ACT Questions and Answers - February 15, 2017

KU Modifier

Suppliers can adjust their claims after July 5, 2016. Suppliers must use the KU (DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number 3) modifier for claims submitted on or after July 5, 2016, with dates of service on or after January 1, 2016, and before January 1, 2017, for codes listed describing a wheelchair accessory or seat or back cushion when furnished in connection with a Group 3 complex rehabilitative power wheelchair. The KU modifier is to be implemented as an informational modifier and must be reported to receive the unadjusted fee schedule amount. In addition, suppliers may work with their MACs to submit a list (spreadsheet) for dates of service (DOS) 1/1/16-6/30/16 identifying the necessary criteria for the claims that meet these requirements for adjustments, however, submitting spreadsheets are no longer acceptable for claims with DOS on or after 1/1/2017. DME MACs will process the adjustments brought to their attention.

Standard Documentation Language

Many errors reported in DME MAC Medical Reviews and Comprehensive Error Rate Testing (CERT). Audits arise from problems associated with submitted documentation; so the DME MACs created a standardized language for use in Local Coverage Determinations (LCDs) and Policy Articles (PAs). The standard documentation language (SDL) has been located in the applicable LCDs and PAs. However, the SDL will now be moving to its own policy article and linked within each LCD. This change will facilitate a quicker response time when changes or updates occur with less chance of error. This SDL article is also good for items that do not have an LCD and PA like Continuous Passive Motion (CPM) devices. Even though a policy may not have an LCD, the standard documentation requirements still apply.

Thus, in 2017, Noridian will be reverting back to the previous LCD format that existed prior to 2011, and general documentation requirements that have appeared within individual policies will be removed from all DME MAC LCDs. The general documentation requirements will thereafter be located in a separate LCD article in the Medicare Database, which will be linked to all DME MAC LCDs. In addition to the general documentation requirements, LCDs often contain documentation requirements that are unique to that specific policy. These requirements are termed "Policy Specific Documentation Requirement". Historically, these requirements have appeared within the individual LCD Documentation Requirements section.

Suppliers are reminded that these changes in the LCD format do not add any new requirements, nor remove any existing Medicare documentation requirements. In the event of a claim review (audit), the LCD format change does not remove a supplier's obligation to provide sufficient documentation to demonstrate compliance with Medicare payment rules.

Social Security Number Removal Initiative (SSNRI)

Social Security Number Removal Initiative (SSNRI) is a new CMS initiative that suppliers are able to read about this initiative on the Claims and Appeals tab under claim submission. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new randomly generated Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards for transactions like billing, eligibility status, and claim status. The Medicare numbers and cards will require significant changes to the CMS systems and how CMS does business. The same is true for suppliers. CMS has already started this work and wants to help suppliers shift to the new MBIs by April 2018. No earlier than April 2018, CMS will start sending the new Medicare cards with the MBI to all Medicare recipients.

CMS plans to have a transition period where suppliers will be able to use either the HICN or the MBI. The transition period will begin no earlier than April 1, 2018 and run through December 31, 2019. Once the transition period's over, suppliers will need to use the MBI for most transactions. Suppliers will only be able to use the HICN in a few limited situations. The MBI will be clearly different than the HICN and Railroad Retirement Board (RRB) number. It will be 11-characters in length and made up only of numbers and uppercase letters (no special characters).

Suppliers are encouraged to review their practice management systems and business processes to determine what changes will need to be made to use the new randomly generated MBI. Suppliers will need to make these changes and test them by April 2018, before CMS sends out the new Medicare cards. If suppliers use vendors to bill Medicare, suppliers are encouraged to contact them to find out about their MBI practice management system changes.

Supplier Transition to Exclusion Program (STEP)

Supplier Transition to Exclusion Program, better known as the STEP Program is a voluntary educational program offered to hospital bed and Positive Airway Pressure (PAP) suppliers within Jurisdiction A. A medical review nurse will provide tailored education and resources for each supplier to independently complete self-audits prior to billing in efforts to reduce error rates and increase reimbursement. If a supplier is interested in STEP, you are encouraged to send an email to The email should include a contact name, direct phone number, the Provider Transaction Access Number (PTAN) and indicate if the request is for hospital beds or PAP.

Balance Billing

Balance Billing is prohibited for all Qualified Medicare Beneficiary (QMB) enrollees and is outlined in the MLN Matters Article Special Edition (SE) 1128. A Qualified Medicare Beneficiary (QMB) is a beneficiary that has both Medicare and a State Medicaid plan. All original Medicare and Medicare Advantage Plan (MA) suppliers, not only those that accept Medicaid, must abide by the balance billing prohibitions. QMB individuals retain their protection from balance billing when they cross state lines to receive care. Suppliers cannot charge QMB individuals even if the beneficiary's QMB benefit is provided by a different state than the state in which care is rendered. A QMB cannot choose to "waive" their QMB status and pay Medicare cost-sharing. Suppliers are encouraged to review the billing requirements outlined in the SE1128 which provides CMS guidance to Medicare suppliers to help them avoid inappropriately billing QMBs for Medicare cost-sharing, including deductibles, coinsurance, and copayments.

Pre-Payment Review Updates

The most recent pre-payment quarterly updates for have been posted to the Medical Review page of the website. Suppliers are encouraged to review the "results" and "notifications" as they pertain to their business needs.

February Webinars Available

The Noridian Outreach and Education (POE) team offers the following educational event for all DMEPOS suppliers. Attendance at events is encouraged to obtain the most current information. To attend an upcoming event, visit the POE Schedule of Events.

Title Date Time (ET)
Enteral Nutrition 2/15/2017 3:00 pm
Parenteral Nutrition 2/16/2017 3:00 pm
PAR Condition of Payment for K0856/K0861 2/21/2017 11:00 am
Recovery Auditor Collab with Performant Recovery 2/21/2017 2:00 pm
Urological Supplies 2/22/2017 11:00 am
Prior Authorization Condition for Payment K0856-K0861 2/22/2017 3:00 pm
RAD 2/23/2017 1:00 pm


A new webinar will be conducted on Prior Authorization Condition for Payment on February 21 CMS has implemented a Prior Authorization Request, better known as a PAR for the HCPCS codes of K0856 and K0861 power wheelchairs for Medicare beneficiaries residing in the four high population states which include Missouri, New York, Illinois and West Virginia. effective for DOS on or after March 20, 2017. Suppliers may began submitting the PARs for these codes in New York for Jurisdiction A on March 6.

Additional Education Opportunities

Noridian offers suppliers the opportunity to attend the Online Q&A which are held the second Monday of each month. Suppliers are encouraged to register and attend the Q&A sessions to have direct contact with POE to address your current policy related questions.

DME On Demands are prerecorded training modules that are available for suppliers to attend at times that are convenient for them. There are many policies specific as well as general in nature. All DME on Demands are on average between five and ten minutes in length.

Electronic supplier visits (ESV) provide individualized one-on-one with POE and/or medical review staff. The request form can be found on the Forms page of the website.

Upcoming Events

Noridian education representatives will be in attendance at the following association events:

  • February 23 - Pennsylvania (PA) Association of Medical Suppliers (PAMS), Harrisburg, PA
  • February 27- March 1 - Spring Medtrade, Las Vegas, NV
  • March 1-4 - American Academy of Orthotists and Prosthetists (AAOP), Chicago, IL
  • March 2-4 - International Seating Symposium, Nashville, TN

2017 In-Person Seminars

Noridian is in the process of planning and preparing for our spring/summer in-person seminars. Be sure to watch for the website/listserv for registration information when it becomes available to secure a spot.

Noridian Medicare Portal (NMP)

Noridian offers training currently for the portal on the website to assist suppliers in the various roles on the NMP. One of the enhanced benefits to the portal is that the billing supplier is able to perform password resets, account unlocks and the various administrative and end user roles.

Multi-Factor Authentication (MFA)

Noridian is implementing stronger security guidelines for accessing the NMP by adding a Multi-Factor Authentication process on December 17, 2016. This process includes a second method of authentication when accessing the NMP. Noridian currently requires suppliers have both methods verified so that they are able to access the portal in the case that their primary method is unavailable. Each time users log in to the portal, the user will be required to provide their user name, password and a one-time passcode delivered to them during the log-in process.

Important Portal Reminders

Passwords that are saved in a user's internet browser may prevent login to the portal. Users are encouraged to enter their password in each time they are accessing the portal. Inactivity of 30 minutes will automatically time the user out and a prompt displayed at top of page offering an extension to remain logged in. Users should always sign out when finished; otherwise, the NMP requires a user to wait three (3) hours before logging in again. Accounts are disabled after 60 days of inactivity and to reactivate the account, users must contact NMP Support. Accounts are deleted after 90 days of inactivity, therefore, users must re-register for a new account.

Website Survey

Noridian encourages suppliers to complete the ForeSee Survey on the Noridian website by clicking yes, "I'll give feedback". Noridian values your input and feedback to continue to enhance the website.

Email Updates

Suppliers are encouraged to register for the Noridian listserv to be able to receive informative emails on Tuesdays and Fridays. Users are able to customize the listserv to your business. The Listserv signup is available on the DME home page under the navigation box to the left side of the website. A tutorial is also available on our website which provides instructions on how to sign up for listserv if suppliers have any questions. The listserv is a great way for supplier to stay on top of any changes or updates as they roll out.

Additional Information

An update was provided to a previous question regarding the KT modifier when beneficiaries change their address and it was suggested to use the KT modifier because the beneficiary is traveling and to get the claim paid. Utilizing the KT modifier would not be appropriate in this instance. Noridian clarified that when a beneficiary changes their address with the Social Security Office and the new jurisdiction is denying claims, to please verify with the beneficiary to make sure the Social Security Office has been updated and contact the new jurisdiction to verify that they have the updated address. It does take some time for that address to be updated. There is the potential that there might be a delay from the new jurisdiction having that address because that information comes to the DME MAC from Social Security. The KT modifier is for competitive bid areas only. If the beneficiary resides in a competitive bid area, for example, in New York and they decide they want to visit North Dakota, which is a non-CBA where they experienced a need for supplies, the supplier would add the KT modifier. If the beneficiary is going from one CBA to another CBA, the KT modifier would also be appropriate. It is not appropriate to add the KT modifier just to get a claim to go through. The suppliers first action should be verifying with that beneficiary to make sure Social Security was updated.

Q&A Session

Q1. If a physician faxes over an original prescription with all of the elements of a detailed written order, can it count as both the prescription and the detailed written order?
A1. Yes, it can.

Q2. Who can we contact to get help with the portal?
A2. Users are able to call the contact center at 866-419-9458 to receive assistance with questions on registration and use of the NMP.

Q3. In reference to the Transmittal 3716 that CMS issued to the DME MACs pertaining to the transition to the fully adjusted Fee Schedule from the Cures Act legislation. Supplier adjustments that were due for dates of service in July through December of 2016. Do you have any information or direction on that yet?
A3. We are still waiting for formal direction from CMS.

Q4. We're a dental office. We're starting to bill for oral sleep appliances so I have two questions. First of all, when can I bill paper? Are there certain requirements we have to meet in order to bill paper claims and when it has to be electronic?
A4. Suppliers must electronically bill their claims unless they meet one of the exceptions. These include suppliers that have to have less than 10 full-time employees (FTEs), submit less than 10 claims per month or 120 claims per year and there's the Administrative Simplification Compliance Act (ASCA) requirements that must be met.

Q5. If we chose to be a non-participating provider, we can choose per claim to bill assigned or non-assigned?
A5. Yes. If your PTAN is registered with National Supplier Clearinghouse (NSC) as non-participating, you can submit your claims based on whether it being assigned or non-assigned. However, the beneficiary must be informed up front that you are non-participating and that you are going to bill your claim non-assigned, so they can make a decision whether or not they still want to do their business with you. Also, please note that there are certain circumstances and items that require mandatory assignment (i.e. competitive bid items furnished in a competitive bid area, drugs and biologicals).

Q6. What is the policy when a patient has a change in insurance and is renting a wheelchair, bed, etc., then they go onto to traditional Medicare?
A6. When the beneficiary enters Medicare Fee-For-Service (FFS) for the first time, the beneficiary must meet the qualifications based on the Local Coverage Determination (LCD). Chapter 3 of the Noridian Supplier Manual provides specific instructions for beneficiaries Entering Medicare in regards to certain documentation that suppliers must assess the piece of equipment.

Q7. What is a considered good Advance Beneficiary Notice of Non-coverage (ABN) and what is not a good ABN?
A7. Noridian offers a DME On Demand on the ABN that is available at your convenience to assist with understanding ABNs. CMS also has an informative brochure that you can download that is also very helpful with regard to the purpose of the ABN and how to complete it.

Q8. If a prescription is about to expire within the years' time span and we have documentation on file such as a current face-to-face, a pressure change RX, etc., are we still required to get a new prescription or is that documentation sufficient enough for the continued need and use of the equipment? This is specific to supplies (not anything on the Affordable Care Act (ACA) list).
A8. When a prescription expires, a new prescription would need to be obtained. On-going medical need can be shown by medical records entered in the past twelve months or a new prescription.

Q9. I have a question regarding the DWO requirements specifically around the route of administration. We're seeing a lot of pushback from our physicians when we are requesting they clarify the actual route of administration. We receive the drug name and it says internal suspension and the physician is stating that it is implying the route of administration and they shouldn't have to provide any further clarification. Do we need to actually have it spelled out in a formal type of a route of administration kind of description?
A9. The route of administration is a required element of the detailed written order and must be included. This element cannot be assumed.

Q10. This question is in regard to Redetermination denials for the delivery date and the signature date. Sometimes they don't match because the patient hasn't been discharged yet or is getting discharged. In other words, is the beneficiaries signing one date and the document was delivered on a different date, should the review be denied?
A10. The beneficiary signature date will be considered the date of service. The only exception is if the item is delivered within two days of discharge, the DOS will be the discharge date.

Q11. We have a Certificate of Medical Necessity (CMN) for a patient and didn't realize they didn't have Part B coverage but they do have Part A. The CMN is dated today and down the line, for example, in November, the patient gets Part B coverage. Will the CMN that we have currently be good or will we need to start over?
A11. The CMN would have to be current to the date that the patient started Part B coverage.

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Last Updated Aug 30, 2018