ACT Q and A - February 23, 2020 - JA DME
ACT Questions and Answers - Standard Written Order - February 23, 2020
The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Teleconference (ACT) on the Standard Written Order (SWO). 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.
NOTE: During the ACT, it was clarified that if the physician dates his/her signature, that date does not supersede the original SWO date.
Q1. Does the Standard Written Order (SWO) or face-to-face (F2F) medical documentation need to be date stamped?
A1. Date stamping is no longer required.
Q2. Is there is any requirement that the National Provider Identifier (NPI) be present on the prescription? We are constantly sending them back for no NPI.
A2. The SWO can have either the supplier name or NPI.
Q3. How does SWO effect preliminary orders being on file prior to dispensing?
A3. Documentation of a preliminary order is no longer required by Medicare. However, the treating practitioner must communicate the need for the item to the supplier prior to dispensing.
Q4. Can a supplier bill with the SWO if it just states "CPAP and supplies" or is a Detailed Written Order (DWO) still needed?
A4. The DWO is no longer applicable. While the SWO allows a general description, if it is not specific to the items billed, reviewers will look to the medical record to confirm items ordered and provided.
Q5. Can verbal orders be accepted by a physical therapist?
A5. Medicare does not recognize physical therapists as treating practitioners with the ability to order DMEPOS. Therefore, verbal orders should not be accepted from them.
Q6. Why are prescriptions basically obsolete now as documentation? Why can't physicians write prescriptions on the company prescription pads?
A6. The prescription pad can still be used to communicate the order to the supplier. If it contains all of the elements needed on a SWO, it can be considered the SWO as well. The only change is that Medicare is not "requiring" proof of documentation to validate the prescription or preliminary order.
Q7. When will the required list be published?
A7. We expect for the required list to be published in the spring of 2020.
Q8. What documentation is needed for post mastectomy products, such as L8030, L8015, L8020, L8000?
A8. The standard documentation requirements and coverage criteria outlined in the External Breast Prostheses Local Coverage Determination (LCD) (L33317) will need to be provided to prove medical necessity. Documentation of mastectomy needs to be within the beneficiary's medical record.
Q9. Can an ABN (Advanced Beneficiary Notice of Noncoverage) be signed for an upgraded mask style that exceeds Medicare's allowable amount?
A9. An ABN cannot be issued based on exceeding allowable amounts for assigned suppliers. Depending on equipment being provided, upgrade guidelines may apply.
Q10. It is acceptable to bill for three units of L7510 and is it acceptable to bill for both parts and labor (L7520) simultaneously?
A10. Billing for three units of L7510 would be applicable if three different parts were being repaired or replaced. Labor code L7520 cannot be billed if the part being replaced has an assigned HCPCS.
Q11. What is considered chronic stable state? In the case of Obstructive Sleep Apnea (OSA), is it after the beneficiary meets compliance with a Positive Airway Pressure (PAP)?
A11. Chronic stable state is defined as "Not during a period of acute illness or an exacerbation of their underlying disease." All co-existing diseases or conditions that may cause hypoxia must be treated and the beneficiary be in a chronic stable state before oxygen therapy is considered eligible for payment.
Q12. Can an item be supplied on the spot? For example, for someone who is out of town or is hurt and needing immediate care.
A12. Regardless of the permanent address of a beneficiary, suppliers must follow the same process in providing service. If Medicare coverage qualification cannot be established, an ABN could be utilized.
Questions Asked During ACT
Q1. The SWO we would initially receive will not contain the accessories for a complex power chair. We have the standard order in place that says "Power Mobility" and we have all of the visit stubs, Assistive Technology Practitioner (ATP) assessment and then create the detailed written order, does that detailed standard written order need to be received prior to delivery or prior to billing?
A1. The SWO with those accessories listed needs to be received prior to billing Medicare. Keep in mind as well that the contemporaneous medical record should to the two together because it becomes difficult to link accessories with a date nine months later.
Q2. Will Advance Determination of Medicare Coverage (ADMC) requests be available through the Noridian Medicare Portal (NMP)?
A2. ADMC status in NMP is in process but is currently available only through the Interactive Voice Response (IVR) system.
Q3. Does the date on the SWO have to be on or before the date of service or is it prior to billing Medicare? For example, we have a date of service of February 11, it's not dated until February 13 and we bill it out on February 14. Is that a valid SWO?
A3. That would be valid as long as it is not a power mobility device, at this time. For the supplier's benefit, it might be prudent to try to put down the date when you first receive the communication from the treating practitioner regarding the item. Medical review can then tie the medical records to the communications.
Q4. You mentioned on CPAP supply prescriptions, it should just say "mask". Does it need to specify nasal versus full face?
A4. If nasal or full face is not indicated on the SWO, it does need to be indicated in the medical record to prove which one was ordered and/or provided to the beneficiary. Although that description can be generic on the SWO, it is suggested to be as specific as possible because if it is not, it will be looked for in the medical records.
Follow-up Question: What do you mean by medical records?
Answer: This is the medical information from the treating practitioner as to what is being ordered and the medical need for the item.
Q5. If we send the SWO with an order date and the physician signs and dates it, the signature date becomes the order date. Let's say we send out an order prior to that signature date and we have a verbal authorization on file, are we able to send that verbal authorization, would it be considered covered for that date of service since it's prior to that signature date?
A5. The order date will always remain the date that the supplier was initially contacted. It is acceptable for a physician to sign the SWO following delivery, however the supplier must have a valid SWO prior to billing.
Q6. With the Length of Need (LON) for refills requirement that was removed, we are going by the state timeframe. There are some states that don't have an expiration date; they say to have refills noted. If we receive ‘unlimited refills' on a DWO, would that be good and not expire?
A6. That's correct as long as it's not indicated in the LCD or the medical need has not changed, and it meets state requirements.
Q7. Is the CMN/DWO no longer needed if the SWO is completely filled out by the physician? Can we still complete the CMN because many times the physicians don't know what type of mask or tubing a beneficiary needs until setup.
A7. The CMN guidelines did not change. There are five policies that require a CMN as a part of the policy. For those policies not requiring a CMN, if the accessories are not determined until after, that will need to be outlined on the SWO by the supplier and sent back to the treating practitioner for signature. The Standard Documentation Requirements article A55426, clearly indicates that if a CMN contains all the elements required, that CMN can serve as the SWO, but an SWO cannot take the place of a CMN.
Q8. If a physician signs and dates a prescription a week after my pharmacy dispenses on a verbal order, is the SWO valid?
A8. Since the supplier is the one preparing the order, enter the date that communication from the treating practitioner was received, which will be before the drug was dispensed.
Follow-up Question: But you're saying the signature date will supersede that order date.
Answer: The SWO doesn't have an element for physician signature date. It is helpful when trying to clarify things, but it will not override the date entered as the date of the order.
Q9. In regard to our supplies, we have to bill in kits. These kits involve different supplies. Can we put "IV supplies", "admin kit per week" or "catheter kit per week" or do have to have the quantity because they aren't actual kits, it's just all the supplies combined.
A9. It is best to always be as specific as possible. Putting down "kit" could mean two supplies or 10 supplies so putting "kit" or "cpap supplies" won't work. The rule is to list everything that is separately billable.
Follow-up Question: These are not separately billable items. We have to bill the administration kit and catheter care kit.
Answer: List that and if three are provided, put down three. If someone a year from now decides to audit, being as specific as possible upfront will only help down the road.
Q10. If we indicate standard mask, for example, is that sufficient or do we need to include brand names?
A10. As long as the type of mask, nasal or full face, is indicated, that's fine. The brand name, model number, etc. are not required. It is always helpful to be as specific as possible. Some auditors require more than Noridian does and it's to your advantage to include the brand name, model number, etc. If the information is generic on the order, they will look at the medical records.
Q11. We are questioning what is in the Oxygen policy for a beneficiary who is prescribed oxygen and CPAP at the same time. Once they get that beneficiary in a stable state in that particular study, is that considered a chronic stable state or do they need to be on the CPAP and compliant before they can get oxygen?
A11. The first thing to always remember is that the requirements are separate and independent from one another. Just because you might need both, doesn't mean you don't need to meet all of the CPAP and all of the oxygen requirements. When someone with OSA goes on a CPAP, one of the first things to do is a titration PSG to make sure the OSA is adequately treated. The chronic stable state requirement is an oxygen policy requirement and it's meant to say that this particular beneficiary has been treated as well as he/she can and there is nothing left. At this point, if the beneficiary still needs oxygen, that is the chronic stable state.
Follow-up Question: Do beneficiaries need to be on the CPAP for several months? Can it be done during the study or do they have to be prescribed the CPAP and on the CPAP?
Answer: There is not a requirement for PAP to be tried in the home setting prior to prescription of oxygen. If there is a split night study showing oxygen desaturation and all other oxygen qualification criteria are met, the beneficiary may qualify for home oxygen therapy.
Q12. If we are taking on a beneficiary from another company for CPAP, the sleep study was not scored at 4% and the beneficiary was on BiPAP. Since the sleep study was not scored properly, we are asking the beneficiary for another test. Besides a new study that scores at the proper percent, do we need documentation of a titration study showing that the beneficiary can't tolerate the CPAP or can we use the study that was done previously?
A12. In this case, when the beneficiary is coming to Medicare on therapy, we need to use the Beneficiaries Entering Medicare portion of the policy, which requires the F2F after they become Medicare-eligible and then they have to have the qualifying sleep study. If they have a sleep test that is scored at 3% and the data is available on that sleep study that can be used to score at 4%, then that is acceptable for Medicare.
Follow-up Question: What if it can't be rescored?
Answer: If the original sleep study can't be rescored, then the beneficiary would have to have a new study that meets the Medicare coverage criteria. They are still following the Beneficiaries Entering Medicare portion of the policy and that only requires that F2F after they enter Medicare indicating ongoing need, used benefit, etc., and a sleep study that meets Medicare coverage criteria. There is no requirement for a trial period or the compliance associated with that trial in this scenario.
Q13. Our facility is in the process of obtaining a DME license. We are going to be a provider and supplier. Is additional enrollment needed?
A13. If you're going to be providing supplies as both the provider and supplier, yes. You'll need to obtain a DME Provider Transaction Access Number (PTAN) from the National Supplier Clearinghouse (NSC).
Q14. Regarding power mobility devices, can the SWO and letter of medical necessity (LMN) be completed by the doctor at the same time?
A14. Yes, the SWO can be completed at the same time as other documentation. Be sure all of the accessories are listed out.
Follow-up Question: If we get an SWO in January, and the F2F is in April, but everything else is dated November, is that ok?
Answer: The easiest way to remember is "six months" from the F2F. If the clinician sees the beneficiary in January and the order isn't received until August, the order will not be valid and another F2F would be required.
Q15. When we submit a PAR, the SWO date is the date the practitioner came to us to tell us the equipment is needed. How do you know if that date is correct because normally you have the F2F to match or does the ATP evaluation have to match that date?
A15. The six months is from the F2F, not the concurrance date.
Follow-up Question: To clarify, if the F2F is in January and the concurrence isn't until May, then I receive the order in July, that would not be valid because it is no longer based on the concurrence date, it's based on the F2F date.
Written Questions During ACT
Q1. I'm looking for clarification regarding the billing date versus the order date. Can you provide this?
A1. The order date is the date the order is communicated by the practitioner to the supplier. The order date is the only date that is required and the SWO must be obtained prior to billing.
Q2. Previously, it was required to list the medication, dosage and frequency for a nebulizer. Is this no longer required?
A2. Correct, only the elements listed on the SWO are required for Medicare purposes, however the medical record will need to support amounts ordered and provided.
Q3. If we get a verbal order but need to send a SWO to the doctor and they sign the new SWO with a date, what is the order date?
A3. The order date would be the original contact date with the treating practitioner.
Q4. If we continue to use our regular DWO, which has all of the elements of the SWO, do we need to change the name on the form from DWO to SWO?
A4. The name on the form would not need to be changed from DWO to SWO. The previous DWO can still be utilized as long as all of the elements necessary on the SWO are present.
Q5. If a SWO that includes the printed name and National Provider Identifier (NPI) of the physician but another physician in the same practice signed the SWO and included his name in the electronic signature, can we use this as a valid SWO, even though the physician who signed the order does not match the NPI and physician name that was pre-printed on the SWO?
A5. As long as the physician who printed his/her name and signed the SWO is the treating physician, the order would be valid.
Q6. Since managed care programs are supposed to follow Medicare guidelines, are they required to update their policies as of January 1, 2020, to reflect these new policies?
A6. Medicare Advantage plans are not required by CMS to following Medicare Fee-for-Service (FFS) guidelines.
Follow-Up Question: If it states in our contract that they follow Medicare guidelines, wouldn't they have to adopt these policies effective January 1, 2020? We are worried about seven-element orders (7EO) and no dates.
Answer: We are only able to speak to Medicare FFS guidelines. Please reach out to the other insurance providers directly for their guidelines.
Q7. If we receive a SWO with the codes A7030 and A7034, upon initial setup of the Positive Airway Pressure (PAP) device, can we bill for either one of those codes or would a new order be required with only one item listed?
A7. The order can contain both items but either the treating practitioner should indicate which is ordered or the medical records should support what was provided.
Q8. If we are getting a Prior Authorization Request (PAR) on a wheelchair base with tilt, would we not need to make sure that the tilt and cushion are being obtained in order for the reviewer to approve the base or are they just looking at the base alone and approve the bases even though there is lack of information that the required accessories are being obtained?
A8. Keep in mind that all supporting documentation should be included with the medial record submitted for prior authorization. The fact that there were some items removed from the order does not change the need to present the full clinical picture for prior authorization.
Follow-up Question: So we can send in a power chair with tilt and recline with just a SWO and without the final script without all the accessories?
Answer: A SWO for accessories is required prior to billing Medicare. All supporting documentation should be included with the medical records when submitting a PAR.
Q9. I understand that the SWO for Power Mobility Devices (PMDs) must be completed in its entirety by the prescribing practitioner. Prior to sending the practitioner a template SWO for the PMD base, can the supplier pre-populate a list of the accessories on the same SWO or is a second SWO needed for the accessories?
A9. It needs to be clear that the SWO for the base item was completed by the treating practitioner. The accessories can be on the base SWO completed by the practitioner or a second one prepared by the supplier then reviewed and signed by the practitioner.
Q10. For PMDs, if a detailed SWO is used to show all of the accessories, does it have to be received prior to delivery or prior to billing?
A10. If the SWO for the base is obtained prior to delivery, there can be a second SWO for accessories prior to billing.
Q11. For infusion, can the supplies be listed as "IV supplies" or does it have to be descriptive, such as "catheter care kit per week".
A11. Each item that is separately billable to Medicare should be listed.
Q12. As a supplier, we deal a lot with Home Health (HH). The physician will send orders to HH. Our first contact with the physician is based on the order they sent to HH to advise we have been brought in, we don't technically get an order until the client has their F2F. Could we use this as the order date since it is when we actually had the contact with the physician?
A12. Yes, that date would be a valid order date.
Q13. For PAP supplies, if frequency of use is no longer on the SWO, does that mean that each individual type of supply must be documented in the medical record with how often to change them?
A13. Frequency of use would only need to be documented in the medical record if that frequency exceeds normal utilization guidelines. Otherwise, quantity to be dispensed does need to be documented on the SWO along with each item to be dispensed. The allowance for supplies will remain as indicated in the PAP LCD utilization schedule.
Q14. Are doctors still required to date the concurrence when they sign off on therapy exams? Right now they have to sign off and date it but new guidelines say you don't need a date on a SWO.
A14. The LCD requirements have not changed; however, the sequence of F2F, licensed/certified medical professional (LCMP) and 7EO is no longer an issue. The six-month period begins at the time of the F2F.
Q15. Do "weekly" and "daily" qualify for the quantity dispensed?
A15. "Weekly" and "daily" would usually be a frequency. Quantity would normally be the amount that is going to be dispensed at one time.
Q16. If a SWO is for 60 catheters, can we dispense 180 catheters as a three-month supply, or would we need a new SWO for 180 catheters?
A16. A supplier would be able to dispense a three-month supply based off the order described.
Q17. From my understanding, Affordable Care Act (ACA) requirements for the PAP device no longer apply as of January 1, 2020. If this is correct, the Written Order Prior to Delivery (WOPD) and F2F do not have to be within six months of each other and the NPI does not have to be on the SWO. Is this the correct interpretation of the information provided?
A17. Correct, as of January 1, 2020, ACA requirements are not in effect. The NPI or the treating practitioner's name can be on the SWO.
Q18. If we receive a SWO and it lists multiple PAP mask types because the doctor does not know the type of mask the beneficiary will select at the PAP setup, do we need a new order with just the mask requested instead of multiple types of masks?
A18. Yes, an updated SWO needs to be obtained once the specific accessories are selected.
Q19. A beneficiary has a new colostomy and the practitioner orders "colostomy supplies". In discussing with the beneficiary, we determine he/she needs wafers, pouches, paste and an ostomy belt. We submit the SWO back to the practitioner for those items. Does each item need to be mentioned in the medical record as medically necessary?
A19. Each item that is separately payable to Medicare must be listed on the SWO. If those items are utilized in a frequency above normal utilization, the reason for that frequency must be addressed within the medical record. Also, if LCD policy states specific criteria for any ostomy item, that must be addressed within the medical record.
Q20. Regarding a new PAP order, as of now we are not required to have a F2F visit on file within six months of the order and prior to the diagnostic sleep study. Has this changed?
A20. The LCD in-person visit requirements are still in place. The beneficiary does need to have a visit with the treating practitioner prior to the sleep study though there is not a specified timeframe.
Q21. Regarding a complex rehab product, we are submitting the initial SWO from the doctor and the description is "power mobility device". The therapist and ATP conclude the client needs a Group 3 multiple power seating and it is justified in the therapist evaluation and signed by the doctor. Will we have issues because the doctor's notes do not comment on the need for seating?
A21. The LCD requirements for PMD have not changed. It is the sequencing of evaluations and orders that has been simplified to only the SWO and the six-month window begins at the time of the initial F2F. SWO does allow for the general description.
Q22. For PMDs, is the order date the date that we receive the request from the physician?
A22. Yes, and for PMD base items, the SWO needs to be completed by the treating practitioner who completed the F2F. For accessories, suppliers can also use the order date that you receive the request.
Q23. For Advance Determinations of Medicare Coverage (ADMCs), we can send in a SWO, but we are no longer requested to send in the script with all the final accessories, as that is not required until we bill, correct?
A23. A SWO for accessories does need to be included with the ADMC packet so the reviewer is able to determine what is being requested since ADMC includes all accessories.
Q24. If we have an order with an illegible physician signature but the NPI is also on the order, does that qualify as an approved illegible signature?
A24. Signatures must still comply with CMS signature requirements outlined in CMS Internet Only Manual (IOM), Publication 100-08 Program Integrity Manual, Chapter 3, Section 126.96.36.199. The NPI alone will not meet that requirement.
Q25. Can the SWO be done by the doctor before the F2F takes place?
A25. No. For PMD, the SWO needs to be completed within six months after the F2F. For other DMEPOS, the treating practitioner needs to have seen the beneficiary prior to the SWO being completed.
Q26. Similar to a CMN, do the same rules apply for a SWO in that the item must be dispensed within three months of the order date for the SWO to be considered timely?
A26. The applicable LCD will still outline the dates for this. If the LCD doesn't specify, then the default would be six months.
Q27. Prescriptions for hospital beds, wheelchairs, etc., are often missing the length of need (LON). We have been requesting the provider add this to the prescription or fax them a confirmation of order to be completed. Based on what was said, we no longer need this to be added to the prescription, correct?
A27. Correct, the SWO does not need a LON.
Q28. If the CMN is used as the SWO, does it matter when the CMN is signed/dated?
A28. CMN date requirements have not changed; therefore, follow the CMN date requirements per the applicable policy.
Q29. Is the E0562 (heated humidifier) considered a piece of equipment?
A29. Yes, any item that can be separately billed requires a SWO.
Q30. If I have a CMN for a seat lift chair mechanism, is a SWO needed?
A30. Seat lift chair mechanisms do not require a CMN. A SWO will be needed.
Q31. What is the best resource to determine if an item needs to be billed to Outpatient Prospective Payment System (OPPS) (Part A) versus DME?
A31. The easiest way to look this up would be to use the Consolidated Billing tool on our website under Education and Outreach > Tools > Consolidated Billing/SNF/Home Health/Hospice Lookup. Key in the HCPCS and the tool indicates whether it is billed to SNF, Part A or DME.
Q32. Is the quantity required on the SWO?
A32. Yes, the quantity is required.
Q33. If the order date is after the date of service, is the SWO valid?
A33. No, an item cannot be dispensed prior to it being ordered.
Q34. Is the SWO still only good for 12 months?
A34. The order is good until an item is replaced, when there is a change in supplier and the new supplier is unable to obtain a copy of the previous order, if there is a change in the quantity being dispensed or when state law requires a new order.
Q35. For a nasal mask to be dispensed every three months, do we have to put 3 instead of 1 on the SWO for that SWO to be valid for 12 months?
A35. No, the quantity will remain one, however the utilization schedule will remain in place allowing suppliers to only provide one mask every three months.
Q36. Is the SWO date the F2F date for PMD?
A36. The date of the F2F is no longer required for PMD orders. The order date is the date the treating practitioner completes the order.
Q37. Is there a timeframe for all LCDs and Policy Articles to be updated?
A37. All LCDs and Policy Articles are being reviewed by the medical directors for potential update and that is expected to be completed by early spring 2020; however, the SWO elements are not found in the LCDs. These are found in the Standard Documentation Policy Article A55426.
Q38. Are electronic signatures and dates allowed on a SWO?
A38. Electronic Signatures and dates are allowed as long as they meet signature requirements found in the Program Integrity Manual.
Q39. Are we at risk if the medical record does not indicate the LON (LON is not on the order either)?
A39. There are policies where permanency and/or LON must be established within the medical record. This still applies and does not need to be on the SWO. Remember, the prescription/SWO is not part of the medical record.
Q40. If a beneficiary walks through the door with a prescription for a walker, would that be the date on the SWO or would the date the prescription was written be the date?
A40. The date would be the date on the prescription from the treating practitioner.
Q41. Can the date of the physician's signature and date on the SWO be after the date of service but before the billing date?
A41. The date of the signature can be after the date of service of the initial claim, however the date of the order should be the date of original contact from the prescribing practitioner which will be prior to the date of service.
Q42. We have a SWO for TENS supplies that is over a year old. Do we need a new one?
A42. Not unless your state statute requires a new order or if the order has changed (ex: quantity of supplies being dispensed has changed).
Q43. If a physician writes a prescription for a PAP device, does a heated or non-heated humidifier need to be listed on the prescription in order to dispense it?
A43. Any item that is provided must be listed on the SWO and the SWO must be obtained prior to billing. Supplies may be on the initial SWO with the equipment or they may be on a separate SWO as long as it is obtained prior to billing.
Q44. Are electronic signatures accepted on face-to-face (F2F) exams and when a doctor signs a therapy exam to concur? Date stamps are not accepted, correct?
A44. Yes, electronic signatures are accepted but date stamps are not.
Q45. Are doctors concurring with therapy exams required to sign off on them?
A45. The SWO update on January 1, 2020, did not change any policy criteria for medical documentation or the need for doctors to sign off on documentation that they concur with.
Q46. When a pump is delivered while a beneficiary is in a Skilled Nursing Facility (SNF) stay, can I change the date, as long as the discharge is the same month as the delivery?
A46. The delivery date to a beneficiary inpatient must be within two days prior to the anticipated discharge date and the billing date or date of service is the discharge date. If the anticipated date changes, and the claim has been billed, a reopening can be done to change the date (to be within two days).
Q47. Can we get paid labor time for our time to assess the parts that are broken on one labor ticket and then bill another labor ticket for the actual parts and time to fix it? I think if we bill labor, we always have to have a part with it or we can't get paid. If that is the case, do we combine all the time together?
A47. Labor is only payable for the time actually used for the repair, not the assessment.
Q48. For PAP supply orders, we have been required to verify that the beneficiary is using and benefitting from PAP within the last 12 months. Does this still apply?
A48. Yes, the continued need documentation still applies.
Q49. Are Certificates of Medical Necessity (CMNs) and DME Information Forms (DIFs) still required in those specific policies?
A49. Yes, the CMN and DIF criteria have not changed.
Q50. Do we have to bill with the signature date on the delivery ticket?
A50. If delivering the items via a shipping service, the date of service may be either the date the shipping label was created or the date that the delivery occurred.
Q51. Can a Registered Nurse (RN) accept verbal orders from a physician?
A51. Yes, with the exception of PMD; however, there must be a SWO signed by the treating practitioner prior to billing Medicare.
Q52. The CMN chapter of the Supplier Manual states an item must be dispensed within three months of either the initial date or signature date to be considered timely. Does this verbiage also apply to items that do not require a CMN, such as a PAP device?
A52. This would only pertain to those items when the CMN is acting as the order.
Q53. We have a sleep study that states "RULE VII.4A and VII.4B are used to define a hypopnea". The sleep center stated that it means this study was scored at 4%. Is this acceptable or does the study need to specifically say 4%?
A53. If that means it was scored at 4% it would be acceptable. It doesn't need to specifically state 4%. It is recommended that the documentation explaining the rule definitions be available in the event of a review.
Q54. If a beneficiary has stopped using their PAP device over 60 days and the physician would like them to restart therapy w/new supplies, what is required to be able to bill for them?
A54. If there is a break in billing more than 60 days plus the days remaining in the rental month, then that would be considered a break in medical need. A new trial period would start, a current (within 12 months) sleep study and F2F would be needed.
Q55. If a sleep lab or physician did not measure a beneficiary's neck, could our respiratory therapist measure it and document the neck circumference in our notes?
A55. Supplier records will not be considered part of the qualification criteria; however, neck circumference specifically is not a requirement for qualification.
Q56. If a beneficiary's old sleep study is scored at 3% and they need to have a new one, will a new F2F be required to document why a new sleep study is required?
A56. There is not a requirement for beneficiaries entering Medicare to have a F2F prior to a new sleep study, however there is a requirement that there be a F2F following Medicare eligibility that documents obstructive sleep apnea (OSA), use and benefit from their current PAP therapy.
Last Updated Sat, 18 Apr 2020 20:53:36 +0000