ACM Q and A - August 8, 2024 - JA DME

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Meeting (ACM). 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.

Questions Received Prior to ACM

Q: Can you bill for a DMEPOS item on the same day as surgery?
A: A DMEPOS item may be billed on the same day as surgery if the patient is discharged the same day to a payable place of service (POS) such as home (12). Medicare does not pay for DMEPOS items during an inpatient stay. As a reminder, review the coverage criteria for the item being dispensed to ensure all proper requirements are met. For more information, review Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Consolidated Billing.

Q: What is the process to request a waiver or change to requirements in the External Infusion Pumps (EIP) Local Coverage Determination (LCD)?
A: When changes to an LCD are necessary, suppliers may request an LCD Reconsideration. The reconsideration process can be found on the Noridian Medicare website > Policies > Local Coverage Determination (LCD) > LCD Reconsideration Process.

Q: When a beneficiary claims a delivered supply package was stolen from their porch, are we required to resupply them or refund the claim?
A: This will be based on a supplier's business practices. Medicare does not have any rules that address this scenario.

Q: What are the coverage requirements for L8035 (custom breast prosthesis) and is a prior authorization (PA) required?
A: There is no allowance for L8035, it is denied as not reasonable and necessary. There is no PA requirement for this item. Please refer to the External Breast Prostheses LCD L33317 for more information.

Q: What are the proper documentation requirements for proof of delivery (POD) when shipping to the beneficiary?
A: For Method 2-Delivery via Shipping or Delivery Service Directly to a beneficiary, if the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the items from the DMEPOS supplier to the beneficiary. An example of an acceptable POD would include both the supplier’s own detailed shipping invoice and the delivery service’s tracking information. The supplier’s record must be linked to the delivery service record by some clear method like the delivery service’s package identification number or supplier’s invoice number for the package sent to the beneficiary. For complete instructions and requirements for POD please review the Standard Documentation Requirements Article found on the Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs.

Q: Will Medicare cover a wheelchair and a lower limb prosthesis if billed simultaneously?
A: If the coverage criteria for both policies has been met, the items should be considered for coverage. If a denial is received, submit to redeterminations with all documentation requirements.

Q: Is the ST modifier applicable to the Master List and Required Prior Authorization List?
A: The ST modifier is only applicable to orthoses codes on the Required Prior Authorization List and is only to be used in acute or emergent situations when the standard prior authorization review time frame of five business days or even an expedited review time frame of two business days could jeopardize the health or well-being of the beneficiary. More information may be found on the Noridian Medicare website > Browse by DMEPOS Category > Orthotics.

Q: How can documentation be submitted for L1843 (knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise) for prior authorization if custom fitting is determined at the time of fitting?
A: Obtain a prior authorization for L1843 and a prior authorization for its corresponding code, L1851 (knee orthosis, single upright, thigh, and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf) prior to delivery. Then after the final fitting, bill for only one of them depending on the type of adjustment that was needed. Medicare will only pay for one.

Q: Why is G0069 (Home Infusion Therapy Professional Services for administration of subcutaneous infusion in home) rejected as unprocessable when billed to the DME MAC?
A: Home Infusion Therapy (HIT) has been a Part B benefit since 2021 and cannot be billed to the DME MAC. Please refer to your Part B contractor for coverage. More information can be found in MLN Matters Article MM11880.

Verbal Questions asked During ACM

Q: A physician sent face-to-face notes, but the signature was missing, so we sent it back. It can take up to four months to get it back. Is there a time limit regarding this? Another contractor suggests a few days so we are wondering if we should get an attestation.
A: Medicare does not specify a time frame for this situation. Recent updates were done in June to the Program Integrity Manual, Chapter 3, Section 3.3.2.4 that loosened requirements.

Q: Regarding the Positive Airway Pressure (PAP) re-evaluation, does the beneficiary have to wait until adherence is met to have the face-to-face? The beneficiary went back to the physician on day 45; symptoms were improved; adherence was not documented because it wasn't met yet. The doctor went in 10 days later to add an addendum to add adherence was met.
A: The policy is not specific in this timeline, but the notes do need to show the improvement in symptoms.

Q: If a beneficiary is entering Medicare from a previous payer, but he/she does not want the supplier to come into their house to inspect, how does the supplier handle this? Can the supplier look at the download to see if the equipment is functioning?
A: There needs to be documentation to show the supplier examined the equipment, it's in good working condition, and expected to last five years.

Q: A beneficiary became eligible for Medicare January 1, 2024, and previously had commercial insurance. For surgical dressings, can we use records from December prior to eligibility, or does the beneficiary need another physician visit?
A: The records can be used but the timeliness of the re-evaluation must be met.

Q: What are the current refill requirements? Our understanding is that it changed from 14 days out to 30 days out and we still need to assess the number of supplies on hand and ensure we ship within 10 days or less.
A: Beneficiaries no longer need to count remaining quantities. MLN Matters 13480 states: "evidence that the patient or their representative has confirmed their need to refill the supplies within 30 calendar days from the expected end of the current supply" is required.

Q: Regarding code A4239 (supply allowance for continuous glucose monitoring (CGM)) and refills, if the beneficiary receives a 90-day supply, then calls for a refill 12 days prior to the last day of the previous 90-day supply, will those be paid if all other requirements are met?
A: For this particular HCPCS code, the date of service on the claim does not need to match the shipping date because A4239 is a supply allowance, not tied directly to individual products. A4239 can be billed every 30 days and throughout the month, the supplier is responsible to monitor usage of supplies and ensure the beneficiary has enough.

Written Questions asked During ACM

Q: A secondary payer requires documentation showing why Medicare did not provide benefits. A copy of the explanation of benefits (EOB) showing member responsibility (PR code) is not acceptable. They are requesting a screenshot from the Medicare website or other documentation from Medicare stating the service is not covered. Where can I access this documentation?
A: The Noridian Medicare website provides a Denial Code Resolution tool which includes the Reason and Remark codes used to provide a supplier with the reason for denial. In addition, there should be an explanation on the Remittance Advice which defines the reason and remark codes. The Noridian Medicare Portal may be used to view, save, and print remittance advices.

Q: If a clinician forgets the "4" on 2024, can they just add the "4" and initial and date the correction or do they have to strike through it and rewrite the full year with an initial and date of correction?
A: For consistency, the physician should strike the whole 202 and add 2024 initial and date that addendum.

Q: On shipping documentation for an immunosuppressive drug refill request, the amount remaining, and day's supply remaining are required before we ship. Is that still the case or did something change?
A: The refill requirements no longer require that the quantity on hand be documented for Medicare documentation purposes. Suppliers are still responsible for ensuring what they dispense is reasonable and necessary.

Q: Will there be an updated lower limb prostheses webinar available soon in light of the updates to the LCD and Policy Article, effective September 1, 2024?
A: We will be scheduling an updated webinar. Please visit the Schedule of Events page under Education and Outreach.

Q: Can a Subjective, Objective, Assessment and Plan (SOAP) note generated in an e-prescribing platform take the place of a traditional face-to-face (F2F) note as long as the beneficiary was still seen in the doctor's office and the date of that visit is documented?
A: A SOAP note from a visit with the treating practitioner may be used, so long as the coverage criteria for the item provided is clearly documented in the note

Q: Which date does Medicare look at on the detailed written order (DWO), the start or the date the physician signs the DWO?
A: A DWO is no longer a requirement, the SWO replaced the DWO in 2020. The date the Standard Written Order (SWO) is communicated to the supplier is the order date.

Follow-up Question: So, the start date on the detailed written order is the date Medicare looks at. The signature on the detailed written order can be after the start date.
Answer: As a reminder, the DWO is no longer a requirement. If the physician dates their signature on the SWO, the signature date can be after the order date.