ACT Q and A - August 9, 2022 - JA DME
ACT Questions and Answers - August 9, 2022
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: How do we fix the units and days billed on a submitted claim?
A: The best way to correct units and date spans billed is to do a reopening. Suppliers can utilize the Noridian Medicare Portal (NMP) and complete a self-service reopening of the claim. If the item is not available to reopen via the NMP, a telephone reopening can be completed. For more information, go to the Noridian Medicare website > Billing, Claims, and Appeals > Reopening.
Q: How do we bill deluxe frames?
A: Per the Refractive Lenses Policy Article, "only standard frames (V2020) are covered. Additional charges for deluxe frames (V2025) will be denied as noncovered." The Policy Article continues to state, "when billing claims for deluxe frames, use code V2020 for the cost of standard frames and a second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames." Please see the Refractive Lenses Policy Article for more information.
Q: I am a non-participating supplier; however, I have a beneficiary that wants a E0260 (semi electric hospital bed), can I bill Medicare?
A: Yes, a non-participating supplier can bill Medicare as either assigned or non-assigned. For more information go to the Noridian Medicare website > Billing, Claims, and Appeals > Claim Submission > Participating vs Non-participating Supplier.
Q: Is respiratory events index (REI) now being accepted as a measurement on a positive airway pressure (PAP) sleep study?
A: As of July 1, 2022, Noridian will now be accepting REI as a valid measurement on a PAP sleep study. This does require that respiratory events related arousals (RERA) not be included in the calculation as Medicare does not recognize RERA.
Q: How can we have every Medicare beneficiary sign an Advanced Beneficiary Notice of Non-Coverage (ABN) when receiving DME?
A: It is not appropriate to have every beneficiary sign an ABN for DME. Providers should be issuing ABNs when they believe that Medicare may not pay for an item or service which is expected to be denied by Medicare based on one of the following: Statutory exclusion, lack of medical necessity, prohibited unsolicited telephone contacts, no supplier numbers, denial of an Advanced Determination of Medicare Coverage (ADMC) request, non-contract supplier furnishing an item listed in a Competitive Bid area, frequency limitations have been exceeded. Please see the Noridian Medicare website, under Browse by Topic > Advance Beneficiary Notice of Noncoverage (ABN) for more information.
Q: Do you have any updates on the new oxygen guidelines?
A: The oxygen National Coverage Determination (NCD) was updated and effective September 27, 2021. However, none of those changes will be implemented until January 2023. Please watch for webinars throughout the fall for updated information. You will find all webinars listed on the Schedule of Events.
Q: When is it appropriate to use the ST modifier?
A: Correct use of the ST modifier for spinal orthotics codes L0648 and L0650, and knee orthotics codes L1832, L1833, L1851 can be found on our website under the Medical Review tab > Pre-Claim Review > Required Prior Authorization Programs > Prior Authorization for Orthoses. There is a chart on the page with information as well as written text that states: this modifier is only to be used in acute/emergent situations when a two-day expedited review would delay care and risk the health or life of the beneficiary. Claims billed with the ST modifier will be subject to 100% prepayment review. This applies to both suppliers and practitioners/physicians who are also suppliers none of which are in a competitive bid area.
Q: Are there two data sets I should be checking to prevent N265 (missing/incomplete/invalid ordering provider primary identifier) denials due to Provider Enrollment, Chain, and Ownership System (PECOS) edits?
A: Noridian has a Denial Code Resolution tool which provides support for this question. There is a section in the tool titled, "How to Avoid Future Denials". For N265, this section states: Verify that ordering physician National Provider Identifier (NPI) is on list of physicians and other non-physician practitioners enrolled in PECOS. Even if a provider has an individual NPI, it does not mean that his/her enrollment record is in PECOS and/or is active. Verification of enrollment in PECOS can be done by checking the CMS ordering/referring provider downloadable report which contains the NPI, first name, and last name of providers enrolled in PECOS. Also be sure the name and NPI entered for ordering provider belongs to a physician or non-physician practitioner. A group NPI cannot be used as the ordering NPI on a Medicare claim.
Q: If the beneficiary does not meet the Local Coverage Determination (LCD) coverage requirements for a brace and they sign an ABN, can the beneficiary bill Medicare themselves?
A: If the beneficiary selects Option 1 in Blank G, the supplier is responsible to bill Medicare. If the beneficiary selects Option 2, you do not need to bill Medicare but remember that if the beneficiary changes their mind, you will need to bill Medicare. Additional information can be found on our website at the following: Browse by Topic > Advance Beneficiary Notice of Noncoverage (ABN). For beneficiary claim submission, please see the Internet Only Manual (IOM) 100-04 Chapter 1.
Additionally, for services furnished on or after September 1, 1990, physicians and suppliers must complete and submit both assigned and non-assigned durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims for beneficiaries. Beneficiaries should not be asked to file their own claims. Information is available on our website under Billing, Claims, and Appeals > Claim Submission > Mandatory Claim Submission.
Q: What happens when the ordering physician loses their PECOS certification during a capped rental period?
A: If the ordering physician is not enrolled in PECOS, the claim will deny with either N265 (Missing/incomplete/invalid ordering provider primary identifier) or N276 (Missing/incomplete/invalid another payer referring provider identifier). The physician will need to update their PECOS enrollment, or the beneficiary will need to see a PECOS-enrolled physician. Additional information can be found on our website under Billing, Claims, and Appeals > Claim Submission > PECOS Edits or the CMS website under PECOS Edits.
Q: What are my options to fight a denial on a Performant post pay claim review?
A: The options are found on the Noridian website under Medical Review > Other Review Contractors > Recovery Auditor > Recovery Auditor Determinations - Agree or Disagree.
Note: The Noridian Supplier Contact Center is only able to answer general questions about the Recovery Auditor program. Suppliers are advised to contact the Recovery Auditor directly with inquires related to their activities.
Q: If home infusion therapy (HIT) started prior to January 1, 2021, and an initial claim for HIT professional services was missed (G0089), can we bill for subsequent HIT professional services (G0069)?
A: Claims must be filed with the DME Medicare Administrative Contractor (DME MAC) no later than one calendar year (12 months) of the date of service (DOS) or Medicare will deny the claim. Claims on or after January 1, 2021, for HIT services are not billable to DME MAC. Please refer to your Part B contractor for clarification.
Q: What are the coverage rules for HCPCS A4224 (supplies for maintenance of insulin infusion catheter, per week) and HCPCS A4225 (supplies for external insulin infusion pump, syringe type cartridge, sterile, each)?
A: Code A4224 includes all cannulas, needles, dressings, and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via external insulin infusion pump (E0784). Code A4225 is the supply code only for insulin-based infusion pumps. This code does not include the drug for use in the reservoir. It is to be used in conjunction with A4224 and replaces use of K0552, suppliers submitting claims with K0552 will receive denials when billing for insulin infusion cartridges and supplies. Refer to the Local Coverage Determination (LCD) related Policy Article A52507 for billing and coding guidelines.
Q: On the standard written order (SWO), is the signing provider NPI required or is a signature and printed name acceptable? We are facing obstacles with mailing supplies; can you clarify proof of delivery (POD) requirements?
A: The Standard Documentation Requirements for All Claims Submitted to DME MACs (SDR) article A55426 requires that the SWO include either the treating practitioner name or NPI and the treating practitioner's signature.
Regarding POD, there are three methods of delivery:
- Delivery directly to the beneficiary/authorized representative
- Delivery via shipping/delivery service, or
- Delivery of items to a nursing facility on behalf of the beneficiary.
Suppliers may not bill the DME MAC for dates of service prior to the date of discharge from an inpatient facility. There is no exception for delivery prior to discharge for supplies. As a general Medicare rule, the date of service shall be the date of delivery. The POD must notate a description of the item being delivered and the POD must be available upon request. Please refer to the SDR A55426 for more information on POD and methods of delivery.
Verbal Questions Asked During ACT
Q: We have a large hospital system using the WatchPat to qualify beneficiaries for PAP devices. At one point, we were told they were not valid for qualification, but they are coded by the Pricing, Data Analysis and Coding (PDAC) contractor. Are they still not valid?
A: The WatchPat device was approved in 2018 and is valid for qualification.
Q: Regarding REI, is this a permanent position Noridian is taking or just during the PHE?
A: As of July 1, 2022, it is permanent position.
Written Questions Asked During ACT
Q: There appears to be two datasets regarding PECOS validation for ordering providers. Based on what I have read one appears to be used for edits/validate specialty while the other is used to validate the physician is in PECOS. I have one doctor in one list but not the other.
A: If the ordering physician is in PECOS but is not of the specialty to order or refer the claim will be denied. Noridian has seen claims ordered by physical and occupational therapists, massage therapists, opticians and others who are enrolled in PECOS or may have an NPI, but these health care personnel are not allowed by statute to order DME for Medicare purposes. Additional information can be found on our website under Billing, Claims, and Appeals > Claim Submission > PECOS Edits.
Q: After a face-to-face (F2F), a SWO is received by the supplier. In the case there is an update/addendum to the notes by the physician, does the supplier need to obtain a new SWO?
A: A new order is not needed after an amendment is completed unless the update to the medical record would change the DMEPOS item needed. In that case a new order would be required.
Q: I would like to clarify if a distinction is being made between the initial SWO and the detailed SWO [previously detailed product description (DPD)]. Do the same rules apply regards to obtaining new initial SWO as the detailed SWO when changes are made to the equipment selection?
A: A detailed product description (DPD) is no longer required. The DPD requirement was removed January 1, 2020, with implementation of the SWO. The SWO can have a general description of the item. However, each item that will be billed must be on the order. "Accessories" would not give enough detail to know which items are being ordered.
Q: Do suppliers need to obtain a new SWO or is it okay to proceed with the SWO provided after the F2F is completed when a physical therapist (PT)/occupational therapist (OT) evaluation happens after the F2F?
A: A new SWO would not be required. The physician medical records need to support medical necessity of the item(s) ordered. The PT/OT records should support the physician medical records.
Q: The date of order on the SWO was defined as the date the order was communicated with the supplier. Does this remain static, or does it change whenever an updated SWO is signed and sent back?
A: The order date remains the date that the order was communicated to the supplier.
Q: Is a supplier permitted to use a physician's EMR program to generate a SWO within the physician's program (such as EPIC) if the physician has granted these permissions for the physician to then review and electronically sign? If yes, is the supplier's representative creating the order, permitted to sign the SWO and the ordering physician co-sign?
A: Electronically signed SWOs are allowed as long as they meet the signature requirements. A SWO signed by the supplier and co-signed by the physician is not valid. However, if the physician is also the supplier, the SWO is not required if the medical record contains all required elements of the SWO.
Q: For positive airway pressure (PAP) SWOs, we have a provider that lists all the supplies, including both mask types on their orders, but has a spot at the top where they put "mask interface type: nasal mask" or "full face mask" to specify. Would this be an invalid SWO?
A: While multiple items may be listed, the items that are being used and billed to Medicare must be clearly identified on the SWO.
Q: Can progress notes contain an "or" statement under the criteria? For example, a patient lift is required "to transfer between bed and chair, wheelchair, or commode" or does it have to specify to which item the beneficiary is being transferred? In the case of a bed, should there be specification that the bed needs to be elevated due to "congestive heart failure, chronic pulmonary disease, or problems with aspiration?"
A: Progress notes must detail why a beneficiary needs a patient lift to transfer. Types of transfer need are also beneficial, but the primary information that would be reviewed relates to the condition that prevents the beneficiary from being able to accomplish transfer on their own. The same would be true for an elevated bed. While identification of the disease is important, it would also be necessary to see documentation in the medical record about why that condition required elevation.
Q: Under the Public Health Emergency (PHE), are suppliers required to obtain Certificates of Medical Necessity (CMNs)? For recertification CMNs, what do suppliers need to get?
A: If a supplier cannot obtain a CMN (initial, recertification or revised) during the PHE for any reason, the CR modifier with the COVID-19 narrative should be appended to the claim from now until January 1, 2023, when the CMN will be eliminated.
Q: For prosthetic devices, is it acceptable for the physician's notes to show amputation and current physician's visit while the prosthetist notes show K-level, activities of daily living (ADLs) and justification for individual components or does all of this need to be in the physician's notes? I understand that the prosthetist notes are considered part of the medical record but what does this mean?
A: Functional ability information must be clearly documented and retained in the prosthetist's records. The simple entry of a K modifier in those records is not sufficient. There must be information about the beneficiary's history and current condition which supports the designation of the functional level by the prosthetist. Medical need must exist in the physician's medical record and be corroborated in the prosthetists record. The LCD and Policy Article (PA) contain additional information about these responsibilities.
Q: As of today, telemedicine is still allowed under PHE guidelines for Assistive Technology Professional (ATP) evaluations. In this process, are there any applications that are not allowed, applications such as Google Duo, Facetime, Zoom, etc.?
A: Please follow the CMS Telehealth requirements.
Q: Medicare pays for a K0822 (power wheelchair) as a rental only, however the client does not meet criteria for Medicare's coverage due to skilled nursing facility (SNF) for example, is the supplier able to bill the K0822 as a purchase versus rental for the proper denial to seek alternate insurance funding for the secondary payer that will fund this item for the beneficiary as a purchase? If so, is there a specific modifier to utilize?
A: For claims billed to Medicare, the K0822 must be billed as a rental. If the beneficiary is in a SNF stay on the initial date of service, suppliers can deliver within two days of discharge from the SNF and bill with the date of discharge if the beneficiary went home. If the beneficiary is going to be in a SNF for an extended period of time, the supplier can wait to deliver until the beneficiary is discharged to home.
Q: If the client does not meet CMS coverage criteria for a capped rental item, such as K0004 (lightweight wheelchair), however does meet criteria for payment as a purchase for K0004 for a commercial payer that is secondary and secondary only purchases the item, is the supplier able to submit a claim for a denial of the purchase of a K0004 with modifiers NUGA to secure the proper denial to secure funding from their commercial plan?
A: The K0004 cannot be billed as a purchase. The claim for correct denial must be billed as a rental. This information can be found on the fee schedule with the PDAC contractor. If billed as a purchase the denial will be incorrect billing as a purchase instead of a rental.
Q: Is a physical therapist's or occupational therapist's documentation (letter of medical necessity and/or therapy chart notes) considered "medical records" as defined in the Manual Wheelchair Local Coverage Determination (LCD)?
A: The medical record is not limited to treating practitioner's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary. A letter of medical necessity is not considered part of the medical record.
Q: Is the capped rental form that is an accreditation supplier standard for external infusion pumps a condition of Noridian payment?
A: Per supplier standard 5, suppliers are required to advise beneficiaries of the rental/purchase option for capped rentals and inexpensive or routinely purchased items. This must be documented in the supplier records and available for review upon request. Additional information can be found on our website under Browse by Topic > DMEPOS Payment Categories > Capped Rental Items.
Q: Is Medicare updating the LCD or putting out guidance in writing that we can accept REI? Is there an effective date for that?
A: Medicare is not updating the LCD currently. Starting July 1, 2022, Noridian will be accepting REI as a valid sleep study measurement.
Q: I would like a definition of standard frame under the refractive lenses policy. In the past that was always based on price. Recent documentation mentioned it involved frame features. Can you please clarify? Also, for a deluxe frame, when did the definition change?
A: These clarifications should be brought to the PDAC contractor. They will be able to define and identify frames.
Q: If a beneficiary obtains Medicare coverage and does not disclose that to the supplier, what is the extent of the beneficiary's responsibility for non-covered equipment? We cannot execute an ABN because Medicare is not yet active at the time of initial service.
A: Please see Beneficiaries Entering Medicare which can be accessed on our website under Billing, Claims, and Appeals > Billing Situations. This webpage will detail scenarios for beneficiaries in this situation. If the coverage is retroactive, then the supplier would want to work with provider relations of the insurance that was active at the time the service was provided. Suppliers are responsible to monitor insurance for changes in coverage.
Q: Medicare paid for a beneficiary's positive airway pressure (PAP) machine five years ago. At some point, the beneficiary discontinued using it because he was intolerant, per the new face-to-face (F2F) notes. He is now requesting a replacement machine. What are the guidelines on treating this like a Medicare reasonable useful lifetime (RUL)?
A: The beneficiary would need to start over from the beginning if therapy has been stopped for over 12 months.
Q: I have denied enteral claims due to not having a calorie amount on the DME Information Form (DIF). How do we go around this?
A: The calories per day are a required element for enteral nutrition and are entered in question 4 of the DIF. There is no work-around to allow omission of this question, the calories utilized determine the number of units billed. Claims submitted with an incomplete DIF will be denied. The medical records must substantiate the information on the DIF, as the DIF is not sufficient evidence for medical necessity. In addition, the DIF must correspond with the current order on file. For more information on Enteral Nutrition please visit the Noridian website > Browse by Topic > Enteral and Parenteral Nutrition.
For claim specific questions, please contact the Provider Contact Center at the numbers listed below.
- 1-866-419-9458 (JA DME Contact Center)
- 1-877-320-0390 (JD DME Contact Center)
Q: Can an ABN be used when Medicare is secondary to a primary insurance that uses HCPCS codes which are not recognized by Medicare?
A: This is not a valid reason to issue an ABN to a Medicare beneficiary. Please see the following for more information on acceptable uses of ABNs: Noridian Medicare website > Browse by Topic > Advance Beneficiary Notice of Noncoverage (ABN).
Q: Have there been additional updates regarding the new adjunctive continuous glucose monitors (CGM) codes that were effective April 1, 2022?
A: The Glucose Monitor and Supply LCD and PA were updated to reflect these changes. There was also a Coding and Billing article posted to the website: Policies > Medical Director Articles > 2022 > PDAC Code Verification Reviews for CGM Devices - Coding and Billing.
Q: If a physician is no longer in PECOS and the beneficiary needs a new physician for their positive airway pressure (PAP) machine and supplies, do they need a new F2F and a new SWO from the new doctor to continue on with PAP and supplies billing to Medicare?
A: A new SWO should be on file for a new physician taking over care. A new F2F is not required unless there is a change in needed care.
Q: At the beginning of the PHE an update came out saying that the KU modifier could be added to accessories and seating options, when provided with some of the mobility assistive equipment codes, K0005, E1161, etc., can we also use KU on those base HCPCS?
A: The direction states to continue including the KU modifier when billing the manual and power wheelchair accessories and seat and back cushion codes given with the wheelchairs K0005, E1161, E1231-E1238 and K0008. The KU modifier should be used just for those qualifying accessories with the wheelchairs listed and not for the actual base equipment.
Q: What are the frequency limits for HCPCS A4394 (ostomy supply)?
A: The A4394 is not listed within the ostomy policy specifying frequency. Noridian has also published a Medically Unlikely Edit (MUE) tool and that is found on our website under Tools. According to our tool this information is not published and not available to suppliers.
Q: If a beneficiary is set up with a PAP device and we dispense E0601, E0562, A7034, A7035, A7037, and A7038. Can we send the SWO to the doctor with the additional codes of A7032 and A7046 because technically the E0562 has the A7046 attached and the A7034 has the A7032? We are not billing for the A7046 or the A7032 but listing them on the SWO/CMN for the practitioner to sign. Are we only allowed to list on the SWO/CMN the supplies that were dispensed that we are billing for?
A: It would be acceptable for replacement only codes to be listed on the SWO as they will be needed when the originally dispensed supply must be replaced.
Q: For temporary one-month loaner equipment for a wheelchair, is the reimbursement only calculated to be the least costly version of that item group, such as repairing a K0004 (lightweight wheelchair), providing a loaner K0004? Would reimbursement be for a K0001 (standard wheelchair)?
A: If the loaner is being provided during the capped rental, then no payment will occur, and the supplier should continue to bill for the wheelchair. If the loaner is being provided after the rental period, the payment will be for the cost of one month rental of the item being repaired.
Q: Can a diagnosis of anoxic brain injury qualify a beneficiary for an E0465 (invasive ventilator)?
A: The medical record must support the medical necessity for the ventilator. A diagnosis alone will not justify payment.
Q: How do we bill a walker with seat as an upgrade and collect payment for accessories, such as brakes system and basket?
A: If the physician ordered a walker with no seat, you would bill the Walker that is R&N with a GK modifier and the upgraded walker with a GA modifier. An ABN will need to be obtained If you are wanting the beneficiary to be liable for the upgraded accessories. Brakes other than hand operated brakes, provided at the same time as a walker (E0141, E0143, E0149) may not be billed separately to the DME MACs or the beneficiary upon initial issue. This will deny as supplier liable. A Basket would be considered non-covered as it would be a convenience item. You would bill with the GY modifier as it would never be a covered item. There is additional information within the LCD L33791 and Policy Article A42503 for more information. Our website offers great information under the Browse by Topic tab > Upgrades, we have instructions that walk suppliers through billing for an upgrade. We also have DME on Demands (Education and Outreach tab) for upgrades that will walk you through the claim requirements.
Last Updated Tue, 30 Aug 2022 17:15:13 +0000