ACT Questions and Answers - February 13, 2019

Questions Received Prior to ACT Meeting

Q1. When in the rental period, can we bill a patient for soft O2 Cannulas because of his/her preference?
A1. No, all accessories are included in the rental of oxygen equipment per the policy requirements.

Q2. How does the competitive bid gap period affect existing rental items before and after this period?
A2. It is expected that beneficiaries will not need to change suppliers. Contracted suppliers providing service on December 31, 2018 should complete the capped rental period.

Q3. Why are we required to bill G codes in 15-minute intervals for Home Infusion when Medicare only pays for one unit?
A3. These are the billing guidelines and direction received from CMS.

Q4. If we send one TPN bag to infuse 12 hours, starting at 7 p.m. and ending 7 a.m. the next day, are we billing one or two units of B4220 and B4193?
A4. Only one of each can be billed in this scenario. It is only one infusion and is billed per one administration.

Q5. If a patient meets criteria for two vents, can he/she have two vents with E0467?
A5. There has been no change to the current policy for allowance of two ventilators when one is needed bedside and one on a wheelchair. This includes the multi-function ventilator.

Q6. Are Oral Anti-Cancer meds required to be billed with their HCPC code or S5001?
A6. Oral anti-cancer medication must be billed with the corresponding HCPCS. See the Oral Anticancer Drugs (L33826) Local Coverage Determination (LCD)) or the Pricing Data Analysis Contractor (PDAC) for additional information on the correct coding.

Q7. Is continued use/need documentation required for minor repairs and replacements of prosthetics (such as socks and liners)?
A7. Socks and liners are considered non-consumable items and would be included on the detailed written order for items provided on a periodic basis. These items are subjected to the continued use and continued need documentation requirements. Refer to the CMS Standard Documentation Requirements Article A55426 for additional criteria needed.

Q8. To provide a knee brace to document instability, is it enough for a clinic note to indicate that a patient has medial lateral laxity?
A8. The Knee Orthoses (L33318) LCD, requires knee instability to be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).

Q9. A beneficiary is receiving a prosthesis that will be osseointegrated (OI) using implants in the bone of residual limbs to allow direct skeletal attachment of the prosthesis, thereby eliminating the need for a socket and other suspension systems. Since there is no socket and no suspension system, what are the proper L codes for the OI prosthesis?
A9. Refer to the PDAC as they are responsible for determining what code is applicable.

Q10. Scenario: A patient comes into the office (physician practice) and has measurements done for a custom-fabricated knee brace, specific to their body type, which no other patient would be able to wear once made, (Ex: HCPCS code L1834). The custom-made brace arrives and is applied by a Certified Fitter. Since it was custom made, but not fitted by a Certified Orthotist (per CMS guidelines) can it be billed as an off the shelf product instead (Ex: HCPCS L1836)? 
A10. When a custom fabricated item is provided, it is created for that individual and the certified fitter does not play a role in that requirement. The certified fitter is only required when a pre-fabricated orthosis is provided at the time of delivery and custom fitting is required.

Verbal Questions Received During the ACT meeting

Q1. Do we need a polysomnography and titration sleep study to provide the Positive Airway Pressure (PAP) supplies?
A1. All coverage criteria must be met prior to dispensing supplies.

Q2. What is the trigger for the 90-day requirement of the face-to-face notes?
A2. See the ACA: Face-to-Face and Detailed Written Order webpage; however, the face to face actually needs to be conducted within six (6) months prior to the order.

Q3. Can a patient get Positive Airway Pressure (PAP) supplies if he/she hasn't used the PAP within 90 days?
A3. When dispensing supplies, the supplier must ensure all coverage documentation has been met.

Q4. When submitting a redetermination within the Noridian Medicare Portal (NMP), how do we get our notes read?
A4. A cover letter or form is very beneficial to inform the redetermination staff what needs to be reviewed. A separate comment won't necessarily get to the appropriate reviewer. Be as specific as possible.

Q5. If Medicare paid for a PAP five or six years ago, is compliance still needed for the replacement after the reasonable useful lifetime (RUL)?
A5. Compliance requirements must be met during the initial 12-week period. There is no compliance/trial period required for the replacement equipment after the RUL.

Q6. When beneficiaries move to different jurisdictions throughout the reasonable useful lifetime of an item, how do suppliers obtain same and similar?
A6. Same or similar information can be obtained within the Noridian Medicare Portal (NMP) for claims processed through Jurisdiction A and Jurisdiction D. Suppliers will also need to verify same or similar information through MyCGS for Jurisdiction B and Jurisdiction C claims.

Q7. A beneficiary qualified for oxygen based on testing requirements, but the clinician didn't write the prescription for the settings that qualified for use of a PAP. Is the beneficiary required to be retested for the recert CMN to obtain the new setting information?
A7. A new sleep study is not required. Ensure all information is updated on the CMN for the recertification.

Q8. A beneficiary has been on straight catheters since 2010 but medical records do not specifically state the words "permanent." They state he/she had Benign Prostatic Hyperplasia (BPH) with obstruction, frequency, quantity, needed due to radiation from colon cancer. If evidence for continued need based on radiation from 2010 is presented in the medical record, can this be accepted as clinical evidence?
A8. The documentation is subjected to clinical review determination and a decision based on the probability of the permanent need based on the radiation therapy. It all must be well documented.

Q9. If a beneficiary enters Medicare with an existing CPAP, do we start billing the rental for Medicare at month one?
A9. Follow the "Beneficiaries Entering Medicare" portion of the LCD. Medicare does not recognize rental months paid prior to Medicare eligibility; therefore, if a beneficiary enters Medicare while renting, rental will begin again at month one.

Q10. Where does it indicate that a supplier can recover monies when returning a device after Medicare denies the device and monies cannot be taken back from the patient?
A10. See CMS Internet Only Manual (IOM), Publication 104 Chapter 30, section 50.13.4.

Q11. As a DME Pharmacy provider, we receive prescriptions for IV therapy and dispense; however, the Home Health Agency (HHA) often disputes who is supposed to supply the IV kits and who is supposed to bill Medicare for reimbursement. There is no J code for the flushes. Please advise.
A11. The IV supply code includes all the supplies needed for the infusion. For the Home Health billing, discuss reimbursement opportunities with the HHA. Use the Consolidated Billing/SNF/Home Health/Hospice Look Up Tool to determine if the specific code being questioned is billable to DME when the beneficiary is in Home Health.

Q12. What additional information is needed under section H of the Advance Beneficiary Notice of Non-coverage (ABN) form?
A12. There is specific verbiage that must be entered when the claim is being submitted as unassigned and the last line in option 1 must include a single strike through. The verbiage is "The supplier doesn't accept payment from Medicare for the item(s) listed in the table above. If I checked Option 1 above, I am responsible for paying the supplier's charge for the item(s) directly to the supplier. If Medicare does pay, Medicare will pay me the Medicare-approved amount for the item(s), and this payment to me may be less than the supplier's charge."

Q13. What should be indicated on an ABN when the beneficiary is receiving a new item within the RUL but it's due to a change in medical condition?
A13. The ABN should state the item is being replaced within the RUL and that medical necessity may not warrant coverage. When the claim denies for same or similar, request a redetermination, and submit the medical documentation along with the ABN. The documentation will be reviewed and, if medical necessity is met, payment may be made to the supplier. If medical necessity for the replacement is not warranted, and the valid ABN is presented during the appeal process, the beneficiary can be held liable.

Q14. When billing for a G code for infusion, what documentation is needed to support the units that are being billed?
A14. Include a statement of the infusion length of time. This can be on the delivery ticket which should coincide with the number of units being billed.

Q15. What is the rationale for breaking out the units for billing G codes when only one payment amount will be issued, regardless of the number of units billed?
A15. This is the direction the DME MACs received from CMS on processing of these new codes.

Q16. Is an Albuterol prescription for Chronic Obstructive Pulmonary Disease (COPD), use 3-4 times a day, as needed, acceptable and should we limit the dispense to the smallest package available?
A16. The order must have the detailed instruction on how to use the drug and the specific dispensing information. Orders that state PRN or as needed are not acceptable. See the Nebulizers LCD and the CMS IOM, Publication 100-8, Chapter 5, Section 9.

Q17. For continued use of their PAP machine, a beneficiary saw his/her physician in November. He/she has been using the same machine for almost six years. In February, the PAP machine stopped working. Since he/she was seen by his/her physician within the last six months, is a verbal order to replace the PAP acceptable?
A17. In this situation, the face to face requirements have been met for a visit within six months of a new order. A five-element order (5EO) would be required prior to delivery and a detailed written order for accessories would be required prior to billing.

Q18. Is the standard RUL for prosthetics five years?
A18. Prosthetics are not subjected to the same 5-year RUL in some cases. Refer to the applicable LCD to determine what the RUL is for the item.

Q19. An Ankle Foot Orthosis (AFO) claim denied same or similar for a patient who had a stroke and drop foot. Why would a claim for this new condition deny against one from 4.5 years ago for a fractured ankle?
A19. Since the claim is within the RUL for the AFO, submit a redetermination request and be sure to include documentation which supports the medical need of the second brace for the new condition.

Q20. What has changed in the databases that is causing more denials and the need to submit so many additional redetermination requests?
A20. The editing is determined by many factors and are driven by direction the DME MACs receive from CMS. Medical necessity must be determined on some items before those claims are paid.

Q21. Will the new Medicare Beneficiary Identifier (MBI) and Health Insurance Claim Number (HICN) be crossed to receive the same and similar information?
A21. The new MBI is associated with an individual beneficiary's personal social security number and links to the previously used HICN. Same and similar information should be available when using MBI.

Q22. Can we make suggestions on what we want to see on the same or similar code tool?
A22. Yes, such suggestions can be provided to us when completing the ForeSee survey. Access the survey link from the JA homepage.

Written Questions Received During the ACT meeting

Q1. Will the addition of a GA modifier automatically cause a claim denial?
A1. If coverage is available for the item being billed, a denial will not be issued. To change the liability, submit a redetermination request with the valid ABN.

Q2. When a PAP patient changes from one provider to another, what documentation is required?
A2. Medical records that support all coverage criteria has been met will be needed. In addition, a new prescription is required as there is not the ability to obtain the prescription from the previous supplier.

Q3. For initial PAP supplies, can we drop ship the order or does the supplier need to see the patient first?
A3. When a beneficiary has been using supplies received from another supplier, a new supplier can continue with the same supplies and drop ship when they transfer; however, the new supplier must have an order from the treating physician to do so. In addition, the new supplier will want to confirm the medical necessity and continued need information is available.

Q4. Are we required to obtain the initial PAP compliance report when a patient transfers from another company and only needs PAP supplies?
A4. A supplier assuming service for a PAP beneficiary would need to ensure all coverage criteria has been met. See the "Replacement of accessories for Medicare-paid, Beneficiary-owned Equipment" for additional guidance.

Q5. What qualifies a patient for excessive daytime sleepiness, the Epworth scoren or just the physician stating it in the notes?
A5. Either the score or statement could qualify them. The information used in determining that excessive daytime sleepiness is occurring needs to be part of the medical record.

Q6. If a beneficiary cannot pick up his/her order, are there shipping options?
A6. There are three different methods of delivery. Delivery directly to the beneficiary or authorized representative, delivery via a shipping or delivery service, and items delivered to a nursing facility on behalf of the beneficiary. See the Standard Documentation Requirements Article A55426 for specific information on the options.

Q7. Is proof of delivery enough for billing?
A7. A proof of delivery alone is not enough for billing as claims for items billed to Medicare require a prescription (order). In addition, there are certain medical necessity and documentation requirements that must be met for each beneficiary prior to billing Medicare.

Q8. Does the patient need to sign anything for proof of delivery or is the tracking number enough?
A8. For method 1 (direct delivery to the beneficiary), the beneficiary or authorized representative must sign the proof of delivery. For method 2 (shipping service), the tracking sheet indicating shipment was made (if it is linked to an invoice or similar, with the tracking number) is enough.

Q9. Are supplies covered, if a PAP was converted to purchase after three months by a previous provider and the order narrative states the beneficiary owns the PAP? Example: patient received E0601 in 2015, billed three months as a rental, then it was converted to purchase at zero. Does the patient need to be restarted to bill for supplies but not the machine?
A9. Reimbursement for supplies can be considered when the equipment is patient owned and the beneficiary meets the coverage criteria as outlined in the LCD under "Beneficiaries Entering Medicare."

Q10. When billing for accessories, is E1225 (recline back) able to be billed as a lump sum purchase?
A10. E1225 is a capped rental item and cannot be billed as a lump sum purchase.

Q11.  Can you charge CPT 99211 with chemo infusions on the facility side? Can modifier 25 be appended to it?
A11. This code is found in (A53296) for Medicare Part A and any additional questions regarding this service should be directed to Part A.

Q12. Are the pulse oximeters (E0445) and replacement probes (A4606) billable separate from the oxygen rental?
A12. HCPCS E0445 and E4606 will be denied as non-covered by DME because they are monitoring devices that provide information to physicians to assist in managing the beneficiary's treatment.

Q13. Will contralateral orthotics be denied as same or similar if a beneficiary only received one for the opposing extremity?
A13. If the applicable RT or LT modifier is submitted on each claim, a same or similar denial should not be issued in this scenario.

Q14. Will a Continuous Passive Motion Machine (CPM) be covered if a patient has a total knee replacement and is in the hospital longer than 48 hours after surgery? (The patient used the CPM provided by the hospital immediately after surgery and upon discharge the physician orders a CPM for home use. The delivery date of the CPM would be after the 48 hours).
A14. The CPM must be started within 48 hours of the surgery and can be billed for 21 days after surgery minus the time spent in the facility. He/she can be in the hospital longer than 48 hours, but you must not bill the DME MAC until discharge. The two codes for CPM are E0935 and E0936. 

Q15. If an order is initiated when the beneficiary is in his/her home, but he/she is in the hospital when they need to be fitted, can we fit them? Does this apply to off the shelf and custom products? Is it different if the beneficiary is in a Skilled Nursing Facility instead of a hospital when they are being fitted?
A15. If an item is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to discharge and the beneficiary uses the item for medically necessary inpatient treatment or rehab the item must not be submitted to the DME MAC in this situation. However, if the orthosis is provided to the beneficiary within two days prior to discharge home and the orthosis is not needed for inpatient treatment or rehab but is left in the room for the beneficiary to take home this is allowable. Note: in this case the date of service is the date of discharge. This applies to off the shelf and custom products.

Q16. When billing a salvaged claim for a custom order that a patient did not end up being fit with, are there any modifiers needed? Should it be billed as a normal claim and use the date of death as the date of service?
A16. When an order is cancelled, or the beneficiary expires prior to delivery of the custom fabricated item, the supplier may bill Medicare for the cost of the suppliers/labor involved in fabrication up to the point when the supplier became aware of the cancellation. Suppliers are to bill the claim as normal with a claim narrative indicating why the order was cancelled (i.e. bene expired, bene cancelled order, etc.). The DOS billed on the claim is either the date of death or the date the order was cancelled. See CMS IOM, Publication 100-02, Medicare Benefit Policy Manual Chapter 15, Section 20.3 for more information on this scenario.

Q17. If we receive a signed order for a prosthetic or orthotic device from Dr. A but Dr. B does the face to face visit and notes, which doctor signs the DWO? Can it be either one?
A17. The treating physician (the one completing the face to face exam) should be the physician signing the Detailed Written Order (DWO).

Q18. Can a fitter, certified by ABC, service a Medicare beneficiary for a custom made/custom fit device under the supervision of a Certified Orthotist?
A18. At this time, a Certified Orthotist or (Physician, Physical Therapist, Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, or Occupational Therapist) must be the specialist performing the modifications and these could not be completed by a fitter, even if they are being supervised by a Certified Orthotist.

Q19. In October 2018, a beneficiary had a face to face evaluation and a qualifying sleep study while covered by a private insurance, but he/she did not start PAP therapy at that time. He/she was transferred to Medicare February 2019. Is a new face to face and sleep study necessary? Or can we use the sleep study from October 2018? 
A19. Medicare expects therapy to be initiated within a reasonable timeframe from the sleep study (generally defined as three months); however, allowance may be may for circumstances. In no case, can the study be greater than 12 months without re-establishing medical need. In this case, the face to face prior to the sleep study and the sleep study is acceptable if the Medicare coverage criteria for the study are met. The beneficiary must begin as a new PAP user and is required to follow the trial period requirements.

Q20. The beneficiary has more than 10 days excess of enteral formula left at the time of the refill request but has run out of enteral supplies. Do two separate deliveries need to be made to comply with the "no sooner than 10 calendar days prior to the end of usage for the current product" requirement for the formula?
A20. Yes, the formula must be delivered at a later date than the supplies to follow the policy requirements.

Q21. When we are billing a claim with the GY modifier for a patient responsibility (PR) denial, is the physician still required to be PECOS certified?
A21. Yes, the physician must be PECOS certified.

Q22. In addition to a resident MD or DO, is it acceptable to have a supervisor sign a DWO?  
A22. The Certifying Physician must be an MD or DO and be treating the beneficiary for his/her condition, it cannot be co-signed.

Q23. Is a bilateral diagnosis code acceptable when a patient received two of the same products, one for the left and one for the right, and they are billed on separate line items?
A23. Yes, a bilateral diagnosis code can be used for both the LT and RT if needed. Bill them on separate lines one with the RT and one with the LT.

Q24. Please clarify when a supplier should bill with the GZ vs GY and GA modifiers?
A24. The GA modifier is used when a not medically necessary denial is expected, and a valid ABN has been obtained. The GZ modifier is used when the item or service is expected to deny as not reasonable and necessary and no ABN was obtained, or the ABN is invalid. The GY modifier indicates the item or service is statutorily excluded and the beneficiary it automatically responsible.

Q25. Can insulin be billed as a 90-day supply and does it require span dating or a narrative to indicate that?
A25. Insulin is not covered by the DME contract and should not be billed to the DME MACs.

Q26. Is it true that three mastectomy bras (L8000) every three (3) months up to the 12 as prescribed is covered or is there a yearly limit Medicare considers?
A26. There is not a published medically unlikely edit (MUE) for bras. The physician will prescribe what is medically necessary and, if 12 were ordered, a 3-month supply should be provided at one time.  

Q27. Are A6531/A6532 considered a same/similar to A6545? Or can both a A6531 and A6545 be provided at the same time?
A27. Per the Surgical Dressings LCD, coverage is for A6531 or A6532 or A6545. These are considered same or similar.

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Last Updated Feb 06, 2020