensed on the same day as a billable office visit?
A: As of January 1, 2024, the KV modifier is no longer in use during the gap period of the Competitive Bid Program. During the gap period, the ST modifier can be used by ALL DME suppliers in acute/emergent situations when prior authorization is required. This includes non-contract suppliers who are physicians/practitioners who were part of the competitive bid program. The same day billable office visit is no longer a requirement for non-contract suppliers who are providing braces to their patients during the Competitive Bid gap period.

Verbal Questions Asked During ACM

Q: At the end of the Public Health Emergency (PHE), CMS published a fact sheet regarding telehealth. It was approved and stated many flexibilities will continue through the end of this year. Can we accept valid telehealth visits until the end of this year?
A: Valid telehealth visits were extended through 2024. There is information available on our website under Browse by Topic > Documentation > Telehealth.

Q: Why would a claim deny as bundled when a back orthosis is billed with a kyphoplasty? The brace is needed after the procedure.
A: The procedure must be billed to Part B and the brace to DME.

Q: Regarding the letter on the positive airway pressure (PAP) masks blanket Standard Written Order (SWO), the Noridian response is that you are waiting for direction from the DME Medical Directors (DMDs). Will there be further changes to the article, or can we start accepting these orders?
A: We received clarification from the DMDs that this is correct and there will not be any changes to the article at this time.

Q: If we are executing an Advance Beneficiary Notice of Noncoverage (ABN) because a brace does not meet medical necessity, do we need a prior authorization denial or can we bill with the GA modifier to reflect the ABN?
A: You can bill the claim with the GA modifier.

Q: For Qualified Medicare Beneficiaries (QMBs), the Noridian Medicare Portal (NMP) shows $0 for the deductible. When I submit the claim, the reimbursement is lower than my cost. Is there a way to find out exactly how much the deductible is for each beneficiary?
A: QMBs are not liable for Medicare deductibles, therefore deductible information for QMBs is not provided in the NMP. Noridian recommends contacting the beneficiary's state Medicaid agency for questions about deductible billing.

Written Questions Asked During ACM

Q: I am not specifically addressing any policy. If a beneficiary needs an item for a condition that is not listed on a Policy Article or LCD or if the beneficiary needs more items than is allowed, is there any option to submit a request for an exception to the rule?
A: There are not exceptions. If medical necessity of the policy is not met, an ABN can be obtained.

Q: When we do prior authorization for a knee brace, which is billed under a code requiring authorization, but we don't know if it will be an off-the-shelf or custom fit code, can we get authorization for both?
A: Yes, an authorization can be submitted for both the off-the-shelf code and the custom fit code. Medicare will only pay for one knee brace when billed.

Q: With the new lymphedema compression coverage, I understand three units are covered per year. Is this three pairs (socks) or three garments?
A: We can only advise that medical necessity would need to be demonstrated per body part (for example left lower extremity and right lower extremity, thus a "pair") however, when laterality is indicated, the LT and RT modifiers would need to be appended to separate claim lines with units of service indicated per claim line, not LTRT on the same claim line. If this is in regard to packaging, separating packaged items for dispensing is a business practice decision but only items meeting medical necessity will be considered for coverage.

Q: In regard to therapeutic footwear, can the supervising physician for a physician assistant (PA) or nurse practitioner (NP) sign the certifying statement and the clinical notes from the podiatrist?
A: The "incident to" requirements are laid out in Policy Article A52501. If the PA or NP is the certifying physician, meaning he/she completed the certification statement, and is practicing incident to a supervising physician, the PA or NP would need to sign, date, and acknowledge agreement with the podiatrist notes. The supervising physician would then also need to review, sign/date both the certification statement and any other records that the NP/PA is reviewing and signing.

Follow-up Question: There is no need for the NP or PA to review the notes from the podiatrist and to complete the certifying statement since this has already been done by the supervising physician, correct?
A: Correct. If the supervising physician has already completed the statement of certifying physician, then the NP/PA would not need to sign and date the certifying statement nor sign/date and agree with the podiatry notes.

Q: Where exactly does it spell out what constitutes an objective assessment of fit for therapeutic footwear? Is there a definition or examples of "objective assessment"? Isn't a pedorthist's assessment objective because it does not take into account the beneficiary's subjective comments?
A: There is no definition provided on what constitutes an objective assessment. However, at the time of dispensing, the supplier should be conducting an exam and objective elements may include assessing the proper length/width of the shoes, if there's any slipping during ambulation, proper space in the toe box etc. Additional information is available on the Noridian Medicare website > Browse by DMEPOS Category > Therapeutic Shoes > Resources section > Clarification of Criterion 5.

Q: Regarding sleep study 4% scoring, on a study under oxygen saturation, it lists the desaturations percentage, number of events and index for each level 2%, 3%, 4%, 5%. Would that support showing that it was scored at 4% or does it have to show the specific apnea hypopnea index (AHI) in relation to the 4% result?
A: The specific AHI or respiratory disturbance index (RDI) must be listed, and it must clearly document the 4%.

Q: A beneficiary meets criteria under central sleep apnea (CSA)/complex sleep apnea (CompSA); however, on the titration with the beneficiary on the E0471 (respiratory assist device [RAD]), an optimal E0471 setting wasn't found, and the recommendation was to either proceed with another E0471 study or start the beneficiary at a rate the physician has chosen. Is it acceptable to set the beneficiary up on the rate the physician, chose or does the titration on the E0471 have to show the optimal setting while on the E0471?
A: The RAD policy requires documentation from the titration showing improvement while using E0470 (RAD) or E0471 at the settings that will be used at home.

Q: Is the start date for a custom power wheelchair the date of the physician's face-to-face (F2F) evaluation or it is the date that the physician concurs with the physical therapy evaluation?
A: The start date is the treating practitioner's F2F evaluation.

Q: To provide a manual wheelchair, a home assessment is needed, per policy. If a supplier needs to deliver a manual wheelchair to a nursing home facility on the day of discharge, how can the home assessment requirement be met?
A: The requirement for a direct, in-person assessment of the home environment remains whether the supplier delivers the wheelchair directly to the beneficiary or if a caregiver picks up the chair from the supplier. The confirmation of the home assessment may not be met by indirect methods such as telephone or virtual conversations with the beneficiary or their caregiver, regardless of where or by whom the wheelchair is delivered. The supplier ultimately remains responsible for the completion and documentation of the home assessment.

Q: When Medicare is secondary and we bill the primary insurance for two units of A5500 (for diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe) with two units on one line, and then we bill Medicare with the primary's remittance advice, how are we supposed to bill Medicare? Do we bill two units on the same line (like the primary insurance) or the way Medicare requires us to split the two units into two separate lines?
A: Suppliers must bill Medicare with each item on two separate claim lines using the RT and LT modifiers and one unit of service (UOS) on each claim line. Claim lines for HCPCS codes requiring use of the RT and LT modifiers billed without the RT and/or LT modifiers or with the RTLT on a single claim line will be rejected as incorrect coding.