ACT Q and A - February 9, 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 ACT

Q: Where do I find information on fee schedule and rental payments?
A: Information about specific fee schedules can be found on the Noridian Medicare Website under Fees and News> Fee Schedules.

Q: Where do I find updates on the oxygen policy?
A: The oxygen Local Coverage Determination (LCD), Policy Article (PA), and National Coverage Determination (NCD) were recently revised, and the links can be found on the Noridian Medicare Website under Browse by DMEPOS Category> Oxygen. Educational opportunities on this topic may be found on our schedule of events at the following path: Noridian DME Website > Education and Outreach > Schedule of Events.

Q: Are blood pressure monitors (A4670) covered and if so, what diagnosis is required for coverage?
A: There is not published criteria for routinely covered blood pressure monitors covered by Medicare. Medicare may provide coverage for a blood pressure monitor at home if a beneficiary is receiving dialysis treatments at home. Obtaining a properly executed Advanced Beneficiary Notice of Non-coverage (ABN) would be advised as this is not a routinely covered item/service.

Q: Are there any updates on the Public Health Emergency (PHE) regarding oxygen?
A: The Centers for Medicare and Medicaid Services (CMS) announced the end of the PHE on May 11th, 2023. Until then all waivers and flexibilities remain in place. The clinical indications of some policies, including oxygen, are not being enforced during the PHE. When a claim has been impacted by the PHE, the CR modifier may be appended along with a claim narrative indicating submitted during the PHE. For further information on the PHE, refer to our Noridian DME homepage and the CMS current emergencies page.

Q: What documentation will be required for claims submitted with the CR modifier after the Public Health Emergency (PHE) has ended?
A: Claims impacted during the PHE should have the CR modifier appended and a narrative if applicable. After the PHE ends on May 11th, 2023, the CR modifier would no longer be amended, and documentation required would be required per Local and National Coverage Determination (LCD/NCD) policy guidelines.

Q: What are the requirements for oxygen equipment after the five-year reasonable useful lifetime (RUL) has been met?
A: At any time after the end of the five-year RUL for oxygen equipment, the beneficiary may elect to receive new equipment, thus beginning a new 36-month rental period. If the beneficiary elects not to receive new equipment after the end of the five-year RUL and if the supplier retains title to the equipment, all elements of the payment policy for months 37-60 remain in effect. There is no separate payment for accessories or repairs. If the beneficiary was using gaseous or liquid oxygen equipment during the 36th rental month, payment can continue to be made for oxygen contents. If the beneficiary elects not to receive new equipment after the end of the five-year RUL and if the supplier transfers title of the equipment to the beneficiary, accessories, maintenance, and repairs are statutorily non-covered.

Q: Regarding documentation for prefabricated orthotics, is a recommendation specifying if the item is prefabricated off-the-shelf or custom fitted required in the medical record?
A: The determination (off-the-shelf vs custom fit) happens at the time of final fitting and is documented by whomever performs it. That information is not required in the practitioner's record. The supplier would keep documentation of the final fitting in their records. Our Medical Directors provided the article titled Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised available on our website under Policies > Medical Director Articles > 2021.

Q: For a beneficiary that qualifies for oxygen based on Group I criteria but with a length of need less than lifetime, what is required to extend the length of need?
A: A new order is necessary to confirm continued medical need. There is no requirement for retesting or re-evaluation of the test results. Information regarding length of need will be determined by documentation in the beneficiary's medical record. For beneficiaries with an acute condition that qualify for oxygen, the supplier is obligated to maintain close communication with the beneficiary and the treating practitioner to determine length of need. Suppliers are reminded that Medicare will only pay for items and services that are reasonable and necessary. Once the acute need is resolved, depending on co-existing chronic conditions, the oxygen may no longer be reasonable and necessary.

Q: After beneficiaries get re-evaluated and testing for groups II and III, do we have to do re-testing every year or do they only need to do that within the 61st - 90th day?
A: For beneficiaries who meet Group II or Group III criteria for their oxygen needs, retesting and evaluation of the test result by the treating practitioner is required between the 61st and 90th day. Only documentation of continued medical need is necessary thereafter.

Q: We are being denied for same or similar. Could you please provide coverage guidelines for walkers and wheelchairs?
A: We have two resources to help answer this question. One is the Local Coverage Determination (LCD) Manual Wheelchair Bases L33788, criteria B states, “The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.” The LCD along with additional information on Manual Wheelchair Bases can be found on the Noridian Medicare Website under Browse by DMEPOS Category > Manual Wheelchairs.

Our second resource is the same or similar chart found on the Noridian Medicare Website under Browse by Topic > Same or Similar Chart. The chart shows the codes that are considered same or similar to each other and walkers and manual wheelchairs are considered same or similar. If a denial is received for same or similar; however, there is a medical need, an appeal can be submitted with all documentation requirements.

Q: What if a Group II patient wasn’t re-evaluated and a repeat blood gas test was not done between the 61st and 90th day but was done after the 90th day? Can we just pick up billing after they have retested and been re-evaluated?
A: Yes, if the repeat blood gas study and/or evaluation is not completed between the 61st and 90th day, but is subsequently completed, coverage may resume on the date of completion.

Verbal Questions Received During ACT

Q: If the beneficiary had a mastectomy due to a cancer diagnosis and then had reconstruction, are they eligible for breast prostheses L8020, L8030, and L8000? If yes, what are the requirements for coverage after reconstruction?
A: For the external breast prosthesis policy, the requirement is that the beneficiary had a mastectomy. The beneficiary would need to have this in their medical history. If there's reconstructive surgery and a breast prosthesis is still needed, the medical record would need to support the medical necessity of those items.

Follow-Up Question: After reconstruction, if the reconstructed side was uneven from the natural remaining breast, would prosthesis be covered?
A: We cannot preapprove claims, however, if the criterion in the policy is met and documented this would be acceptable.

Follow-Up Question: What if the beneficiary had a mastectomy due to a diagnosis other than cancer, would it still be covered?
A: Diagnosis codes specific to the external Breast Prostheses policy can be found in the Policy Article.

Q: If a beneficiary is syringe fed through sponges, tape, etc. but not syringes, do you still bill 30 kits, or do we try to change the units since we are not sending the main item?
A: Anything included in the kit would still be billed as a daily unit using the kit code. The number of units billed would be dependent on how long the items are expected to last.

Q: Since DME Information Forms (DIFs) are no longer needed, if there were beneficiaries that had a DIF in a non-payable status, are they going to continue to deny starting with January 2023 dates of service with the DIF no longer being needed?
A14: Claims that were not payable prior to 2023, will continue to not be payable going forward. You can appeal these denials with the supporting documentation.

Written Questions Received During ACT

Q: If we are in a competitive bid area do, we still need authorizations for L0648, lumbar sacral orthosis (LSO) back brace?
A: Regardless of competitive bid the L0648 requires prior authorization. For more information on prior authorization see the Noridian Medicare website under Medical Review tab > Pre-Claim Review > Prior Authorization.

Q: A CPAP beneficiary has an overnight oximetry showing oxygen dropping below 88%. Do they need to complete an in-lab titration?
A: Oxygen qualification testing for a beneficiary with obstructive sleep apnea (OSA) can only be done in a titration study.

Q: What documentation is required for intermittent urinary catheters A4353 and A4351?
A: Intermittent catheterization using a sterile intermittent catheter kit (A4353) is covered when the beneficiary requires catheterization, and the beneficiary meets one of the five criteria listed in the Local Coverage Determination (LCD), a new Standard Written Order (SWO), Proof of Delivery (POD), and beneficiary Authorization.

Q: For the five-year RUL for oxygen, is a visit to the physician needed to say the beneficiary still needs the oxygen?
A: A new visit to the physician is not required. However, a new Standard Written Order (SWO) would be required and would meet the requirement for ongoing medical need.

Q: If items are not Pricing, Data Analysis and Coding (PDAC)-registered; however, can fall under the description of a specific code such as L3908, can we still bill the supply?
A: If the item is not PDAC approved, the accessories will not be paid either.  

Q: For pneumatic compression devices (PCDs), if the prescribing physician co-signs another Licensed Certified Medical Professional's (LCMP's) chart note, does that acknowledge concurrence or agreement with the documentation or does it require a specific written statement by the physician?
A: If the prescribing physician signs off on the LCMP's notes, Noridian will accept this without stating concurrence. This is for PCD's only and although Noridian will accept this, other contractors may not.

Q: What documentation is required for replacement after RUL of pneumatic compression devices?
A: The medical record will need to support continued medical need and a new order will be needed as well. More information on replacement and documentation requirements for continued medical need can be found in the Standard Documentation Requirements Article found on our website under Browse by DMEPOS Category > Pneumatic Compression Devices (PCD).

Q: With the elimination of the CMN requirement for oxygen, are all elements that were on the CMN now required in the physician documentation (for example, the estimated length of need)?
A: The medical record should demonstrate medical necessity with documentation including hospital records, provider progress notes, test results, documentation regarding evaluation of testing results if applicable (not an all-inclusive list). Length of need should now be included in the medical record.

Q: On a physician's enteral order it states: Enfamil 55 cc hr per g-tube. Can the physician add "may substitute solution/formula if needed"? We are having issues with shortages so if substitution is the same HCPCS, we do not have to contact physician for a substitution, correct?
A: If the order has a HCPCS and not a specific formula, the substitution would be appropriate as long as the HCPCS doesn’t change. Of the order did specify a formula brand or name, a new order would be required if the formula is changing from what is specified on the order to a different formula. If the order indicates that a specific formula may be provided is the prescribed formula is not available, that does not invalidate the order. The documentation would need to specify why the substitution was provided.

Q: If physician documents length of need (LON) "99" but does not specify days or months, can it be assumed months?
A: If the physician lists a LON of 99 that is considered lifetime.

Q: If I have an Advance Beneficiary Notice of Non-Coverage (ABN) that says A7521 trach tube, but they have an A7520 trach tube, would the ABN still be valid?
A: This would be considered sufficient. Additional ABN information can be found on our website under the Browse by Topic > Advanced Beneficiary Notice of Noncoverage (ABN).

Q: Is a 59 modifier ever needed for DME items?
A: Modifier 59 is not a valid modifier for DME items.

Q: Is E0900 an appropriate HCPCS for a pneumatic lumbar home traction unit?
A: An E0900 is defined as a traction stand, free standing, pelvic traction device. An E0900 falls under the Traction and Other Orthopedic Devices Benefit Category.

Q: We have a beneficiary who received oxygen over five years ago. She rented it for 34 months and returned it. Would a new rental period begin or would the remaining two months pay and then enter the free period?
A: In this scenario, since the equipment was returned and no oxygen was required, it demonstrates a break in need (greater than 60 days without medical necessity) and the beneficiary would need re-qualify for coverage under current coverage criteria and a new rental period would begin.

Q: With regard to oxygen, would medical review expect the actual diagnosis of hypoxemia to be listed somewhere within the medical record?
A: Oxygen is not a diagnosis driven policy so there would not be that need. Medical review would expect to find documentation supporting coverage criteria for medical necessity including test results, provider progress notes, other medical records/notes.

Q: If a beneficiary fails PAP compliance, chooses to return the device, and more than a year later decides to obtain an in-lab sleep study to attempt compliance again, how would this be viewed? Would month four stay on PAP hold until compliance is met, or would it be acceptable to process as new and begin billing?
A: If the equipment was returned for a year, then medical necessity ended and the beneficiary would have to start over with a new face to face (F2F), sleep study and compliance period.

Q: If a beneficiary obtains oxygen under Group I, short term upon re-testing they fall under Group II, have a diagnosis of congestive heart failure, would they stay in Group I?
A: They would stay in group I. While there is no formal requirement for re-evaluation and retesting for Group I, providers should ensure that once qualified for home oxygen therapy, the oxygen therapy and oxygen equipment remain reasonable and necessary. Length of need would be determined by the treating provider. 

Q: If oxygen is ordered for a beneficiary who is not in a stable condition, we require they be seen in three months after the order. Would new testing be required or just documentation of continued need for oxygen?
A: Repeat testing and evaluation is required for beneficiaries that qualify for coverage in Group II and III specifically between days 61-90. There is no requirement for repeat testing for Group I continued coverage.

Q: Has there been clarification on continued acceptance of telehealth once the PHE ends, if so, will audio only be acceptable?
A: CMS has not given direction on this topic. Once we receive direction, we will provide education.

Q: Why is the Watch Pat system not acceptable for testing?
A: A WatchPat may be used as the qualifying sleep study, so long as the results meet the coverage criteria as indicated in the PAP LCD. For questions specific to coverage of a sleep test, please refer to your local A/B MAC.

Q: Regarding diagnosis of hypoxemia, do the records need to show/discuss the condition that is causing the hypoxemia?
A: Including documentation of the condition that is causing the hypoxemia would be best practice as maintaining a comprehensive medical record demonstrating that the oxygen therapy is reasonable and necessary and fits into coverage criteria for Groups I or II. This could be diagnosis list, hospital records, provider notes, other medical documentation as appropriate.

Q: If we are billing a covered item with an ABN and the beneficiary selected Option 2, do we have to have a valid standard written order (SWO) for that item?
A: If the beneficiary selects option 2, you would not be billing Medicare so that would be up to your business practice. Keep in mind that a beneficiary can change their mind and ask you to bill to Medicare. If this change happens, you will need an SWO to bill to Medicare.

Q: Since the recertification requirement has been removed, at the one-year mark, does the beneficiary need to be seen with an order supporting continued need?
A: There is no requirement for an annual face-to-face (F2F) visit specifically for continued coverage of oxygen and oxygen equipment. However, continued medical need does need to be proven annually and the SWO as well as supporting documentation can help establish and maintain the record of medical necessity.

Q: Is there something going on with the correspondence, such as overpayment letters, being sent out? We aren't receiving as many of them as we've seen in the past, (no changes have been made to our information)?
A: Suppliers will be receiving a new demand letter with the ARs ending with “M1” to restart the collection process. If partial collections have occurred, the new ARs will be setup with the remaining balance due. Suppliers will also receive new appeal rights and timeframes.

Q: If the beneficiary wants to restart but doesn't want different oxygen equipment, they want the same equipment that the currently have, what does the supplier need to do?
A: If the beneficiary elects not to replace a concentrator or trans-filling equipment and if the supplier retains title to the equipment, coverage for maintenance and service is the same as in months 37-60. If the beneficiary elects not to replace a concentrator or trans-filling equipment and if the supplier transfers title to the beneficiary, maintenance and service is statutorily noncovered. Contents are separately payable for beneficiary-owned gaseous or liquid systems.

Q: Will Noridian host live Provider Education meetings and Open Public Meetings this year?
A: Thank you for your question. That is under consideration. We will put out announcements if we decide to proceed with them.

Q: Since E0748 falls under the written order prior to delivery (WOPD)/F2F list, do suppliers have to have the operative report in hand prior to dispensing the equipment for a multilevel spinal fusion?
A: You will want to verify within those medical records that there was failed spinal fusion where a minimum of nine months has elapsed since the last surgery, or

1. Following a multilevel spinal fusion surgery or
2. Following spinal fusion surgery where there is a history of previously failed spinal fusion at the same site.

You should have these records to verify that information. Please refer to the LCD for more information. Noridian Website > Browse by DMEPOS Category > Osteogenesis Stimulator > Osteogenesis Stimulator Local Coverage Determination (LCD).

Q: For PAP prescriptions, is it appropriate to have 90-day supply with the quantity and length of need versus how many refills, 90-day supply and quantity. Which is the correct format?
A: If it is clear the quantity required is for a 30 or 90-day supply then this would be acceptable, there is not a required format. The requirements for the Standard Written Order (SWO) can be found on our website for the Standard Documentation Requirements Article.

Q: Where do we go to get our local coverage for Pennsylvania for prescription requirements?
A: Please contact the Pennsylvania state health services for that information.