ACT Q and A - February 10, 2022 - 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: Can you please review the changes in the oxygen policy?
A: On September 27, 2021, Centers for Medicare & Medicaid Services (CMS’) final decision memo announced the revision of National Coverage Determination (NCD) 240.2-Home Use of Oxygen and removed NCD 240.2.2-Home Oxygen Use to Treat Cluster Headache (CH). Following the issuance of these policy changes, the DME MACs are in the process of revising the Oxygen and Oxygen Equipment Local Coverage Determination (LCD) and related Policy Article to reflect the national CMS policy changes to NCD 240.2 and the removal of NCD 240.2.2.

Please note that even though this decision memo was published, it is not yet implemented. On February 10, CMS released guidance on implementation of the NCD updates on June 14, 2022. That guidance made clear that removal of the CMN was not a part of the NCD update. The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) will educate on all changes as they are implemented.

Q: Can a sleep specialist order a respiratory assist device (RAD) (E0470) or bi-level (E0471) using pressures that were not used during sleep study?
A: Yes, they can. The sleep technician will set different pressures during the study and there will be data provided at those pressures. When the sleep physician evaluates the study, they use that data to determine the pressures that they want the beneficiary to start therapy at. Please see the RAD LCD for more information on RAD testing.

Q: If a beneficiary has a continuous positive airway pressure (CPAP) device paid by Medicare and they have reached their five-year reasonable useful lifetime (RUL) and are eligible for replacement, do they need a new sleep study if their current one is scored at 3%?
A: If Medicare paid for the full five years of the PAP device, a new sleep study is not needed for replacement. Please see the PAP LCD for more information on the five-year RUL.

Q: If oxygen testing is done at a skilled nursing facility (SNF) within 30 days of discharge, is that considered out-patient testing on the Certificate of Medical Necessity (CMN)?
A: Oxygen testing for Medicare qualification in a SNF does fall under the out-patient guidelines and may be completed within 30 days of the initial oxygen CMN.

Q: We are unable to obtain enough inventory to provide different equipment to beneficiaries, specifically portable oxygen systems (E1392) once the five-year reasonable useful lifetime (RUL) has been reached. What should we do?
A: This is a business decision and not one we can directly educate on. However, if a device has reached its five-year RUL and is still working, the beneficiary can continue to use it, or you can bill for maintenance and servicing if needed. Please see the Oxygen LCD for more information on the five-year RUL.

Q: Can you provide clarification on Medicare’s DME Information Form (DIF) for external infusion pumps?
A: This form must be completed, signed, and dated by the supplier, must be kept on file by the supplier and made available upon request. The initial claim must include an electronic copy of the DIF. All items being billed to Medicare must be on this form. In the case of upgrades, we ask that the DIF only include the item(s) that the beneficiary qualifies for, not the item(s) that are being upgraded. An initial DIF is required when the therapy begins and must be included with the initial claim submission. The initial date must be either the specific date the practitioner gives at the start of the medical necessity or if the practitioner does not give a specific start date, the initial date would then be the date of the order. When completing the DIF, make sure all appropriate codes are entered including the pump, drug, or any supply codes. A revised DIF is required when there is a change to the therapy. Whenever there is a change, a revised DIF would be submitted with the appropriate claim to insure proper processing of the claim. There are four questions that must be answered for the DIF to be valid. The answers are specific to the drugs being administered. There are policy specific requirements for each covered drug to ensure coverage criteria has been met. The answers on the DIF must be substantiated within the medical record as the DIF is not a substitute to meet medical necessity.

For more information, see the External Infusion Pumps webpage.

Q: What is considered a medical document?
A: A medical record can be documentation from a treating practitioner’s office and may also include records from hospitals, home health agencies, and other healthcare professionals. This list is not all inclusive. The beneficiary’s medical record must contain sufficient documentation of the beneficiary’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 information should include the beneficiary’s diagnosis and other pertinent information including, but not limited to, duration of the beneficiary’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, experience with related items, etc. In addition to the general requirements discussed above, certain DMEPOS items may have specific documentation requirements. Details regarding these policy specific requirements are contained in the applicable LCD-related Policy Article. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an Standard Written Order (SWO), a Written Order Prior to Delivery (WOPD) (if applicable), a CMN (if applicable), a DIF (if applicable), information from the treating practitioner concerning the beneficiary's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The best source for clarification on all documentation requirements is to become familiar with the guidelines set forth in the Policy Article (PA) Standard Documentation Requirements (A55426). This Policy Article will explain, in depth, each component needed as a supplier to bill a DMEPOS item correctly: Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

Q: Does an entire claim get paid if a beneficiary passes away during service dates and the claim was billed?
A: Per the Medicare Claims Processing Manual, Publication 100-04, Chapter 20, Section 30.5.4, for the month of death or discontinuance of use, DME MACs and A/B MACs (HHH) pay the full month rental.

Q: What durable medical equipment (DME) parts are billable by a SNF?
A: It is the supplier's responsibility to check with the facility to see if their beneficiary is a resident in a covered Part A stay. If so, all services must be billed to Medicare by the SNF except for certain excluded items. A complete list of these excluded items, listed by HCPCS, may be found on the CMS SNF Consolidated Billing webpage. If a HCPCS code appears on this list it may be billed to the DME MAC for reimbursement, even if the beneficiary is in a covered Part A SNF stay.

Q: Why is the Common Electronic Data Interchange (CEDI) rejecting claims for blood glucose monitors (E0607) when an RA modifier is used?
A: When billing for the E0607 the KX modifier must be appended to the claim. The use of the RA modifier to replace the E0607 due to replacement at the end of the reasonable useful lifetime (RUL) is not appropriate. See the Policy Article for correct coding for Glucose Monitors and the RA modifier article. Please see the links below for more information.

• JA DME - RA Modifier
• Article - Glucose Monitor - Policy Article (A52464)

Q: What are the billing criteria for codes E1810 (dynamic adjustable knee / flexion device, include soft interface material) and E1811 (static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories) for the 13-month capped rental?
A: These items are paid on a monthly rental basis for 13 months and then convert to beneficiary-owned. Information regarding the monthly rental fee schedule, payments during continuous use, and conditions affecting rental periods can be found on our website under the Capped Rental webpage.

Q: If a beneficiary only qualifies for off-the-shelf (OTS) but the written order prior to delivery (WOPD) states custom, may we bill the OTS code without getting a WOPD listing OTS?
A: When providing a custom fitted brace as OTS the brace must be coded with the correct corresponding HCPCS code. The medical record must support the medical necessity of the brace provided. Please visit our website for additional information on custom fitted versus OTS at the Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding webpage.

Q: Can you provide more information on the medically unlikely edit (MUE) list for prosthetic items?
A: An MUE for a HCPCS code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

MAI1: Applied at line level (claim-line) - Appropriate use of modifiers to report the same code on separate lines of a claim will enable the reporting of medically necessary units of service in excess of MUE. HCPCS that fall under this would need a modifier on the claim line that is for the units in excess. The medical record must support the medical necessity of the units in excess.

MAI2: Absolute criteria (date of service) - CMS has not identified any instances in which a higher value is payable. HCPCS that fall under this indicator must follow the policy. There are no instances where HCPCS/units that fall outside of the policy criteria would be covered.

MAI3: Value unlikely to appear on correctly coded claim but could, in usual circumstances, be payable (date of service) - Exceptions rare, supporting documentation required. HCPCS units that fall under this indicator could be covered if there are medical records to support medical necessity, but coverage is rare.

Q: For the prior authorization process and requirements for orthotics, is there a specific timeline and information for submission?
A: On January 13, 2022, CMS released an MLN Connects with a link titled, “DMEPOS Requirement Updates Effective April 13.” All HCPCS that have been added to the required Prior Authorization and Face-to-Face and Written Order Prior to Delivery lists are noted here along with effective dates. Please note that the effective dates for prior authorization differ by state.

Q: Since the public health emergency (PHE) is still in effect, can we CPAP device supplies if the baseline study was scored at 3%?
A: The clinical indications for coverage of a PAP device are not being enforced during the public health emergency. However, this is only for claims affected by the pandemic. Regardless of the PHE, medical necessity for the device must be met. Please see the COVID-19 webpage for more information on waivers and flexibilities during the PHE.

Q: Which rendering provider do we submit on the CMS-1500 claim form for services provided by the orthotist?
A: The rendering provider is the provider that supplied the DME item to the beneficiary. The referring physician is the provider that signed the standard written order. There are instructions on our website at CMS-1500 Claim Form Instructions.

Verbal Questions Asked During ACT

Q: How does the Option Code 1 work regarding Health Maintenance Organization (HMO) and Medicare Advantage Plan (MA)? The denials received indicate that Medicare is primary. What are the guidelines on how this works?
A: When you receive Option Code 1, you can bill either the Advantage plan or Fee-for-Service (FFS) Medicare. If you are receiving a denial that Medicare is primary, bill FFS to avoid future denials.

Written Questions Asked During ACT

Q: How do we handle DME that has not been capped and the previous supplier has shut down?
A: You can continue billing the months left of the capped rental and then any possible maintenance and servicing after the capped rental period has been met. Please see our Capped Rental Items webpage for more information.

Q: Can we resupply PAP supplies with a 3% scored study?
A: The only time that a sleep study scored at 3% is acceptable is if Medicare has previously paid a full five years of a PAP device. Please see the PAP LCD for more information on billing PAP supplies.

Q: Are suppliers allowed to bill a beneficiary for an A9279 (monitoring feature/device Not Otherwise Classified (NOC)) for a modem for a PAP device?
A: Code A9279 is not for monitoring services provided by the DME supplier and must not be billed for monitoring services nor should the beneficiary be charged by the DME supplier for monitoring services as part of the DME equipment under A9279.

Q: We have been billing an E1399 (durable medical equipment, miscellaneous) for the partial multifunction ventilator per the policy. How does Medicare determine the rate of pay for a miscellaneous code? If we are providing a vent and cough assist device only, why would the reimbursement be so little?
A: Information on billing for NOC codes can be found on the Noridian Medicare website under Billing, Claims, and Appeals-Billing Situations-Billing Not Otherwise Classified Codes (NOC) HCPCS Codes. When there is no fee schedule gap-filling is utilized. This methodology considers fee schedule amounts of other DME MACs, supplier price lists and manufacturer wholesale pricing.

Q: If a beneficiaryis in an inpatient facility and an orthotic needs a prior authorization, is there and option for retroactive authorization to be obtained or must the prior authorization be obtained first, no matter what?
A: Prior authorization is required prior to delivery, there is no option for retroactive prior authorization. However, we have not received direction from CMS on how orthotics will work for the prior authorization program. Please see MLN Connects - January 13, 2022 for further information.

Q: I have a beneficiary who resides in New York and Florida. The address on his Medicare verification is Florida. Are we able to service him in New York if his Medicare billing address is in Florida?
A: You can see the beneficiary for service but for DME guidelines you will bill the jurisdiction for the state listed on file with the Social Security Administration (SSA). So, if the address on SSA is Florida, you will bill Jurisdiction C. To accomplish billing Jurisdiction C, the beneficiary's home address must be included on the claim to allow the correct routing through the electronic data interchange.

Q: I have a beneficiary who just entered Medicare and needs new PAP supplies. There is a face-to-face (F2F) within the last year that states the beneficiary continues to use and benefit from their PAP device, however, she was not seen after she enrolled in Medicare. Are we able to dispense under the pandemic relaxed policy that started in 2020 or will a F2F be needed after enrollment?
A: For beneficiaries who received a PAP device prior to enrollment in FFS Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:

1. Sleep test - There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and
2. Clinical Evaluation - Following enrollment in FFS Medicare, the beneficiary must have an in-person evaluation by their treating practitioner who documents in the beneficiary’s medical record that: The beneficiary has a diagnosis of obstructive sleep apnea; and the beneficiary continues to use the PAP device. Only claims affected by the PHE can be billed with the CR modifier.

Suppliers should only bill with the CR modifier and "COVID-19" narrative under the relaxed PHE guidelines if the claim is directly affected by the pandemic.

Q: Are we required to have a beneficiary's body mass index (BMI) and neck circumference in their medical chart to set them up on a PAP device?
A: The examples given in the policy for the initial evaluation are commonly documented elements, each element would not have to be addressed in every evaluation. There must be sufficient information included in the medical record to demonstrate that all the applicable coverage criteria are met. Neck circumference is not required per the policy, it's just another element that could help paint the picture. Please see the PAP Policy Article for more information on the initial evaluation for PAP.

Q: Is there any guidance on oxygen documentation requirements post-PHE for beneficiaries who received oxygen equipment during the PHE?
A: At this time, CMS has not provided directive to the DME MACs for oxygen requirements after the PHE. When an end to the PHE is announced and CMS provides additional direction, education will be provided. Please monitor the Emergencies and Disasters webpage for updated COVID-19 information.

Q: When a beneficiary is discharged from the hospital into a SNF, are we able to use the same hospital testing within 48 hours once the beneficiary is ready to be discharged from the SNF?
A: Testing within 48 hours of discharge is only valid if the beneficiary is being discharged to their home. Additional testing will be required prior to SNF discharge, but is allowed within 30 days of the initial order date.

Q: Is a re-evaluation by the treating practitioner with documentation that symptoms of obstructive sleep apnea (OSA) are improved; and objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner still required to bill beyond the first 90 days?
A: Correct, this is still required per the PAP Medicare guidelines. Please see the PAP LCD for more information on billing beyond the first three months.

Q: Can a home assessment for a manual wheelchair (MWC) that is delivered to a facility be done via the phone with the beneficiary when they have been discharged and are home?
A: A home assessment for a MWC may be obtained over the phone but an in-person assessment must occur on or before the delivery of the wheelchair to confirm the assessment taken over the phone was factual, and the beneficiary is able to use the wheelchair in their home.

Q: Why is the sequestration being reinstated?
A: The sequestration is a CMS mandate so we unable to speak to why it's being reinstated.

Q: If a beneficiary was set up on a PAP device that is in the Philips Respironics recall and stopped using the equipment and did not have other equipment to use, are we able to continue the billing when the beneficiary receives their replacement PAP device or will they be required to have a new F2F and a new sleep study since it has been more than the 60 plus days remaining in the rental since they used the equipment? Do they have to re-establish medical necessity?
A: Once a replacement device has been obtained, the supplier would pick up billing where it left off. A new capped rental period would not begin, and medical necessity does not have to be re-established in the case of the recall. For more information please see question number seven of the Frequently Asked Questions - Philips Respironics Respiratory Products Recall document.

Q: For a PAP replacement, would the supplier need to verify the beneficiary meets compliance by getting the download and a follow-up F2F after setup?
A: For replacement PAP devices, a new F2F showing that the device is still being used and a new order are required per the LCD. Please see the PAP LCD for information on PAP replacement.

Q: For repairs to be billable, is it correct that we may either have clinician notes from within 12 months showing continued need OR an order showing they need the items within 12 months of the repair?
A: For reimbursement for the repair, there are two documentation requirements. The treating physician/practitioner must document that the DMEPOS item being repaired continues to be reasonable and necessary and the treating physician or supplier must document that the repair itself is reasonable and necessary. Documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified in the relevant Medicare policy. You can find more information on our website under the Repairs webpage. You’ll see documentation that justifies continued medical need like a recent order for refills, a recent change in the order/prescription, timely documentation in the beneficiary’s medical record showing usage.

Q: For continuous glucose monitors (CGM), does the ordering provider have to be the provider that saw the beneficiary within six months prior to ordering the CGM or can it be a different provider completing the F2F from who signed the order?
A: In the absence of directive otherwise, there can be more than one treating practitioner as long as they have access to the medical record.