ACT Questions and Answers - May 8, 2018

The following questions and answers (Q&As) are cumulative from the Ask the Contractor Teleconference. Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies.

Questions Received Prior to ACT meeting

Q1. To assist in understanding the serial claims initiative, here are two questions regarding that series of claims. Once a determination has been made on one claim, will the adjustments only occur on claims already submitted (on file with the DME Medicare Administrative Contractor (MAC)) at the time of the determination? Or. Will future claims (claims of continued use) also be held to the same initiative process?
A1. Both claims already submitted and those submitted in the future will receive the benefit of this initiative.

Q2. Extension from Q1. If yes and future claims will be adjusted, will claims begin to pay upon submission; therefore, relieving suppliers of the Redetermination appeal process for every serial claim? How long will future claims take to be reprocessed if they had already denied?
A2. Per the article, Serial Claim Initiative, once the reason for denial, for one claim in a series, is resolved at any appeal level, the DME MACS will identify other claims in the same series that were denied for the same or similar reasons and will take that determination into consideration when adjudicating such claims. DME MACs will also communicate the favorable decisions to the DME Qualified Independent Contractor (QIC) and Administrative Law Judge (ALJ) offices. The Medicare claims processing system will also be updated to reflect a favorable decision for that series to allow future claims. Once a claim has been received or adjusted, processing must be completed within 30 days.

See an additional reference in CMS Medicare Learning Network (MLN) Matters Special Edition (SE)17010 -  Improvements to the Adjudication Process of Serial Claims.

Q3. If the DME MAC is going to audit the first claim through prepay, how will they know that there will be serial claims for the beneficiary?
A3. If the claim is for rental there is an assumption that subsequent months will be billed, meeting the allowed schedule for the device being reviewed.

Q4. Is there a list of Healthcare Common Procedure Coding System (HCPCS) codes that will be part of this implementation?
A4. No.

Q5. CMS Change Request (CR)10426 indicates there is a mainframe HCPCS code spreadsheet.
A5. Suppliers may find a list of HCPCS codes attached to the CR10426, see the Additional Information section of the CMS Medicare Learning Network (MLN) Matters (MM)10426.

Q6. Please define "Complex Medical Review."
A6. This is a review of the documentation that is submitted pertaining to the claim that was billed for the DMEPOS item provided to the Medicare beneficiary. These reviews are completed by the DME MAC Clinical Review team.

Q7. Is a complex medical review different from our typical audits?
A7. No.

Q8. A supplier's pharmacy dispenses immunosuppressant medication to post transplant patients. When there is contact with the patient for refill; one of the questions we ask, "are you at home or in a facility." On occasions, the patients will tell the supplier that he/she is home when he/she is in a rehabilitation facility. In addition, the Noridian Medicare Portal (NMP) or Interactive Voice Response (IVR) do not show the admission of a Part A stay. Medicare will pay and then take the money back within two years.

The supplier's patients tell them they are home because the rehab facility will not order his/her tacrolimus or myfortic. He/she is not upfront or honest because he/she knows they must have their medications.

The Local Coverage Determinations (LCDs) tell the pharmacy they must absorb the cost because the supplier billed in error. By checking the NMP/IVR/patient response, the supplier did what was expected.

There was no other way a supplier could figure out this patient was in a facility.

With that in mind, please respond to the following questions:

Q8a. Are these rehab units allowed to tell the patients to get their Part B meds somewhere else? They don't want to absorb the cost of these expensive medications.
A8a. If the beneficiary's stay is covered under Part A, the facility is required to supply their immunosuppressive drugs.

Q8b. Why should a supplier (pharmacy) be punished by taking back the Medicare payment when the supplier did their due diligence?
A8b. It is the responsibility of the supplier to ensure that the beneficiary is at home or in a Part A facility before dispensing. The discharge paperwork from the hospital should list to where the beneficiary is being discharged.

Q8c. Medicare doesn't have the correct information either but suppliers lose payment for an expensive medication that was provided to the patient.
A8c. The Part A facility has the same timely filing requirements as Part B/DME. The IVR records are updated as information is received from the facility confirming a Part A stay. It is imperative that suppliers work with the Part A facilities and the beneficiary to ensure their location is accurate.

Q8d. In a situation like this where the patient isn't being truthful, can suppliers ask the patient for the cost of the medication given to them? If the patient was upfront and honest, the supplier may have been able to figure out how to get the medication correctly for all parties.
A8d. No. The only time a supplier can ask the beneficiary to pay the cost of the medication is when a patient responsibility denial is issued.

Q8e. Can a supplier bill the Part D plan for the medication unbillable to Part B while he/she is in a facility?
A8e. Inquire with Part D if there are any benefits for denied Part B claims due to inpatient stays. We are unable to educate on Part D benefits.

Q9. Please address acute oxygen diagnosis for patients being discharged from the hospital. There is much confusion as to whether a customer who is being discharged from an inpatient facility with an acute diagnosis or an exacerbation of a chronic condition qualifies for coverage or not. It is indicated that "oxygen is not driven by specific oxygen diagnosis codes" …but then other areas read "Conditions for Which Oxygen Therapy May Be Covered,

  • A severe lung disease, such as chronic obstructive pulmonary disease, diffuse interstitial lung disease, cystic fibrosis, bronchiectasis, widespread pulmonary neoplasm, or…"

Is this not contradicting?
A9. Noridian reviews oxygen claims based on what is presented in the beneficiary's medical record. The records must be clear and descriptive as to what is causing the hypoxia. We stress the importance of the medical records needing to paint a clear picture of the events that have led up to the beneficiary requiring home oxygen therapy.

Q10. Blood gas testing. Supplier understands that there are two circumstances.

*If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test
Must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date


*If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state – i.e., not during a period of acute illness or an exacerbation of their underlying disease

Question 1: Why has the supplier had audit denials and recoupments for patients who qualify under the inpatient stay for them not being in a chronic stable state?

Question/comment 2: When it was discovered that there was a disconnect between how CGS and Noridian review oxygen claims for inpatient discharges where CGS was approving them but Noridian claims reviewers/auditors were not, the supplier was told that the physician must be present the full "picture." As an intake specialist trying to determine whether a customer qualifies for oxygen or not for these hospital stays, this is very difficult. Some companies tell suppliers they push them through and get paid, others execute an Advance Beneficiary Notice of Noncoverage (ABN). When one supplier takes over another supplier's patient, it is noticed that the acute diagnosis is being paid. Please help us understand how a supplier is to determine the full picture and whether chronic stable state is applicable for inpatient discharges.
A10. We are unable to address specific claim denials in this forum. Whenever a supplier has disagreement with a review outcome, Noridian recommends exercising appeal rights.

In addition, training is on-going for clinical review and revisions in interpretation can occur.

We cannot speak on behalf of how CGS reviews claims. At Noridian, claims are reviewed based on what is presented in the beneficiary's medical record. The records need to be clear and descriptive as to what is causing the hypoxia.

Q11. Suppliers have been given the following: "The length of need will play a role in determining if coverage can be allowed. Medicare routinely sees oxygen Certificates of Medical Necessity (CMNs) indicating lifetime length of need for beneficiaries discharging from the hospital with medical records that do not support a lifetime length of need."

How is the supplier to control what the doctor puts on the CMN? Should the CMN be sent back to the doctor to review the length of need before we submit the claim?
A11. The length of need indicated on the CMN should be supported by the information presented in the beneficiary's medical record.

Q12. If oxygen is not covered for an inpatient hospital discharge with an acute diagnosis or an exacerbation of a chronic diagnosis why doesn't the LCD indicate that the beneficiary needs to be in a chronic stable state for inpatient discharges? Also, does this not contradict the statement that it is not diagnosis driven?
A12. The requirement for "chronic stable state" is associated with beneficiaries whose testing does NOT occur as part of an in-patient stay.

Q13. Are there any items that require a start date on the order in addition to the physician signature prior to dispensing the product?
A13. Per the Standard Documentation Article,

    • "If the prescriber creates the detailed written order (DWO), only a single date - the "order date" - is required. This order date may be the date that the prescriber signs the document.
    • If someone other than the prescriber (e.g., DME supplier) creates the DWO then the prescription must be reviewed and, "…personally signed and dated…" by the prescriber. In this scenario, two dates are required: an "order date" and a prescriber-entered "signature date."

Q14. Has the supplier stamp date requirement for Affordable Care Act (ACA) items that require Five Element Order/Written Order Prior to Delivery (5EO/WOPD) prior to delivery been rescinded?
A14. Items impacted by the Affordable Care Act require a 5EO prior to delivery. There is no longer a requirement that the 5EO be date stamped however there must be evidence that the 5EO was in the supplier's possession prior to delivery.

Q15. Do seat lift chairs, decubitus wheelchair cushions, Group 1 and 2 support surfaces require a 5EO (patient name, item ordered, Dr. signature, National Provider Identifier (NPI), date of order) OR a WOPD (patient name, item ordered, Dr. signature, NPI start date and date of order) prior to delivery?
A15. Suppliers can find a listing of all items requiring a 5EO as a result of the Affordable Care Act under the "Browse by Topic" section of the Noridian website. The 5EO is considered the WOPD and there are no other WOPD requirements at this time. We would recommend you check the listing for all codes you are billing as there are codes for seat lift mechanisms and support surfaces on the list. It is important to note that not all codes in all policies are affected which creates the need to review the codes the supplier plans to be billing.

Questions Received During the ACT

Q1. We've had a of couple patients that will switch insurance mid-rental particularly for Continuous Positive Airway Pressure (CPAP) rentals. Now they're coming on to Fee-for-Service (FFS) Medicare and there's information that says we should get all the required documentation for Medicare billing and then start the rental over. We have some patients with only a couple months rental left and they get upset about that.

I'm wondering if can we bill for just the last three month's rental to Medicare if we have all the appropriate documentation or would the rental have to start with month one?
A1. There is a portion of the PAP LCD that specifically addresses beneficiaries entering Medicare.
"For beneficiaries who received a PAP device prior to enrollment in FFS Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessory, both of the following coverage requirements must be met:

  1. Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare Apnea Hypopnea Index/Respiratory Disturbance Index (AHI/RDI) coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and,
  2. Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating practitioner who documents in the beneficiary's medical record that:
    • The beneficiary has a diagnosis of obstructive sleep apnea; and,
    • The beneficiary continues to use the PAP device."

Because Medicare does not recognize payment prior to enrollment, it will be necessary to begin with month one when billing to Medicare and complete the full thirteen months of capped rental billing.

Q2. This question is regarding the policy for pneumatic compression devices and the CMN. When it comes to the CMN, it limits the actual types of diagnoses as compared to the policy coverage criteria. For example, when talking about primary lymphedema, on the CMN, it states that the patient has lymphedema since childhood or adolescence, but in the policy, it encompasses all congenital primary lymphedema. Is there anything that we can do to get the CMN changed because the doctors aren't qualifying the patients because the CMN doesn't match the policy?
A2. The DME MACs do not issue the CMN. CMS is responsible for any changes made to the CMN requirements.

Q3. Is there someone that we can contact at CMS to go over this with, if it's not directly with the DME MAC contractors?
A3.  Please see CMS contact information on the CMS website

Q4. Is there any action we as a supplier can take in the meantime?
A4. At this time, the only suggestion that Noridian can make is to add a narrative to the claim providing the additional information.

Q5. Does the CMN/DME Information Form (DIF) for enteral nutrition need to be transmitted with every claim or only with the initial claim and the first claim after a revision?
A5. Only the initial claim and the first claim after a revision require an electronic copy of the DIF to be submitted.

Q6. Do HCPCS codes B4034-B4036 need to be span dated or can the 30 - day supply notation be used?
A6. The supply kit should be date spanned to match the number of days of nutrition that was sent to the beneficiary. Claims will only be paid up to one unit of service per day billed in that span date.

Q7. Do codes B4149 – B4162 require a date span or a single date for the 30 - day supply to be used?
A7. Nutrition codes must be billed with a date span.


  • Medicare Beneficiary Identifier (MBI)
  • Use of MBI began April 1, 2018
  • Suppliers may submit with either Health Insurance Claim Number (HICN) or MBI between April 1, 2018 and December 31, 2019.
  • Beginning October 2018 claims submitted with HICN will be returned with both HICN and MBI.
  • January 1, 2020, MBI must be used for claim submission.
  • Suggest adding questions to your intake process
    • Have you received a new Medicare card?
    • Did you know that Medicare is sending out new cards to their beneficiaries?

Targeted Probe and Educate (TPE) results

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Billing Instruction – Oxygen CMN Question 5 – Revised

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  • April 26, 2018

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Resources and Reminders

  • Overview of Comprehensive Error Rate Testing (CERT) error rate for projected 2017 improper payment rates
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Next Call

  • August 14, 2018 O&P ACT – 3 p.m. ET
  • Please note updated to August 21 – 3 p.m. ET
  • November 7, 2018 DME ACT – 3 p.m. ET


Last Updated Feb 05, 2020