ACT Q and A - August 12, 2021 - JA DME
ACT Questions and Answers - August 12, 2021
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
Q1. When a beneficiary is on E0601 (continuous positive airway pressure (CPAP)) for over five years then gets a new E0601 and apnea/hypopnea index (AHI) is high, so the physician wants to go to E0470 (respiratory assist device (RAD)), is a new visit with the physician required?
A1. To switch from an E0601 to an E0470, the beneficiary would need to be seen by their treating practitioner where medical documentation is provided stating that the E0601 has been tried and ruled ineffective. Since there is not a change in diagnosis, medical documentation from the practitioner would be sufficient. See the PAP LCD.
Q2. If a beneficiary comes in for an outpatient visit for a tracheostomy change, can we bill for the new tracheostomy tube used as a DME supply?
A2. The Durable Medical Equipment (DME) utilization schedule still applies. If the beneficiary is not due for a tracheostomy tube then one will not be reimbursed.
Q3. Can you provide orthotics requirement in states for professional licensure? Which codes are billable by unlicensed staff?
A3. Per Change Request (CR) 12282, the healthcare common procedure code system (HCPCS), codes that fall under product service codes OR01 Orthoses: Custom Fabricated and OR02 Orthoses: Prefabricated (Custom Fitted) require the use of a licensed/certified orthotist or prosthetist in 17 states: Alabama, Florida, Illinois, New Jersey, Ohio, Oklahoma, Rhode Island, Texas, Washington, Arkansas, Georgia, Kentucky, Mississippi, Tennessee, North Dakota, Iowa, and Pennsylvania. Codes that do not fall under the codes OR01 Orthoses: Custom Fabricated and OR02 Orthoses: Prefabricated (Custom Fitted) do not have that requirement. This CR is found by searching CR12282 on the Noridian Medicare website or on CMS website.
Q4. Does a recent order/prescription by the treating practitioner for continued medical need have to be from treating practitioner on file?
A4. Continued medical need should be documented by the current treating practitioner. See Standard Documentation Requirements Article- A55426.
Q5. For home oxygen, is there a timeframe that oxygen must be delivered once the beneficiary is tested? For example, delivered within 30 days.
A5. Per the Oxygen and Oxygen Equipment Policy Article, there must be "evidence of qualifying test results done within 30 days before initial date of service." The date that the supplier is delivering the equipment would be the date of service. To ensure that an item is still medically necessary, the delivery date/date of service must be within three months from the "initial date" of the Certificate of Medical Necessity (CMN) or three months from the date of the physician's signature in Section D. See Supplier Manual Chapter 4.
Q6. Please provide clarification on oxygen and CPAP documentation for continued medical necessity during the COVID disaster.
A6. Oxygen and Positive Airway Pressure Device (PAP) are included in the policies where the clinical indications for coverage are not being enforced during the public health emergency (PHE), however there must be documentation of medical necessity in each case. Claims are submitted with the CR modifier and a narrative indicating “COVID-19”. Please see the COVID-19 page on the Noridian website under Browse by Topic > Emergencies and Disasters (COVID-19) for more information.
Q7. Can Medicaid oxygen clients be sent to collections for outstanding balances and refusal to see the physician to recertify their oxygen?
A7. Medicare and Medicaid are two separate entities. Please contact your state’s Medicaid program for information regarding collections.
Q8. Is billing for knee/back braces in a competitive bid area physician office, during a global surgery period, appropriate qualifying procedure or service?
A8. In limited situations, physicians are allowed to both prescribe and furnish OTS back and knee braces under the in-office ancillary services exception to the physician self-referral law described at 42 CFR 411.355(b), provided they meet all requirements of that exception. Unless an exception applies and its requirements are satisfied, the physician self-referral law:
- Prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship (ownership, investment, or compensation).
- Prohibits the entity from presenting or causing to be presented claims to Medicare (or billing another individual, entity, or third party payer) for those referred services.
OTS back and knee braces are considered “designated health services” under the physician self-referral law. There is nothing in the competitive bidding program rules or regulations that changes or limits the application of the in-office ancillary services exception to the physician self-referral law or any other provision of the physician self-referral law. All provisions of the physician self-referral law remain fully in effect in competitive bidding areas. For more information on the physician self-referral law, please see CMS Fraud and Abuse Webpage.
Q9. When billing to the Part A/B MAC, do we still need to follow the Noridian DME medical necessity guidelines?
A9. Medical necessity is required for all clinical services. However, this question would be better addressed by the AB MAC.
Questions Asked During ACT
Q10. We are based in California but looking to open a branch in Florida. Is there additional licensure that will be needed for us to bill complex rehabilitation products?
A10. To have another location in Florida, you’ll need to meet the Florida state licensure and work with the National Supplier Clearinghouse (NSC) to obtain another Provider Transaction Access Number (PTAN) for that location. Florida is in Jurisdiction C so claims will be submitted to that MAC as well.
Follow-up Question: If we operate as an out-of-state provider, are we still required to get another PTAN? We won’t have a brick-and-mortar location initially but will have a tech out there for service.
Answer: If providing a service, a location is needed. DMEPOS supplier standards are found on the national supplier clearinghouse (NSC) website. Supplier standard number seven (7) addresses the requirement for a physical facility with posted hours of operation.
Q11. A 1-800-Medicare representative was on the phone with our company and a beneficiary telling us we have to replace the recalled CPAP devices but I know that’s not what has been communicated to us. Has there been a change in what has been communicated?
A11. CMS has clarified that when Medicare has purchased the PAP device, the supplier receiving payment is responsible to provide a PAP device for the five-year reasonable useful lifetime (RUL). See Recall FAQ for more information.
Written Questions Asked During ACT
Q12. What criteria needs to be met for wrist, hand, finger orthoses (WHFOs), L3807 (static, prefabricated wrist, hand, and finger orthosis), for example? Do contractures need to be documented?
A12. For the L3807, the medical records must document the medical necessity and substantiate the need for the custom fitted brace. If the reasoning for ordering the brace is for contractures, then the medical records should document those contractures. Additionally, those records need to show why a custom fitted brace was required over a prefabricated.
Q13. What criteria needs to be met for cervical collars, example codes L0172 and L0174?
A13. For any DMEPOS item to be covered by Medicare, the beneficiary’s medical record must contain sufficient documentation of the medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable).
Q14. I had sent in a redetermination to change a ventilator HCPCS code from E0466 to E0465. The claims had paid prior to the code request. The redetermination ended up with a determination that they would be recouping the monies. We wanted to dispute the refund request however I am not sure how to do this. Do we send in another redetermination request to stop the recoupment until the documentation of the appeal is reviewed or would that not be valid because we already sent in a redetermination on this claim? What would we need to do to stop the request until the documentation is further reviewed by Medicare?
A14. If the redetermination level denied, you will need to go to the next level of appeals, reconsiderations. Information on this is found within your redetermination letter. See the Reconsiderations Webpage for more information.
Follow-up Question: We did send it to reconsiderations however the customer service line said that would not stop the recoupment. How do we stop the recoupment?
Answer: The recoupment cannot be stopped. Additional explanation will be provided individually to the supplier.
Q15. For qualifying CPAP, does the beneficiary have to be diagnosed with anxiety or will chart notes showing anxiety suffice? (This is in regard to the mood disorders).
A15. The policy allows the practitioner to determine the additional criteria met, the medical records must support the Local Coverage Determination (LCD) coverage criteria for the items.
Q16. Should we use the CR modifier for COVID diagnosis only or would we use this with any diagnosis during the pandemic where we are not able to get the face-to-face (F2F) or all three sets of SATS for activity, etc.?
A16. The CR modifier and COVID-19 narrative should be utilized for all claims affected by the Public Health Emergency (PHE). See Noridian’s COVID-19 webpage.
Q17. An overnight oximetry is required for an oxygen bleed into Continuous Positive Airway Pressure Device (CPAP) with the diagnosis of OSA. If the beneficiary has other diagnoses besides obstructive sleep apnea (OSA), could we use the other diagnosis without the overnight oximetry?
A17. If the patient has Obstructive Sleep Apnea (OSA), then only a titration study is acceptable for qualification purposes if the testing will be done nocturnally. See Oxygen Local Coverage Determination.
Q18. Is the nebulizer filter a billable item?
A18. Some filters and accessories are billable, please refer to the Nebulizer LCD for more information on the billable items.
Q19. Is Covid-19 U07.1 still a valid diagnosis for home oxygen therapy, even though it's an acute condition?
A19. CMS is currently not enforcing clinical indications for respiratory, oxygen, infusion pump, and continuous glucose monitor national coverage determinations (NCDs) and LCDs. If the beneficiary does not meet all coverage criteria, append the CR modifier and COVID-19 on the narrative. See Noridian’s COVID-19 webpage.
Q20. Is an E2207 (wheelchair accessory) covered for a group 2 power wheelchair?
A20. Coverage will be dependent on the medical record. That documentation would need to show why it is reasonable and necessary when the beneficiary has a power wheelchair.
Q21. For an order or Certificate of Medical Necessity (CMN), is a digital/ electronically printed date allowable if the signature is handwritten or does the date need to be in the same "style" as the signature? We have had claims denied before because they did not match.
A21. It is a standard practice that the signature and date should agree in format. See MLN Matters 6698 for more information.
Q22. Regarding Medicare Capped Rental and Inexpensive or Routinely Purchased Items Notification for Services on or after January 1, 2006, if a beneficiary receives items that fall in this category do we need to get the beneficiary to sign this letter? For example, a heated humidifier can be billed as a rental or a purchase.
A22. Suppliers are required to notify the beneficiary of rental or purchase options; however, the form is not required by Medicare. The form could be used if found to be beneficial for record keeping purposes.
Q23. If we are using an already mixed nebulizer solution of Ipratropium and Albuterol, what modifiers should we use, KP or KQ?
A23. If you are referring to J7620: J7620 is the only FDA-approved combination of albuterol and ipratropium and therefore, KO, KP, and KQ modifiers should not be used with code J7620.
Q24. If a beneficiary buys a PAP out of pocket online because of the recall, can we still give them their PAP supplies as long we have a valid order, sleep study and F2F?
A24. Medicare would consider payment of supplies with documentation of all coverage criteria having been met. If the beneficiary meets the coverage criteria, supplies may be submitted for reimbursement consideration as the PAP would be beneficiary-owned.
Q25. Regarding the new PAP policy sleep requirements that were announced on August 5, 2021, are you terminating the use of a home sleep test (HST) and only recognizing a polysomnogram (PSG)?
A25. Both are still recognized as valid testing methods and are mentioned in the LCD. The only item removed are the administration and interpretation guidelines and anything that went with the requirement to complete the study itself. The study is covered under Part B and the information removed was duplicative.
Q26. Regarding the updated PAP policy, is there really no time limit from initial F2F to sleep study? Can it be eight months? Does order matter, can the sleep study be dated after the F2F?
A26. There is a requirement for the F2F prior to the sleep study and needs to be within a 12-month period. There is not an established timeframe for the F2F prior to the sleep study and the conducting of the actual sleep study other than the 12-month requirement.
Q27. A beneficiary was given an osteogenesis bone stimulator while still in a Skilled Nursing Facility (SNF). Is there a modifier that can be added to the E0748 (osteogenesis stimulator) to indicate the beneficiary will be using the item when they go home for our practice to be paid?
A27. For an item to be covered by DME, it must be delivered within two days prior to discharge for use in the home. The date of service to bill would be the date of discharge. If used in the Skilled Nursing Facility (SNF), it would not be billable to the DME MAC.
Last Updated Fri, 08 Oct 2021 13:22:52 +0000