ACM Q and A - August 10, 2023 - JA DME

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Teleconference (ACT). 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

Q1: How can a supplier get paid for orthotic and prosthetic repairs to beneficiary-owned devices?
A1: The following information is found on Noridian’s website under > Browse by Topic > Repairs, Maintenance and Replacement > Repairs.

Per the Standard Documentation Requirements Policy Article A55426, repairs to items that a beneficiary owns are covered when necessary to make the items serviceable. However, "routine periodic maintenance" such as testing, cleaning, regulating, and checking is not covered. If the expense for repairs exceeds the estimated expense of purchasing another item for the remaining period of medical need, no payment can be made for the excess.

Repairs can be completed by any DMEPOS supplier. The initial supplier is not required to do the repair.

Payment may be made for repairs to O&P including items in use before the user enrolled in Medicare Part B.

Payments for repair and maintenance may not include payment for parts and labor covered under a manufacturer's or supplier's warranty.

The treating practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary.

Either the treating practitioner or supplier must document that the repair itself is reasonable and necessary.

The supplier must maintain detailed records describing the need for and nature of all repairs including a detailed explanation of the justification for any component or part replaced as well as the labor time to restore the item to its functionality.

Q2: How can a supplier get a PR96 (non-covered charges) denial for items that don't qualify for benefits? Do I use a GA or GY modifier?
A2: For items that don’t meet coverage criteria, suppliers may append the GA modifier if a valid Advance Beneficiary Notice of Noncoverage (ABN) is on file. If the National Coverage Determination (NCD), Local Coverage Determination (LCD), or Policy Article (PA) indicates an item is statutorily excluded or doesn’t meet the definition of a Medicare benefit, the GY modifier could be appended.

Q3: Is there a minimum percentage of feeding that needs to occur to meet Medicare criteria?
A3: There is not a certain percentage of feeding specified in the LCD; however, adequate nutrition must not be possible by dietary adjustment/oral supplements. Refer to LCD L38955 for more information.

Q4: HCPCS code B4153 describes hydrolyzed formula, which is used to treat diarrhea. B4153 also describes Impact Peptide, which is used to treat oncology patients (without diarrhea). Can you explain the reason for significant differences between products described by HCPCS code B4153?
A4: HCPCS B4153 is used to describe special formulas which may have characteristics based upon unique beneficiary needs. The medical records must justify the use of special formulas. For questions on PDAC coding, please refer to the Pricing, Data Analysis and Coding (PDAC) contractor for more information.

Q5: Because insulin doses vary, what modifier do we utilize if the insulin supplied to a beneficiary is greater than a 30-day supply but less than a 90-day supply?
A5: For a one-month supply of insulin (J1811, J1813, or J1817), the JK modifier is added. For a three-month supply of insulin, the JL modifier is appended. External Infusion Pumps Policy Article A52507 specifies that the supplier can only dispense either a one-month supply or a three-month supply, which is indicated by the modifier utilized. Refer to the policy article for more information.

Q6: Where can suppliers find more information on the JK and JL modifiers?
A6: For a one-month supply of insulin (J1811, J1813, or J1817), the JK modifier is added. For a three-month supply of insulin, the JL modifier is appended. The External Infusion Pumps Policy Article (A52507) and the MLN Factsheet provide more details.

Q7: Since policies no longer mention dispensing orders, are they still required on or before the date of service (DOS).
A7: No, a dispensing order on or before the DOS is not required by Medicare. Note that items on the required list do require a written order prior to delivery (WOPD). Refer to the Standard Documentation Requirements article at the path below for more information on the required list and order requirements.

Noridian Medicare Website > Policies > Local Coverage Determination (LCD) > Active LCDs > Standard Documentation Requirements Policy Article -A55426

Q8: Does the Centers for Medicare & Medicaid Services (CMS) consider ventilator codes E0465 and E0466 to be capped rental items?
A8: No, ventilators are included in the frequent and substantial servicing category.

Written Questions Asked During ACM

Q: Today's ventilators are much smaller and simpler than ventilators of the past. Today's ventilators do not require the monthly care and maintenance once required. Also, current ventilators can be used as a PAP, BiPAP and ventilator. Why is CMS still considering this item under frequent and substantial servicing and is there consideration for capped rental given the improvement in home ventilators and increased usage of these devices?
A: At this time, we have not been provided information pertaining to ventilators being switched from frequent and substantial servicing to capped rental. If we are provided direction, we will educate at that time.

Q: If a purchased prosthetic liner L5679 needs to be replaced every six months due to wear and tear, is a new face-to-face and WOPD needed?
A: Items such as socks or liners are considered non-consumable items and therefore may be treated as a refill item. If the Standard Written Order (SWO) identifies these items with quantity, they may be dispensed as needed without obtaining a new order. For non-consumable supplies the supplier must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. The supplier must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

Q: Do orthopedic clinics need to obtain a Board of Certification (BOC) certification for staff to bill custom fit bracing?
A: To meet the custom fitting requirements, the fitter can be somebody that is certified or someone who has specialized training in the provision of orthotics. An important factor is to check with your state licensing agency because they may have their own requirements for a certified fitter.

Q: I have multiple claims for beneficiary-owned repairs that get denied. I have added a narrative on the CMS-1500 form in Item 19 that we are repairing a beneficiary-owned device but again can't get the claim even considered because it is denied not medically necessary. What can I do?
A: In these cases, since you are adding the narrative, request a telephone reopening to add "beneficiary-owned equipment" to the file for the base item. Once this is placed on file, subsequent claims do not require a narrative. For more information, see the Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Accessories and Supplies Used with Beneficiary-Owned Equipment.

Q: Since an ankle foot orthosis (AFO) does not meet the definition of a Medicare benefit if the beneficiary is non-ambulatory, is that an appropriate time to use the GY modifier?
A: The GY modifier would not be appropriate. If the beneficiary does not meet the coverage criteria outlined in LCD L33686, the claim will deny as not medically necessary, suppliers may obtain an Advance Beneficiary Notice of Noncoverage (ABN) and file the claims with the GA modifier. Or, if a valid ABN is not on file, the claim can be billed with the GZ modifier.

Q: If a beneficiary needs a new AFO within the five-year reasonable useful lifetime (RUL) due to wear and tear and they have state Medicaid coverage, can I use GY modifier in this instance? Since it is within the RUL it does not meet the definition of any benefit.
A: The GY modifier would not be appropriate in this situation. If an AFO is replaced within the RUL due to wear and tear, you may obtain an ABN and bill the replacement with a GA modifier or GZ if there is no ABN. Please see our website for additional information on replacements Browse by Topic > Repairs, Maintenance and Replacement > Replacement

Q: If a positive airway pressure (PAP) device is being qualified as a "Beneficiary Entering Medicare," the LCD says the sleep test must be prior to fee-for-service (FFS) Medicare. Does that mean the test must be done prior to Medicare enrollment or one that is prior to the beneficiary receiving a replacement devices or supplies?
A: For a beneficiary who has been on a PAP prior to Medicare enrollment, a new sleep study may not be needed if a copy of the previous sleep study done prior to Medicare enrollment is available. The sleep study must meet Medicare's current criteria apnea/hypopnea index (AHI)/ respiratory disturbance index (RDI) criteria outlined in the LCD.

Q: Do medical records always require ruling out lesser costly devices in the same category even if the LCD and PA do not specify the requirement to rule out lesser devices? For example, canes and crutches to walkers do not specify the need to rule out a cane to receive a walker. The reference is the CMS Internet Only Manual (IOM), Publication 100-04, Chapter 20, Section 90 - Payment for Additional Expenses for Deluxe Features.
A: Medical records are always required to support medical necessity of the item being provided. Canes and crutches have their own policy criteria and walkers have their own criteria. If the individual criteria is met, the cane does not have to be ruled out.

Q: Can you provide clarity and continued guidance on our interpretation of this language in the Pneumatic Compression Device (PCD) LCD?

At the end of the four-week trial, if there has been improvement, then reimbursement for a PCD is not justified. Where improvement has occurred, the trial of conservative therapy must be continued with subsequent reassessment at intervals at least a week apart. Only when no significant improvement has occurred in the most recent four weeks and the coverage criteria above are still met, may the lymphedema be considered unresponsive to conservative therapy, and coverage for a PCD considered.

At a minimum, re-assessments conducted for a trial must include detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy, with bilateral comparisons where appropriate.

Since "detailed measurements, obtained in the same manner and with reference to the same anatomic landmarks, prior to and at the conclusion of the various trials and therapy" has been removed, we are interpreting this to mean that the second measurements are not a requirement, but that a four-week trial must still be documented in order for a PCD to be found medically necessary. An example would be that the beneficiary is measured and instructed by the prescriber to perform all aspects detailed in the conservative therapy trial (e.g., regular elevation, regular exercise, and adequate compression). At the conclusion of the 28-day conservative therapy trial, if the prescriber's objective findings detail that lymphedema symptoms remain and or persist, then the PCD is justified for claim submission and reimbursement.

A: Per the Local Coverage Determination (LCD) for Pneumatic Compression Devices (PCD) L33829, "The medical necessity determination for a PCD by the treating practitioner must include symptoms and objective findings, including measurements, to establish the severity of the condition." Measurements is a requirement to establish the PCD meets the medical necessity of the policy. The National Coverage Determination (NCD) 280.6, also states the same criteria and includes, "The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home." Therefore, objective findings that include measurements would need to be documented in the medical record.

Verbal Questions Asked During ACM

Q: Codes K0830 (power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds) and K0831 (power wheelchair, group 2 standard, seat elevator, captain's chair, patient weight capacity up to and including 300 pounds) are available for use now, are there any update on reimbursement, and will they require prior authorization?
A: For questions on allowed amounts please see the Pricing, Data Analysis and Coding (PDAC) website or the Noridian Medicare website under Fees and News > Fee Schedules. Only items on the CMS Required Prior Authorization List require prior authorization. The Required Prior Authorization List can be linked to from our website under Medical Review > Pre-Claim Review > Educational Resources > CMS Required Prior Authorization List

Q: We have many beneficiaries who are dual eligible, and they do not meet the coverage criteria in the LCD for various reasons such as needing an AFO to maintain positioning, prevent deformity, etc., but they non-ambulatory. When I bill with the GA modifier with a valid ABN on file, I get the denial of not medically necessary, PR-50, which prevents me from billing Medicaid. How do I get PR-96 denials for noncovered so I can bill Medicaid? Are we able to appeal these?
A: The GY modifier is only used for items that are not covered by Medicare. For those items that do have a benefit, but the beneficiary does not meet the coverage criteria, the GA or GZ modifier should be used. The GA gives a patient-responsibility medical necessity denial PR50 and the GZ would give a supplier-liable denial because a valid ABN is not on file. For the AFO policy, if coverage criteria are not met, it is a medical necessity denial. This would not be an appealable claim, this is the denial that Medicare provides when the beneficiary does not meet the coverage criteria of the policy and it is billed with the GA modifier. Suppliers will need to work with their state Medicaid in these situations.

Q: We had a local orthotics and prosthetics company close about a year ago and many of their beneficiaries have come to our company for repairs to the products provided by this company. The original equipment has been covered by Medicare, sometimes they are over five years old, or obtained prior to being on the Medicare program. I've had denials for the repairs we are billing. I was told I can do a reopening, but these claims have the denial code that appeal rights are not afforded. How can I submit a reopening if I'm not allowed any appeal rights?
A: Because each beneficiary's claim could be different, we suggest calling the Supplier Contact Center for specific claim denials.

Q: Follow-up Question: I've added a narrative of beneficiary-owned and the date of ownership but still get these denials.
A: In these situations, call the Supplier Contact Center and tell them you've added this information to the claim narrative and the claim should be reprocessed. Additional information on repairs and beneficiary owned equipment can be found on our website under Browse by Topic > Repairs, Maintenance and Replacement > Repairs and also under Billing, Claims, and Appeals > Billing Situations > Accessories and Supplies Used with Beneficiary-Owned Equipment

Q: If a physician's digital signature does not have the word "signed", but clearly the Medical Doctor (MD) made the entry based on all other validation of author points in the document with an attestation of time spent, presumably utilized by the MD to bill for the visit. Is this acceptable? CMS states we cannot manipulate the chart entry and it's clearly coming from the referral in the standard patient database charting format. In the event of an audit, can we get an attestation from the physician to use with the appeal?
A: The POE team cannot say whether a signature is valid, we can only direct you to the requirements. In the event of an audit, if you feel they meet the CMS requirements and you receive a denial, you can appeal. We recommend including all pertinent documentation with appeals and you can also include the electric signature protocol.