ACT Questions and Answers - May 11, 2023

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.

Questions Received Prior to ACT

Q: Is telehealth still allowed for power mobility devices (PMDs) for the face-to-face (F2F)?
A: Telehealth continues to be allowed for PMD F2F encounters by the treating practitioner with the requirement for both audio and video as outlined in Code of Federal Regulations (CFR) 410.78.

Q: The new Medicare Learning Network (MLN) Matters MM12521 is missing some base codes. Do the K0005 (ultralightweight wheelchair) accessories still utilize the KU modifiers? The previous MLN Matters MM12345 does have the K0005 listed.
A: Per MM12521 page four, MM12345 contains more information on wheelchair accessory codes. Per MM12345, the KU modifier is required for wheelchair accessories and seat back cushions provided for K0005. Noridian Medicare website > Browse by DMEPOS Category > Manual Wheelchairs

Q: The KX modifier is now required for items in the External Infusion Pumps (EIP) Local Coverage Determination (LCD), does it also pertain to Intravenous Immune Globulin (IVIG) or the IVIG Demonstration?
A: The KX modifier has not been added to the IVIG policy. Please refer to the path for more information. Noridian Medicare Home page > Policies > Active LCDs > Intravenous Immune Globulin (L33610)

Q: When a current continuous positive airway pressure (CPAP) user goes in for a new diagnostic sleep study, is compliance required again for a new machine?
A: Compliance is only required to be met once during the initial three-month trial period. Suppliers are encouraged to maintain communication with the beneficiary to verify continued use for the remainder of the rental period.

Q: How are mixed apnea accounted for when qualifying a Complex Sleep Apnea (CompSA) patient? Can you look at a setting/moment in time when qualifying?
A:  Suppliers are encouraged to work with the treating practitioner to review the medical record including the sleep study. For Medicare’s definition of CompSA, please refer to the definitions section of the Respiratory Assist Device (RAD) LCD. Coverage of a RAD device in dependent on a diagnosis of CompSA and documentation showing significant improvement of sleep-associated hypoventilation with the use of bilevel (E0470) or bilevel with back-up (E0471) during a facility-based sleep study. The diagnosis of CompSA would be determined by the treating practitioner and the treating practitioner should explain how they used mixed apneas in their calculation.

Q: How should suppliers continue billing after the Public Health Emergency (PHE) when a beneficiary qualified under the PHE but does not qualify under the LCD criteria?
A: The clinical indications for coverage of certain policies were not enforced during the PHE. For those items included in these policies which were delivered during the PHE, the CR modifier may continue to be used after the end of the PHE for the remainder of clinical need. For more information, refer to the article at the following path: Noridian Medicare website > Policies > Medical Director Articles > 2023 > Claim Submission Instruction Post-PHE - Continued Use of Modifier CR and COVID Narrative

Q: Can an oral appliance be used during a polysomnogram/home sleep test (PSG/HST) or titration study that is part of qualifying documents for positive airway pressure (PAP) therapy?
A: No, an oral appliance may not be used during a sleep study for the purposes of qualifying for a PAP device under Medicare guidelines.

Q: Why are the sequential claims not being automatically reprocessed by the MAC when a favorable decision is issued?
A: CMS is implementing changes to improve the processing and adjudication of Medicare Fee-For-Service (FFS) recurring (or serial) claims for capped rental items and certain inexpensive and routinely purchased (IRP) items. If you find that this has not happened, and your code is on the Serial Claims Master Listing, please contact the Contact Center with that information and have those dates of service reopened.

Q: When do you expect the new compression garment policy and fee schedules will be available?
A: A benefit for compression garments has been added to the Social Security Act effective in 2024. CMS has not released instructions to the DME MACs at this time. When instruction is provided, we will begin educating.

Q: If the B9002 (enteral pump) is allowed, shouldn't the daily B4035 (pump supply allowance) also be allowed even if it’s not on the Standard Written Order (SWO)?
A: All items billed to Medicare must have an order per the Standard Documentation Requirements Article (A55426). If the coverage requirements for enteral nutrition are met, medically necessary nutrients, administration supplies, and equipment are covered. Denials need to follow the appeals process. Please refer to the path below for more information. Noridian Medicare website > Browse by DMEPOS Category > Enteral and Parenteral Nutrition

Verbal Questions During ACT

Q: We have a beneficiary that lived in Kansas but due to missionary work, now lives in Kentucky. Our claim denied because the address on file is in jurisdiction C. How do I go about billing them?
A: For DME, suppliers must bill according to where the beneficiary's address is on file with the Social Security Administration (SSA). If you bill electronically, the claim is automatically routed to the correct DME MAC by the Common Electronic Data Interchange (CEDI). If you bill on paper and are having trouble with the claims, we suggest you call the Contact Center for the jurisdiction where you have filed the claim.

Q: Has anything changed regarding electronic billing?
A: No, nothing has changed, the Common Electronic Data Interchange (CEDI) will automatically route claims to the correct jurisdiction when it is billed with the beneficiary's address on file with the Social Security Administration (SSA).

Q: We have some claims that have been paid by another insurance first, but they've recouped the payment stating Medicare is primary. We are missing some required documentation per the Medicare policy since it's not required for the other insurance. How should we handle these? In the past, we were told to add the EY modifier and it worked but now we are not receiving a patient-responsibility denial anymore. We are using the EY and GY modifiers.
A: The GZ modifier could be used to show an Advance Beneficiary Notice of Noncoverage (ABN) was not obtained. You may appeal with clinical documentation to support the item and with proof that you didn't know the beneficiary had Medicare at the time you provided the equipment. You may also appeal with the commercial insurance.

Q: The beneficiary qualified for a positive airway pressure (PAP) and it's been over five years. They are being told they need a new sleep study to get a replacement machine. If they get a new sleep study and the apnea hypopnea index (AHI) is below five, they don't qualify, right? If they get a sleep study and they don't qualify, what do we do?
A: A beneficiary receiving a replacement device due to have reached the Medicare five-year reasonable useful lifetime (RUL) does not need a new sleep study. Since Medicare paid for the previous five years, a replacement device is covered.

Q: We are providing a mask with headgear, how many seals can we bill for? We have the A7030 (full face mask), A7031 (face mask interface), and A7035 (headgear). Does that seal count as one and then we would provide an additional two on the side for a total of three?
A: That is correct and, in the LCD, it shows how many supplies can be billed per month. In this case the supplier is billing for one full face mask and two replacement accessories for a total of three months of supplies.

Q: If a beneficiary failed compliance with another company, then moved to ours to resume therapy, how does the billing work? The beneficiary must meet compliance before the fourth month. As the new company, providing the positive airway pressure (PAP) device to the beneficiary would we be trialing it for one month to see if the beneficiary shows compliance and that would be a free month?
A: In this case, the same rules for compliance apply. It is not missing out on a month because the PAP device would be eligible for 13 total months payment. The fourth month may be delayed until compliance is met but the new supplier is eligible for the remainder of that 13-month rental period.

Follow-up Question: We started therapy on May 1. If after 31 days, the beneficiary shows compliance, can we bill May 1 as the fourth month?
A: The fourth month can only be billed once compliance has been met so after 31 days and after receiving confirmation from the treating practitioner, then it can be billed with the KX and KJ modifiers.

Written Questions During ACT

Q: I received a denial for billing a nasal mask with full face cushions for an old mask the beneficiary got six months ago. The representative on the phone said the article regarding this denial is unpublished. Where can I find this information so I know how to bill in the future?
A: Anything unpublished would not be available or published on a Medicare Administrative Contractor (MAC) or CMS website. Regarding PAP supplies, generally, when the Healthcare Common Procedure Coding Systems (HCPCS) description in the LCD states replacement, that item is not billable on the same date of service (DOS) as what it is a replacing.

Q: Is there someone we can contact if we do not agree with what the representative is telling us?
A: If the Contact Center representative has been unable to answer your question, you may ask for a level two representative. For more information on the supplier contact center tier levels, see the Noridian website > Contact Us > Supplier Contact Center (SCC).

Q: Are base codes for DME paid if billed alone or are billed with incorrect companion DME? For example, L1812 KX/KV/RT (knee orthosis) with L2795 KX/RT (knee control full kneecap).
A: HCPCS L2795 is included in the allowance for L1812. It is not eligible for separate payment. Base code L1812 is eligible for payment on its own if it meets all the coverage criteria. More information is available in the Knee Orthoses LCD L33318.

Q: Are supplies included in E0466 (noninvasive ventilator)?
A: Yes, because ventilators are categorized as frequent and substantial servicing items where all accessories/supplies are included in the rental.

Q: In a previous Ask the Contractor Teleconference (ACT) meeting we were advised to check the Pricing, Data Analysis, and Coding (PDAC) to determine which frames are "deluxe" under the refractive lens coverage policy for post-op hardware after cataract surgery. The PDAC only lists about 12 frames from one vendor. I am not sure how that is helpful in determining what is a deluxe frame under the Medicare program. What other guidance is available?
A: The difference between standard and deluxe frames isn’t determined by the cost of the frames. Standard frame is a very basic frame that is covered by Medicare. Deluxe frame is one with additional features such as spring hinges or memory metal construction, something outside of the normal frame composition. Medicare will pay for the standard frame allowance and then the beneficiary would pay for the additional cost. This information can be found on our website under Browse by DMEPOS Category > Refractive Lenses.

Q: Can you provide information on Medicare resources for the coverage and billing of scleral lens for corneal conditions?
A: The Refractive Lenses - Policy Article A52499 provides guidance on when a scleral device may be covered as well as providing coding instruction.

Q: Where do I see if DME has been dispensed to a beneficiary previously?
A: The Noridian Medicare Portal (NMP) or the Interactive Voice Response (IVR) provide information on equipment previously billed to a specific jurisdiction.  For those not registered or unable to register with the NMP, the IVR self-service tool is available for claim status, eligibility, same or similar, ordering remittance advice, pending claims, overpayment information, prior authorization, and phone reopenings. The IVR tool can be accessed through verbal or touch-tone commands and provides a convenient way for suppliers to access important information about their claims and beneficiaries.

Q: Can you source the three months to dispense guidance given? The Program Integrity Manual (PIM) references the three months from the Certificate of Medical Necessity (CMN) or DME Information Form (DIF), which only applied to oxygen and enteral (and no longer applies). I also don’t see a source for the sleep study link I was given outside of the Noridian website. I have a provider pushing back and need a regulation to quote for why we need to dispense within three months or requalify someone. Thanks!
A: For PAP devices, there is not a required timeframe for delivery of equipment, however it is advised that delivery should be within a reasonable timeframe often considered to be three months following a qualifying sleep study. Suppliers are encouraged to have documentation on file in case of review to show what caused delays beyond three months. Additionally, there is requirement for delivery to have occurred no later than 12 months from the qualifying sleep study to show that on-going medical need is met. This information is in the Standard Documentation Policy Article - A55426.

Follow-up Question: To clarify on the dispensing timeline, I'm looking across the board. During Monday's live chat, someone asked about a walker or a wheelchair, I believe, and were told items needed to be dispensed within three months of established need.
A: There is not a rule that states suppliers must dispense within three months. However, if there is a significant delay there should be documentation to explain the reason for delay.

Q: If a beneficiary has received a dental device for sleep apnea in the last five years and is now prescribed a PAP therapy device, does the supplier have to justify the change? Will this deny for same or similar?
A: If Medicare paid for the oral appliance, the PAP device would more than likely deny same or similar. There should be documentation supporting the clinical need for the change in device and taken to appeals.

Q: As a provider of respiratory and DME equipment, we do not have a state license in several states. A beneficiary is a winter visitor and initially got set up on PAP or oxygen with our provider and they split their time between our state and their permanent address state that Medicare has on file. The beneficiary’s address on file with Medicare is in a different state and is one that our provider does not have a state license for. Can we as a provider continue to bill for the PAP or oxygen rental to the Medicare region where the beneficiary’s permanent address is when the beneficiary leaves our state and goes back home for six months and is still using our equipment?
A: State licensure requirements are the responsibility of the supplier to follow. Medicare guidelines are nationwide and claims payment is made based on the address on file with Social Security for the beneficiary.

Q: Would the KS modifier be used for all non-insulin dependent continuous glucose monitor (CGM) beneficiaries who started receiving supplies during the PHE?
A: Yes, if the beneficiary is not on insulin, then the KS modifier would be used on the claim.

Q: Regarding CGM, when a three-month supply is shipped, and the billing is done over the three-month period, does a refill call have to be done for each month prior to billing, or just when the first shipment of the three-month supply was sent?
A: Refill requirements do not apply to code A4238 or A4239. However, the Glucose Monitors LCD L33822 does state "Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating practitioner that any changed or atypical utilization is warranted."

Q: Can "mixed" apnea and hypopnea events be counted as central apnea and hypopnea events when doing the calculation to determine if the central events are 50% or greater of the total apnea and hypopneas?
A: Mixed hypopneas are most common in a form of complex sleep apnea (CompSA) which both hypopneas and apneas are considered breathing events. If the sum total of the apnea and hypopnea is greater than 50% of the total apneas and hypopneas, yes, they will be taken into consideration.

Q: Is there any way to obtain the details for a miscellaneous check, other than calling the Contact Center?
A: The only way to obtain that financial information is by calling the Contact Center.

Q: On a hospital discharge, the oxygen saturations were provided on a flowsheet. In the past, we were told that the flowsheet didn’t need to be signed, but recently were told that it does. Can you please clarify which is the correct response?
A: Evaluation of test results is part of the coverage criteria. In this scenario, oxygen saturations that meet current coverage criteria could be evaluated and acknowledged by a treating practitioner by progress notes, test results, flow sheets with a signature or note.

Q: Should the CR modifier be used for new PAP or oxygen set ups done May 12, 2023, and forward that have a qualifying telehealth F2F and all other requirements met?
A: Use of the CR modifier would not be appropriate for initial dates of service on or after May 11, 2023 as the COVID-19 public health emergency ended May 11, 2023. Telehealth usage, however, has been extended through December 31, 2024. Use of the CR modifier is not required to indicate that telehealth was utilized, however suppliers should verify that the practitioner's office is providing Medicare approved telehealth appointments (audio/visual as required by the appointment type).

Q: Is there anything that shows that tracheostomy supplies, like A7520, A7521, or A7526, are included with the rental of the E0467 (multi-function ventilator)?
A: The E0467 is categorized as frequent and substantial servicing, so with that all supplies are included. On the PDAC website, select DMECS then select HCPCS Details & Fees and enter E0467 into the code box. The description says: Description for E0467: Home ventilator, multi-function respiratory device, also performs any or all the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components, and supplies for all functions.

Q: If a doctor puts the diagnosis of obstructive sleep apnea (OSA) on the Standard Written Order (SWO) and the records support central sleep apnea (CSA), so we bill with CSA, there shouldn't be a problem with the OSA diagnosis on the SWO in the event of review, correct?
A: That is correct. The diagnosis would not make the SWO invalid as diagnosis is not a required element of the SWO. When submitting the claim please make sure you are submitting all documentation to show medical necessity.

Q: A valid telehealth visit meets F2F requirement, but PAP is not subject to F2F since it's not on the required list, so is an in-person initial and reevaluation visit per the PAP LCD now required or will telehealth continue to satisfy the in-person requirement until December 31, 2024?
A: Telehealth will satisfy the in-person initial and re-evaluation requirements for PAP through the end of the extension (until December 31, 2024).

Q: Are replacement CPAP/BIPAP machines covered and what do the notes have to state?
A: For replacement during the reasonable useful lifetime (RUL) due to loss, theft, or irreparable damage, a new Standard Written Order (SWO) would be required. For replacement after the end of the RUL, an SWO and an evaluation is required where the treating practitioner documents continued use and benefit from the PAP device.

Q: If a beneficiary failed compliance with a company and is wanting to switch to another company to restart therapy, does Medicare require proof of a pickup ticket from the old company for the new company to bill? Also, if the new company bills, will it begin at the fourth month?
A: The new supplier is encouraged to obtain the pickup ticket to confirm that the previous supplier has picked up the device from the home, however this is not a Medicare requirement. Billing would resume with the fourth rental month only after compliance has been met.

Q: A beneficiary's mobility has improved since getting a wheelchair, but now needs a walker. Will the walker be covered? If yes, what type of notes will be needed?
A: If there is a change in condition new equipment may be covered. If a denial is received, you would need to follow the appeals process. Medical records must support the level of care provided, the course of treatment, change in condition as well as the coverage criteria located in the LCD. See Noridian Medicare website > Billing, Claims and Appeals > Appeals for additional information.

Q: For method three on refills shipped to a nursing home, do we have to provide the next month's documentation that shows they used up the supply that was delivered? In an audit we supplied the refill request that included what they have used up from the previous month, but we received a denial because they want the following month's information showing they used up what we issued on this date of service. Seems backwards from the other refills since its retro information. We want to make sure we are sending in the correct documents.
A: That would be correct. The criteria for Method three delivery states:

  • Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and
  • Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.

This information can be found in the Standard Documentation Requirements for All Claims Submitted to DME MACs A55426.

Last Updated Feb 07 , 2024