Denial for PMD Claim from a Supplier of DMEPOS When Ordered By a Non-Authorized Provider - Revised

MLN Matters® Number: MM8239 Revised
Related Change Request (CR) #: CR 8239
Related CR Release Date: November 6, 2013
Effective Date: April 1, 2014
Related CR Transmittal #: R1305OTN
Implementation Date: April 7, 2014

This article was revised on September 24, 2015, to change the link to the list of providers authorized to order a PMD on page 5. That link was changed to https://data.cms.gov on the CMS website. For a complete list of any other changes to this article, please refer to the Document History Section. All other information remains the same.

Provider Types Affected

This MLN Matters® Article is intended for suppliers of Durable Medical Equipment (DME) who submit claims to DME Medicare Administrative Contractors (DME/MACs) for Power Mobility Devices (PMDs) provided to Medicare beneficiaries.

Provider Action Needed

Change Request (CR) 8239 instructs Medicare contractors and system maintainers to implement edits to deny claims for certain PMDs if the ordering/referring provider is not on Medicare's list of providers eligible to order/refer these PMDs.

Make sure that your billing staffs are aware of these requirements and you do not order if you are not an authorized provider. Suppliers are required to ascertain that the provider is authorized to order a PMD. A denial of the claim will be issued if the provider is not of an authorized specialty to order a PMD.

Background

Section 302(a)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), added Section 1834(a)(1)(E)(iv) to the Act which provides that payment may not be made for a covered item consisting of a motorized or power wheelchair unless a physician (as defined in section 1861(r)(1) of the Act), or a Physician Assistant (PA), Nurse Practitioner (NP), or Clinical Nurse Specialist (CNS) (as these terms are defined in Section 1861(aa)(5) of the Act) has conducted a face-to-face examination of the beneficiary and written a prescription for the item. This purpose of CR 8239 is to create an edit to deny any Durable Medical, Orthotics, Prosthetics, and Supplies (DMEPOS) claims where the ordering/prescribing provider is not an eligible provider (physician, PA, NP, or CNS).

The following are the policies/definitions that impact Medicare allowances for PMDs:

Key Points of CR8239

The list of specified covered, PMD items: HCPCS Code and Description includes the following:

The list of authorized physician specialties and their corresponding CMS specialty code in Provider Enrollment, Chain, and Ownership System (PECOS) is as follows:

Medicare PECOS

CODE APPROVED PHYSICAN SPECIALTIES
14 NEUROSURGERY
16 OBSTETRICS/GYNECOLOGY
17 HOSPICE/PALLIATIVE CARE
18 OPHTHALMOLOGY
20 ORTHOPEDIC SURGERY
21 CARDIAC ELECTROPHYSIOLOGY
22 PATHOLOGY
23 SPORTS MEDICINE
24 PLASTIC AND RECONSTRUCTIVE SURGERY
25 PHYSICAL MEDICINE AND REHABILITATION
26 PSYCHIATRY
27 GERIATRIC PSYCHIATRY
28 COLORECTAL SURGERY (PROCTOLOGY)
29 PULMONARY DISEASE
30 DIAGNOSTIC RADIOLOGY
33 THORACIC SURGERY
34 UROLOGY
36 NUCLEAR MEDICINE
37 PEDIATRIC MEDICINE
38 GERIATRIC MEDICINE
39 NEPHROLOGY
40 HAND SURGERY
44 INFECTIOUS DISEASE
46 ENDOCRINOLOGY
66 RHEUMATOLOGY
72 PAIN MANAGEMENT
76 PERIPHERAL VASCULAR DISEASE
77 VASCULAR SURGERY
78 CARDIAC SURGERY
79 ADDICTION MEDICINE
81 CRITICAL CARE (INTENSIVISTS)
82 HEMATOLOGY
83 HEMATOLOGY/ONCOLOGY
84 PREVENTATIVE MEDICINE
85 MAXILLOFACIAL SURGERY
86 NEUROPSYCHIATRY
90 MEDICAL ONCOLOGY
91 SURGICAL ONCOLOGY
92 RADIATION ONCOLOGY
93 EMERGENCY MEDICINE
94 INTERVENTIONAL RADIOLOGY
98 GYNECOLOGICAL ONCOLOGY
C0 SLEEP LABORATORY/MEDICINE

 

The list of authorized non-physician specialties and their corresponding CMS specialty code in PECOS is as follows:

CODE APPROVED NON-PHYSICIAN SPECIALTY
50 NURSE PRACTITIONER
89 CLINICAL NURSE SPECIALIST
97 PHYSICIAN ASSISTANT

 

Suppliers are required to ascertain that the provider is authorized to order a PMD. A list of providers authorized to order a PMD can be accessed (beginning April 2014) at https://data.cms.gov on the CMS website.

A denial of the claim will be issued if the provider is not on the PECOS list. Be aware that allof the criteria for coverage of PMDs must be met.

When a claim for a relevant PMD is denied because the ordering/referring provider was ineligible to place the order, Medicare will use the a Claim Adjustment Reason Code of 183 (The Referring Provider is not eligible to refer the service billed) and a Remittance Advice Remarks Code of N574 (Our records indicate the ordering/referring provider is of a type/specialty that cannot order or refer).

Additional Information

The official instruction, CR 8239, issued to your DME/MAC regarding this change may be viewed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1305OTN.pdf on the CMS website.

If you have any questions, please contact your DME/MAC at their toll-free number, which may be found at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map on the CMS website.

For a look at face-to-face requirements and a checklist you may review SE1112, "Power Mobility Device Face-to-Face Examination Checklist" at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/dwnlds/SE1112.pdf on the CMS website.

 

  1. Social Security Act Section 1834(a)(1)(E)(iv) standards for power wheelchairs;
    • Effective on the date of the enactment of this subparagraph in the case of a covered item consisting of a motorized or power wheelchair for an individual, payment may not be made for such covered item unless a physician (as defined in Section 1861(r)(1)), a PA, NP or CNS (as those terms are defined in Section 1861(aa)(5)) has conducted a face-to-face examination of the individual and written a prescription for the item.
    1. Social Security Act Section 1861(r)(1)
      • The term "physician", when used in connection with the performance of any function or action, means (1) a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he performs such function or action (including a physician within the meaning of section 1101(a)(7)).
    2. Social Security Act Section 1861(aa)(5)
      • The term "physician assistant" and the term "nurse practitioner" mean, for purposes of this title, a PA or NP who performs such services as such individual is legally authorized to perform (in the State in which the individual performs such services) in accordance with State law (or the State regulatory mechanism provided by State law), and who meets such training, education, and experience requirements (or any combination thereof) as the Secretary may prescribe in regulations.
      • The term "clinical nurse specialist" means, for purposes of this title, an individual who is a registered nurse and is licensed to practice nursing in the State in which the CNS services are performed; and holds a master's degree in a defined clinical area of nursing from an accredited educational institution.
    3. Based on 42 CFR Part 410.38(c), the following definitions apply: PMD means a covered item of durable medical equipment that is in a class of wheelchairs that includes a power wheelchair (a four-wheeled motorized vehicle whose steering is operated by an electronic device or a joystick to control direction and turning) or a power-operated vehicle (a three or four-wheeled motorized scooter that is operated by a tiller) that a beneficiary uses in the home.
    • K0800-K0808 and K0812: ALL POWER OPERATED VEHICLES
    • K0813-K0891, K0898: POWER WHEELCHAIRS , and
    • K0013: CUSTOM MOTORIZED/ POWER WHEELCHAIR BASE.

 

            Last Updated Wed, 05 Feb 2020 12:36:41 +0000