ACT Q and A - June 9, 2021 - JA DME
Mini ACT Glucose Monitors and Supplies and Therapeutic Shoes Questions and Answers - June 9, 2021
The following questions and answers (Q&As) are cumulative from the mini Ask the Contractor Teleconference (ACT) on glucose monitors and supplies and therapeutic shoes. 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
Q1: What is proper documentation, correct billing, and general requirements for audit purpose?
A1: Proper documentation, including billing modifiers, are listed in the Local Coverage Determination (LCD) and Policy Article which can be found on the Noridian website. Other resources for documentation include the Documentation Checklist, self-paced tutorials and our next glucose webinar which will be held at the end of July once the LCD updates are active on July 18 or the therapeutic shoe webinar on June 29 at 1 p.m. CT. Noridian also offers a general documentation webinar each month which is the best source for general documentation and billing requirements. The next one will be on June 24 at 11 a.m. CT.
Q2: What are our options when billing for a continuous glucose monitor (CGM) when a beneficiary has primary insurance that requires a different code than Medicare?
A2: In order for Medicare to process a claim, the Medicare code must be utilized.
Q3: How are CGM supplies billed?
A3: The CGM supply fee code is billed as K0553. The frequency of this code is one unit every 30 days.
Q4: Please explain required documentation and the correct use of modifiers.
A4: All elements of the Standard Documentation Policy Article A55426 are applicable to the glucose monitor and supply policy as well as the therapeutic shoes for persons with diabetes policy. Additionally, each have an LCD to follow. For modifiers, the KX is utilized for beneficiaries who are insulin treated and the KS is utilized for those who are non-insulin treated. For CGM, the CG modifier must be utilized when all coverage criteria are met. For in-depth guidance please attend one of our webinars found on the Schedule of Events page of the jurisdiction A website or view one of our on-demand tutorials.
Q5: What are the policy and fee schedule changes for CGMs (and if Medtronic CGM will be a covered item)?
A5: On June 3, a joint durable medical equipment Medicare administrative contractor (DME MAC) article was published which included information on the final LCD for glucose monitors. The revision includes removal of the four times or more per day testing with a blood glucose monitor as a prerequisite for CGM coverage. The full LCD is available for review as a future LCD which becomes effective July 18, 2021. At this time, the Medtronic CGM has not received Pricing, Data Analysis and Coding (PDAC) verification.
Q6: We need clarification on the Therapeutic Shoe policy on what is required when a nurse practitioner (NP) or physician assistant (PA) is acting as the certifying physician.
A6: A NP or PA may act as the certifying physician if they are practicing "incident to" the supervising Doctor of Medicine (MD) or a doctor of osteopathy (DO). The NP or PA may conduct the examination and complete the certifying statement however all documentation must be reviewed and signed by the supervising practitioner. Additionally, a NP practicing independently who is enrolled in the Primary Care First (PCF) demonstration project may act as the certifying practitioner.
Q7: If the final blood glucose monitoring LCD has not been issued by this point, can you provide an expected time for release?
A7: Updates to the glucose policy will be effective July 18, 2021. There is an article that is available on the Noridian website that lists the updates. Noridian > Fees and News > Latest Updates > LCD and Policy Article Revisions Summary for June 3, 2021. Additionally, the future LCD is available under the policy tab on the website.
Q8: For CGM, what constitutes sufficient documentation in the medical record to substantiate that criterion 3 (frequent adjustment) is met?
A8: The treating practitioner would determine and document the testing requirements of an individual beneficiary rather that specify a number for greater flexibility in access to CGMs.
Questions Asked During ACT
Q9: Regarding the Interim Final Rule and COVID-19, we are getting many beneficiaries testing multiple times a day. How do we bill with the modifiers?
A9: If the beneficiary is non-insulin dependent, use the KS modifier. If the beneficiary is unable to have their face-to-face, use the CR modifier with a "COVID-10" narrative.
Follow-Up Question: How do we substantiate need? Physicians do not want to notate in the record so we are having a hard time getting paid.
Response: Ensure everything is well documented and show the practitioners the portions of the Interim Final Rule that states coverage criteria is not enforced, but there must be clinical need documented.
Q10: For diabetic supplies and monitors, lancets, etc., are medical records required in addition to the prescription that contains everything for regular utilization?
A10: Medical records must corroborate what is on the Standard Written Order (SWO). The prescription is not considered part of the medical record.
Q11: Are there specific requirements regarding proof of delivery (POD) in addition to the assignment of benefits (AOB)?
A11: Medicare requires that both the proof of delivery (POD) and the beneficiary authorization for billing be signed. During the COVID-19 public health emergency (PHE), CMS has waived the signature requirement for POD, but not for the beneficiary authorization. When POD has not been signed, the CR modifier should be used in billing along with the COVID-19 narrative.
Q12: Can you clarify what is changing in July 18th regarding criterion 2? How would a supplier substantiate the need for adjustments?
A12: The Future LCD is listed on our website under Policies > Future Policies. The future LCD for glucose monitors is removing criterion 2. As a supplier you will need to make sure that medical documentation substantiates any need for adjustment. Noridian is hosting a glucose webinar on July 27, 2021 at 1:00 CT that will cover the LCD changes.
Q13: What are the requirements for frequent adjustments today and does it need to be recorded that it's coming from the customer or from the health care professional (HCP) within the chart note?
A13: There must be specification that testing is occurring four times a day and the documentation needs to come from the medical record.
Q14: Is a sliding scale alone sufficient?
A14: The actual testing details are not required, if the record indicates how the beneficiary is managing control, that can justify payment.
Q15: Is the prescriber name or National Provider Identifier (NPI) or both required on the SWO?
A15: The SWO can contain either the prescriber name or the NPI.
Q16: Physicians are confused on how to do notation; can we send an example?
A16: Suppliers are not able to lead physicians in documentation and cannot provide examples. You can, however, provide them with documentation checklists, for guidance.
Q17: For those of us as long-time suppliers, it's upsetting because physicians do not understand these documentation changes. Does Noridian plan to share or offer webinars to healthcare professionals?
A17: Noridian will offer webinars that practitioners or their staff are welcome to attend. Additionally, Noridian partners regularly with the A/B Medicare administrative contractors (MACS) to provide practitioner education. Additionally, Noridian has clinician checklists that you can send to practitioners that provide all the needed elements to meet LCD requirements.
Written Questions Asked During ACT
Q18: Are we able to mail and bill a 90-day order for code K0553?
A18: You may ship a 90-day supply at one time, however K0553 can only be billed one unit per 30 days. Therefore, you would bill one unit each month for the next three months to cover the initial shipment.
Q19: Is it possible for Medtronic to receive PDAC confirmation mid-year or will they need to wait until next year at this point?
A19: That question should be addressed to the PDAC contractor.
Q20: A beneficiary comes from another supplier requesting strips for an existing monitor. The strips for the old monitor are not available, but the monitor was provided three years ago (less than five-year useful life). What is the procedure to claim payment for a new monitor due to old monitor strips not been available from distributors? What are the options for this beneficiary since this old monitor is not usable?
Q20: Glucose monitors can only be replaced during the RUL for lost, stolen, or irreparable damage. An ABN could be issued indicating the original monitor has not yet reached its reasonable useful lifetime.
Q21: How are supplies billed when a beneficiary has determined they would like to go back to using the standard glucose monitor they already have?
A21: When a beneficiary returns to using a standard glucose monitor after a period on a CGM, Medicare will reimburse for standard supplies, but will not allow a new monitor until the end of the five-year RUL.
Q22: What documentation is needed to properly document beaneficiary files?
A22: Please refer to the Standard Documentation Requirements.
Q23: When looking up A4259 and A4253 on the Noridian portal under same and similar, I get the response that these aren't tracked for same and similar purposes. Why aren't they tracked and will they be at some point in the future?
A23: The NMP tracks the items on the same or similar list that is located on our website. Thank you for the suggestion to add additional codes to the NMP functionality. We will take this back for review.
Q24: Has there been a timeline of when COVID-19 PHE is expected to end?
A24: CMS has not announced any timeframe for when the PHE will end. Once the PHE has ended, Noridian will send out education.
Q25: Can you tell me specifically what is changing with the insulin administration for CGM's or is that to come in July?
A25: The future LCD is applicable for dates of service on or after July 18, 2021. The changes will not be addressed at this ACT however there will be upcoming webinars after the start of the new LCD. You can review the changes in the future LCD. Please join our next glucose webinar on July 27, 2021 at 1 p.m. CT.
Last Updated Fri, 08 Oct 2021 13:20:36 +0000