ACT Q and A - February 11, 2021 - JA DME
ACT Questions and Answers - February 11, 2021
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.
Q1. There is a primary payer who has a denial code that does not match the description. For example, patient responsibility (PR) 44 is on the explanation of benefits (EOB) but the description is for PR242. I called the insurance and they said that their codes are what they choose them to be and they are not required to change them to meet Medicare codes. The description on the denial does have a code with Medicare but I called Medicare and was told that I cannot change a code to match a description. At this point I would be left to send in the claim without the EOB and then send the EOB in with the form to add the EOB; however, the Medicare edit keeps rejecting my claim for the primary EOB information. What would be the proper way to bill the Medicare Secondary Payer (MSP)? Can I change the code to match the description for denial or is there a way to pass the edit to get the claim on file?
A1. When billing Medicare Secondary Payor (MSP), the supplier must provide the information from the primary payor for there to be Medicare consideration. A supplier cannot change primary denial reasons for their own purposes.
Q2. What is the required schedule for oxygen initial and recertification Certificates of Medical Necessity (CMNs)?
A2: An initial CMN is required at the initiation of therapy and for replacement due to the end of reasonable useful lifetime (RUL). Group I (= 88%) oxygen beneficiaries require recertification at twelve months. New testing is not required for Group I. Group II (89%) oxygen beneficiaries require recertification at three months and new testing is required. Recertification following replacement due to RUL is the same as the original recertification.
Q3. A practitioner wants a beneficiary to switch an E0470 to an E0471 (respiratory assist devices (RADs) due to high residual events. Is a new sleep study titration needed?
A3. The E0471 is only covered under the RAD Local Coverage Determination (LCD). There are specific requirements in each diagnosis category that guide the coverage criteria to make the change.
Q4. When a beneficiary is using a covered pump to infuse noncovered drugs under the external infusion pump (EIP) policy, is an Advance Beneficiary Notice of Noncoverage (ABN) mandatory or voluntary?
A4. While the pump is eligible for coverage under the DME benefit, if the drug is not listed in the LCD, all items (pump, drug, and any associated supplies) will be denied as not reasonable and necessary. Suppliers should utilize an ABN and bill with the GA modifier.
See "Drugs used with External Infusion Pumps - Coverage and Billing Reminders."
Q5. Are foot orthotics, code L3000, a covered benefit for traditional Medicare?
A5. Inserts and other shoe modifications, including L3000, are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace. See the Orthopedic Footwear LCD.
Q6. When beneficiaries already have equipment being billed prior to a hospice episode, can the DME supplier still be paid using the GW modifier?
A6. The GW modifier is for use when a beneficiary is in a hospice episode and the condition for which they need the DMEPOS item is not related to their hospice condition. Suppliers must work with the hospice for payment if the need for the DMEPOS item is related to the hospice condition.
Q7. Can a beneficiary get a concentrator from Supplier A and a portable unit from Supplier B?
A7. Medicare does not have a requirement for which equipment is provided by whom, however in the case of oxygen, the supplier who initiates service is expected to continue provision of service for the five-year RUL.
Q8. If we are unable to obtain the raw data for a sleep study, will the signed interpretation be enough to qualify a beneficiary for a positive airway pressure (PAP) device?
A8. Medicare does not require the raw data if the interpretation is sufficiently detailed to confirm that the required coverage criteria have been met.
Q9. Can we bill an unlisted product with more than one miscellaneous code? If there are multiple features, can we use two miscellaneous codes?
A9. Generally, features would not get individual codes unless they are accessories to a base unit. If they are separate accessories that have not been assigned coding, then the miscellaneous code would be appropriate.
Q10. I am looking for clarification on knee instability and joint laxity requirements.
A10. Please utilize the Noridian "Dear Clinician" letter for knee orthoses. It explains to the practitioner that medical records must include the practitioner's' objective description of instability and join laxity (e.g., varus/valgus instability, anterior/posterior drawer test).
Q11. Will beneficiaries provided DMEPOS under the Public Health Emergency (PHE) waivers need to be requalified for the equipment they received once the PHE ends?
A11. At this time, the Centers for Medicare & Medicaid services (CMS) have not provided any direction on requirements post-PHE.
Q12. Does oxygen need to be dispensed within 30 days of the sleep study or 30 days from the initial date on the CMN 484?
A12. The Noridian Supplier Manual, Chapter 4 states that the date of service on the initial claim must be within three months from the initial date of the CMN or three months from the date of the physician's signature.
Q13. In Section B, question 2 on the CMN 484 Option 3 states "under other circumstances." What would be considered other circumstances situations?
A13. The responses to Section B of the CMN must be completed by the treating practitioner and therefore the practitioner would make that determination. The medical record and testing would then need to show that the oxygen was reasonable and necessary to support coverage.
Q14. In Section C of CMS-484, when it states, "list all supplies including accessories," do items not being billed (i.e., nasal cannula, oxygen tubing) have to be listed? If yes, what is the correct way to list pricing?
A14. Supplies included in the rental are not required to be listed on the oxygen CMN.
Q15. What documentation is needed for a beneficiary that is entering into Medicare from either a Health Maintenance Organization (HMO) or commercial insurance that received a PAP unit from that HMO or commercial plan and now needs oxygen under Medicare? Which LCD do we follow?
A15. When both oxygen and PAP are being utilized, both LCDs must be followed. For beneficiaries entering Medicare on a PAP device, the PAP LCD indicates that the beneficiary must have a sleep test that meets the coverage criteria at the time the beneficiary enters Medicare and a face-to-face (F2F) visit confirming obstructive sleep apnea (OSA) and on-going use of the PAP device. When a beneficiary needs oxygen, there must be a F2F with the treating practitioner and a qualifying test result within 30 days of the initial prescription. Per the oxygen LCD, if the need for testing is nocturnal only, the testing must be done in a facility-based titration study while the beneficiary is at his/her optimal PAP pressure settings.
Q16. Is there an update on the documentation requirement for oxygen during the pandemic?
A16. All waivers and flexibilities remain in place while the PHE continues. CMS has not provided direction on what will occur with oxygen or any other policy post-pandemic.
Q17. Please clarify if a standard written order (SWO) must be within six months of the F2F for an E0601 (PAP device). Previously, the Affordable Care Act (ACA) indicated a written order prior to delivery (WOPD) must be within six months of the F2F.
A17. With implementation of the SWO on January 1, 2020, the ACA requirements for WOPD discontinued being enforced for everything except power mobility devices (PMDs). PMD requires the WOPD by statute. For other items previously listed by the ACA, there is not a requirement for a F2F within six months of any order as previously required. There is a listing on the Federal Register of items that may be subject to WOPD or prior authorization. CMS will publish a "required" list at some point in the future to provide new guidance on which items requiring WOPD.
Q18. I am looking for clarification on five-year reasonable useful lifetime (RUL) oxygen restarts. Is a F2F within 30 days required? I know an SWO is required but is a prescription required? I know guidelines are different for the pandemic, but I want to know outside the pandemic what the guidelines are.
A18. Per the oxygen LCD, when oxygen is replaced due to the five-year RUL, there is a requirement for an SWO and oxygen CMN prior to billing. The CMN may serve as the SWO if all elements are present. Repeat blood gas testing is not required. The most recent qualifying test should be used on the new initial CMN. Additionally, there is not a requirement by Medicare for a F2F for completion of the CMN.
Written Questions Submitted During ACT
Q19. If a beneficiary is getting an E0570 (nebulizer) and the A7003 (nebulizer administration set), do the drugs and dosage amount have to be in the doctor notes or on the prescription?
A19. If the supplier of the medication differs from the supplier of the nebulizer, each supplier must have a SWO for the items they will be billing. The medical records must support the medical necessity of all items ordered.
Q20. Do we need to obtain a SWO if our referral does not list quantity?
A20. When dispensing more than a quantity of one per item, the quantity is required to be on the order. If the order does not include the quantity, another order would need to be obtained.
Q21. We've been told of flexibilities with proof of delivery (POD) signatures and for discussing the ABN by telephone, so that beneficiaries do not have to have contact at the door when deliveries are made. Why would we make them sign the assignment of benefits (AOB) in person then?
A21. CMS has not allowed a waiver of the required signature for beneficiary authorization during the PHE.
Q22. Chapter 4 of the Supplier Manual states that the date of service on the initial claim must be within three months from the initial date of the CMN or three months from the date of the physician's signature. Does the same rule apply to the SWO, for example a PAP device?
A22. This requirement is specific to oxygen and does not apply to PAP.
Q23. Are there any situations where a prosthetic leg is payable under the Part A benefits?
A23. There are certain DMEPOS items that can be paid while a beneficiary is in a Part A stay. Please see Noridian's Consolidated Billing webpage for specific prosthetic codes that can be paid during a part A stay.
Q24. What is the correct modifier to use when we have an ABN on file and no medical documentation to support the need or delivery of a DME item?
A24. The GA modifier is to be appended when a valid ABN is on file for the item being provided.
Q25. Will the GA modifier cause an automatic denial?
A25. The GA modifier does not guarantee a denial.
Q26. Can I bill with a GA and a GZ modifier?
A26. The GA and GZ modifiers cannot be billed on the same claim line. The GA modifier indicates that the ABN is on file and the GZ modifier indicates that there is no ABN on file.
Q27. When physicians complete the CMN 484 for oxygen, they usually select option three in section B question two "other circumstances" but we have supporting documentation that the beneficiary was in a chronic stable condition during testing. Will that still qualify under OSA titration study?
A27. When question three on the oxygen CMN indicates "other circumstances", the claim will deny, and the supplier will need to appeal. If there is conflicting information, the medical record will supersede the CMN. The Program Integrity Manual (100-08) Chapter 5, Section 5.9 states: When a CMN or DME Information Form (DIF) and a medical record contain conflicting information due to a minor error or omission within the CMN or DIF, but all coverage, coding and payment criteria are substantiated through the medical record, the reviewer shall rely upon the content of the medical record (absent suspicion of abuse or gaming) and shall not issue a denial.
Q28. Is the GW modifier acceptable when a beneficiary is in a home health episode? For example, the beneficiary is on home health for wound care, but we were providing tracheostomy supplies. Can I use GW modifier to bill Medicare?
A28. The GW modifier indicates the item billed is not related to hospice episode. There is a Consolidated Billing/SNF/Home Health/Hospice Lookup tool on our website. This tool will tell you if a HCPCS code is separately payable during a Home Health episode.
Q29. Since Dexcom G6 is listed in Pricing, Data Analysis and Coding (PDAC), can I assume this is a class III device and that I need to append the KF modifier when billing K0554?
A29. The Dexcom G6 is a class II device and is not billed with the KF modifier. The Dexcom G5 is a class III device and can be billed with the KF modifier.
Q30. For oxygen, is it acceptable for the SWO to say "home oxygen" or does it need to specify concentrator and portable oxygen?
A30. General verbiage is sufficient for the SWO. The CMN must include the specific codes ordered. The medical records must corroborate the SWO information.
Verbal Questions Received During ACT
Q31. We have beneficiaries who receive additional continuous positive airway pressure (CPAP) filters every 90 days. These additional filters are not covered by Medicare because they are extra filters. Can a date span be added to the ABN, so the beneficiary doesn't have to sign one every time?
A31. An ABN may only be utilized at the time the beneficiary receives non-covered supplies. A date span is not appropriate in this case.
Q32. We have a beneficiary who was qualified for oxygen through private insurance and has since enrolled in Medicare FFS. We were unaware of the change in insurance, the beneficiary isn't responding to phone calls. What rights do we have to bill the beneficiary without an ABN if he/she does not respond?
A32. Claims Processing Manual, Publication 100-04, Chapter 30, details the process in this situation. Suppliers have the right to document all the attempts to obtain an ABN, with the information that the beneficiary has become Medicare-eligible and he/she has not received the appropriate testing to qualify for oxygen under Medicare guidelines. The supplier must then send a hard copy of the ABN to the beneficiary.
Q33. We are doing weekend discharges from the hospital so Medicare does not have to pay for additional days and are sometimes unable to review the full medical record or benefits. To avoid a blanket ABN is important but sometimes there is for example, an oxygen beneficiary and the doctor's notes don't state the beneficiary tried another method that were deemed ineffective. Is there a way to write a valid ABN to cover us in these circumstances?
A33. You are correct, an ABN cannot be used for every hospital discharge. You must evaluate each circumstance and make a determination. If you have chart notes that state the need for oxygen but do not reference other treatments being tried or considered, that would be a reason to use an ABN because there is no evidence that other treatments have been tried or considered. When an ABN is used, make sure the beneficiary recognizes they have a need for oxygen and qualifying testing could potentially be obtained from a follow-up with their primary care practitioner.
Follow-up Question: Are suppliers allowed to state the medical record is conflicting and unable to obtain same or similar? Sometimes the doctor is unavailable, and we cannot obtain clarification, even though we can see the medical record.
Answer: It depends on the circumstances. We cannot pre-approve any ABN language. Be as detailed as possible because it is incumbent on the supplier to make sure the beneficiary knows specifically why the services they are receiving will not be covered by Medicare.
Q34. The enteral/parenteral nutrition LCDs were retired and now we go by the National Coverage Determination (NCD). Before we had the restriction in the LCD that some items were statutorily excluded. The NCD is more broad and vague. Is there a clarified diagnosis of conditions that would qualify these previously statutorily excluded items?
A34. If it was statutorily noncovered, it is still statutorily noncovered. The medical record must document the condition for which the item/service is being utilized. Even without an LCD, the coverage remains the same. The NCD, while appears to be broad, still provides the guidance the medical directors felt was necessary.
Q35. If we have a beneficiary with a covered pump but the drug isn't covered, we are still treating the ABN as mandatory but is it the same idea as a statutorily noncovered drug?
A35. Even though the pump is potentially a covered item, if the drug is not listed in the LCD as covered, then the pump, the drug, and the supplies will be denied as not medically necessary. An ABN for the pump in this case is required.
Follow-up Question: If it's a noncovered pump with a noncovered drug, is an ABN mandatory?
Answer: Yes, because Medicare would potentially pay for the pump. If the pump doesn't meet qualifications, it is still a not reasonable and necessary denial, which requires an ABN to transfer financial liability to the beneficiary.
Q36. A beneficiary comes into our office and wants an item that is a Medicare benefit, but we do not have proper medical documentation. The beneficiary is not willing to go back to the physician to obtain the documentation to meet the LCD; however, is willing to pay for it and wants Medicare billed. We have an ABN on file and will bill with a GA modifier. We do not want Medicare to pay us because we know if there is an audit, that money will be taken back. Do we bill with the GZ modifier?
A36. Do not bill with the GZ modifier because that means a valid ABN is not on file. The GA modifier is the appropriate modifier when a properly executed ABN is on file. Indicate on the ABN that there is no clinical documentation to show the need. If you know the beneficiary does not qualify and if Medicare did pay, as a supplier you need to refund Medicare.
Q37. We were told that a Watch-PAT device is not a valid home sleep test (HST) to qualify for a CPAP. There are several physicians wondering why this is not a qualifying HST. Do you have clarification?
A37. Please see the PAP LCD:
APPENDIX B: List of Approved Other Devices that Indirectly Measure AHI/RDI
Watch-PAT devices (Itamar Medical)
Q38. We are getting documents that a sleep study was done December 3rd, but the doctor did not send the order to dispense CPAP with oxygen until January 15th. We are past the 30 days from testing to be able to deliver the oxygen. What do we do at this point?
A38. The beneficiary would need to be retested. This is one area that referral sources need to be worked with to help them understand that oxygen qualification testing is required to be within 30 days of the initial prescription.
Q39. We are having a beneficiary that is currently in-patient and we are going to provide a prosthesis. I'm confused when it states it is separately payable during a Part A stay in the consolidated billing look-up tool. Does this mean we can bill Part B, or we bill the inpatient facility?
A39. When the tool states the item is separately payable, you can bill the DME MAC under Part B. Additionally, please see Chapter 6 of the Noridian Supplier Manual for consolidated billing exceptions.
Last Updated Fri, 08 Oct 2021 13:27:38 +0000