ACT Questions and Answers - August 21, 2019
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. What are the Written Order Prior to Delivery (WOPD) and Face-to-Face (F2F) requirements for change in modality from portable oxygen concentrator (POC) to gas and issues with physicians refusing to sign Certificates of Medical Necessity (CMNs)?
A1. Change in modality does not require a new CMN. The change only requires a new order. The POC (HCPCS E1392) is not on the Affordable Care Act (ACA) HCPCS so there are no additional F2F requirements.
Q2. Is CMS creating a ventilator Local Coverage Determination (LCD)?
A2. CMS offers the ventilator National Coverage Determination (NCD). Noridian is unaware of any plan to produce a ventilator LCD.
Q3. Which V-code is covered for post cataract lenses? Are suppliers required to have an Advance Beneficiary Notice of Noncoverage (ABN) for HCPCS V2760 with GY modifier? Are the V-Codes ICD-10 specific?
A3. The LCD and Policy Article for refractive lenses provide detailed information on use of codes and modifiers following cataract surgery. Coverage is defined for both aphakic beneficiaries and pseudophakic beneficiaries. There is not a requirement for an ABN for the scratch resistant coating (HCPCS V2760) as it is statutorily non-covered. The GY modifier is sufficient.
Q4. Please elaborate on what the requirements are for a failed Positive Airway Pressure (PAP) trial.
A4. When a beneficiary has failed the PAP trial, there must be a F2F visit with the treating physician to determine etiology of failure and a repeat sleep study which must be an in-lab study. The sleep study may be a diagnostic, titration or split night. For additional information, see the Medical Director's "Correct Billing - Continued Coverage for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea" published May 16, 2019 and updated May 21, 2019.
Q5. Please provide modifier information for items used bilaterally.
A5. For items that may be used bilaterally, the RT and LT modifiers must be appended as appropriate. If both are provided at the same time, they must be billed on separate claim lines with unit of service (UOS) one.
Q6. Please address sleep study scoring.
A6. Medicare requires that hypopneas be scored using a 4% oxygen desaturation while the American Academy of Sleep Medicine (AASM) recognizes a 3% desaturation. Noridian encourages education of physicians on the Medicare requirements. See the "Clinician's Corner" webpage.
Q7. Are therapeutic shoes for persons with diabetes available for same/similar look up?
A7. Yes. Same/similar is available within the Noridian Medicare Portal (NMP).
Q8. For HCPCS E0471 (Bi-level with back-up) under restrictive thoracic disorders, can the DME supplier perform the sleep oximetry?
A8. It is never appropriate for DME suppliers to perform any testing related to qualifying for reimbursement.
Q9. What is to be recorded under Q3 on the enteral DME Information Form (DIF)?
A9. Each item/service procedure code(s) being provided must be listed in Q3.
Q10. What are Detailed Written Order (DWO) requirements? Are they different if the item is over $1000?
A10. See the Standard Documentation Article A55426. All items require a DWO prior to claim submission regardless of the monetary value.
Q11. Do upper extremity braces have a five-year reasonable useful lifetime (RUL)?
A11. In the absence of specific direction otherwise, all DMEPOS has a five-year RUL.
Q12. Does the five-year RUL pertain to prosthetic codes? Is HCPCS L5000 considered a prosthetic code?
A12. No, the five-year RUL does not apply to prosthetics. The following statement is found in the Lower Limb Prosthetic LCD. "Medicare payment may be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is reasonable and necessary." Yes, the partial foot, shoe insert with longitudinal arch, toe filler (L5000) is a prosthetic code.
Q13. Has there been any discussion of accepting Respiratory Effort Index (REI) on sleep studies?
A13. This requires CMS to update the NCD.
Q14. Is the date/time stamp still required on documentation?
A14. No, this requirement was removed from the Standard Documentation Article A55426.
Q15. HCPCS J1301 (injection, edaravone, 1 mg) and blood products have to be billed to our local carrier instead of Noridian. Why not others, like Vancomycin?
A15. Noridian can only speak to items billable to the DME MAC which must meet the statutory definition of durable medical equipment, orthotics, prosthetics and supplies.
Q16. When should post-operative DME be billed? How does a supplier bill if the fitting is done one day and the patient receives DME on another date?
A16. DMEPOS required postoperatively can be provided within two days of anticipated discharge for training and fitting purposes. The date of service (DOS) to bill the DMEPOS is the date of discharge.
Q17. What constitutes "alternative treatment" measures for oxygen?
A17. The medical record must document what other common therapies for the beneficiary's condition have been tried or considered prior to determining the need for long term home oxygen therapy.
Q18. Our local hospital is choosing to no longer provide walkers with wheels. We are being told is it because of a reimbursement issue. Please explain the LCD/NCD policies on medical necessity for proper/compliant billing purposes?
A18. Medicare covers walkers for beneficiaries who meet the coverage requirements under the walker LCD. The fee schedule is set by CMS.
Questions Received During ACT
Q1. Since a beneficiary's hospice and Health Maintenance Organization (HMO) will not cover a ventilator, should a supplier bill Medicare with a GW modifier? If so, is the patient required to re-qualify with a pickup and delivery?
A1. Any covered Medicare services not related to the treatment of the terminal hospice condition and which are furnished during a hospice election period, may be billed to Medicare for payment. These services should be coded with the GW modifier and the "entering Medicare from HMO policy" should be followed.
Q2. We have a secondary carrier that is requesting proof of noncoverage before they'll pay. Do you have any suggestions on what we can use?
A2. Some payors require the claim to be sent to Medicare to deny for their claim to process. For items Medicare does cover, there is a mandatory billing requirement when a supplier has a Medicare supplier number. Also, if beneficiaries complete an ABN and asks the supplier to bill the Medicare program, the supplier must do so. For statutorily noncovered items under Medicare, suppliers can share the LCD with the Provider Relations area of those payors, showing that Medicare never pays for the item, and request a Medicare denial not be required; however, it is up to the other payors.
Q3. What documentation is required for a beneficiary that has a bi-level with back up rate and meets compliance but is not doing well now and the doctor feels the beneficiary needs a ventilator?
A3. A ventilator is considered for coverage for the treatment of neuromuscular diseases, thoracic restrictive diseases, or chronic respiratory failure consequent to chronic obstructive pulmonary disease. The medical record documentation would need to fully support that the beneficiary needs to be on the ventilator as the treatment for one of these disease categories.
Q4. We have beneficiaries that like to use a full-face mask (HCPCS A7030) some of the time and a regular mask (HCPCS A7034) some of the time. Can you advise as to what is required as far as documentation and if a new CMN is required each time they change from an HCPCS A7030 to an HCPCS A7034?
A4. The Positive Airway Pressure (PAP) LCD no longer uses a CMN; however, each time the beneficiary changes the mask, they will need a new DWO from the physician showing the change in need for the mask that they will be getting.
Q5. In order to be paid for Enteral Nutrition, does the DIF have to be submitted electronically? If it is not, what denial is received?
A5. Yes, the DIF must be submitted with the claim submission. The denial will indicate the item is not prescribed. Suppliers should also review their software front end edits for the possibility that the DIF was not submitted.
Q6. When we have a beneficiary who returned his/her portable oxygen concentrator (POC) and we delivered a gas portable, what are the documentation requirements? We understand no CMN is required for the change in modality but does it still require a F2F and WOPD? Do the Affordable Care Act (ACA) rules apply?
A6. For a change of modality, there is a requirement for a new order. According to the ACA, a F2F and a WOPD must be obtained. CMS instructed Medicare Administrative Contractors (MACs) not to enforce the F2F requirement; however, the Comprehensive Error Rate Testing (CERT) contractor will still enforce the F2F requirement prior to delivery of the E0431. The five-element order (5EO) is required by all contractors. Noridian recommends the F2F be in the supplier's possession in the event of a CERT review, the supplier has the evidence to meet this requirement.
Follow-Up Question. Usually the physicians are stating the hypoxemia is obstructive sleep apnea (OSA)-related. Some state the patient does not have a history of chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF) but they don't state how they've been ruled out. If the documentation supports that they have ruled these other diagnoses out and have performed other tests, etc., and have found no reason for the hypoxemia, is OSA/hypoxemia alone considered enough?
Answer. Oxygen is not a treatment for OSA so there must be justification in the medical record. If the OSA is optimally treated, then help us understand how the hypoxemia is related to the OSA. Clear documentation is the key in identifying what has been considered. Additionally, if, under evaluation, you do not believe Medicare will cover the oxygen because of your interpretation of the policy, then you are within your rights as a supplier to obtain an ABN, explaining in detail the reasons you expect Medicare will not cover the oxygen, and require the beneficiaries to pay. Appeal rights are still available even with the use of an ABN.
Q7. Is the beneficiary using PAP therapy required to be >70% at the time of the F2F or can the >70% be reached after the F2F but still under 90 days?
A7. At the time of the F2F, the physician would need to be able to determine and document that the beneficiary is meeting the adherence of usage and to evaluate how they are benefiting from the PAP device. If the F2F occurs and the physician indicates that the beneficiary is using and benefitting, then subsequently signs off on an actual download that states they've reviewed the evidence, this may be accepted; however, the ideal scenario is when the beneficiary is meeting compliance of usage before the F2F so it could all be evaluated at the same time.
Q8. We have been using the Dear Physician letters and Medicare resources; however, we still have trouble with physicians refusing to sign CMNs, especially hospitalists at discharge because they are not following the beneficiary's care. What options do we have to enforce the requirement that the CMN be signed?
A8. Beneficiaries can have more than one treating physician. The five-element order that is needed, in most cases for hospital discharge, can come from the hospitalist and the CMN can come from the beneficiary's primary care physician, pulmonologist or whoever is following their treatment and has access to those hospital records. The CMN is needed prior to billing while the five-element order is needed prior to delivery.
Q9. What does the denial CO-16 mean?
A9. CO-16 indicates many reasons for denial. For example, it could be that a claim is missing the DIF, a Provider Enrollment, Change and Ownership System (PECOS) denial or the item billed does not have base equipment on file. See the "Denial Code Resolution" webpage on our website to view specific reasons for denial for certain reason and remark codes and how to fix the errors. For more information on a particular claim, call the Supplier Contact Center for the jurisdiction that processed the claim.
Q10. We are getting a lot of pushback from physicians that hypoxemia and OSA alone is valid for oxygen reimbursement. The physicians are stating the hypoxemia-related issue is the OSA but we are stating that oxygen is not a treatment for OSA, per the LCD. The argument is that if the patient is still at or below 88% at optimal pressure for at least five minutes, it shows the need for oxygen. Are there other materials that can be used to educate physicians?
A10. In addition to the Oxygen and Oxygen Equipment LCD, Noridian offers Dear Clinician letters and many articles written collaboratively by the Noridian and CGS Medical Directors. If the desaturation continues to occur after the OSA is optimally treated, then the hypoxemia is being caused by something else and this is what a reviewer needs to know. They are looking for what is causing the hypoxemia. Reviewers understand that there may be additional testing that needs to be done but the physician must have some indication about what might be causing that hypoxemia and that needs to be recorded in the medical records.
For example, if a beneficiary were to see a new to a physician, rather then having to start all over to try to figure out what is causing the hypoxemia, the physician will want to know what had already been considered.
Q11. Can Medicare be billed for a backup ventilator? If so, is a modifier needed?
A11. In general, Medicare does not pay separately for backup equipment. However, there is allowance for a beneficiary who is confined to a wheelchair and requires a ventilator mounted on the wheelchair to have a second ventilator.
Q12. We were denied in an audit for an oxygen concentrator E1390, DOS January 19, 2019, because the clinical documentation did not support the beneficiary has an underlying lung disease. Can we submit chart notes after DOS January 19, 2019 that support the patient has a lung disease when we appeal?
A12. We encourage suppliers to work with their case manager to have all documentation reviewed during the audit process, if this is a Targeted Probe and Educate (TPE) review. After denial, submit all supporting documentation in the appeals process.
Q13. We've been seeing an increase in denials of glucose testing supplies, particularly for high utilization beneficiaries, because there is no code or modifier to signify these beneficiaries have different than normal utilization. Do we have to reopen every claim?
A13. Each glucose supply claim is independent, and supplies are not able to be handled under the Serial Claims Initiative because these supplies may be provided by different suppliers and they may be for different types of supplies. Noridian may not assume that because the documentation has been reviewed once, it continues to be applicable. These must go through the redetermination process each time to show the need for high utilization of these supplies.
Q14. I have been audited by the Recovery Auditor Contractor on a same or similar claim. The beneficiary received a L1820 (Knee orthosis, stabilizing) from us and the documentation, prescription and DWO were in place. I checked the NMP and no other braces were dispensed. The beneficiary was asked if he/she received a brace; he/she indicated no, so an ABN was issued. I rechecked NMP once the audit was received and now HCPCS L1830 (Knee orthosis, immobilizer) was delivered at the doctor's office earlier that month. How fair is this to the supplier when we do all the necessary steps?
A14. You may appeal; however, until a supplier bills (within the 12-month timely filing), Noridian will not know that a previous brace had been provided.
Q15. The beneficiary had a qualifying F2F assessing for OSA on October 2, 2018, with a qualifying diagnostic sleep test study dated October 6, 2018. The WOPD is dated November 17, 2018. Can the beneficiary be set up on August 19, 2019 or is the beneficiary required to be seen again with timely documentation being within 12 months?
A15. There is no date requirement for the F2F prior to the sleep study. The big issue is that when a diagnostic sleep study is performed, the Noridian and CGS Medical Directors have said that because of the required documentation of ongoing need within 12 months, if no therapy has been initiated in the 12 months since the sleep study was performed, the beneficiary would have to have another one.
Q16. For the dispensing of a CPAP HCPCS E0601, we have a sleep study that is less than a year old; however, the F2F prior to the sleep study is over a year old. Is another F2F and sleep study required?
A16. The diagnostic sleep study is within one year and that is fine to use. There is a F2F prior to the sleep study so that is fine; however, the PAP is on the ACA listing and that requires the F2F within six months of any order. In this case, there will need to be another F2F for the PAP to be ordered.
Q17. Regarding reopening claims for glucose supplies, are other diagnoses (in addition to diabetes) which may have an effect on blood glucose, such as hypothyroidism or injected corticosteroid use, considered?
A17. The LCD is specific related to what is covered with a diagnosis of diabetes mellitus. Clinical records regarding any other conditions causing the need for overutilization must be available. If a review is being denied, Noridian encourages suppliers to have these conversations with the Targeted, Probe and Educate (TPE) case manager. They are the supplier's point of contact, the nurse reviewing the claim and they will be able to help with specific examples.
Q18. When an order is being used to support continued medical need, does Noridian go by the signature date or the order date when considering documentation within 12 months from the DOS?
A18. The signature date is considered for coverage in this situation because the creation of an order doesn't mean anything until the physician reviews and signs it.
Q19. Are shower legs covered for prosthetic patients with special needs?
A19. Convenience items such as bathroom aids do not meet the definition of a DMEPOS item and are therefore not covered.
Q20. If a PAP therapy beneficiary fails the second trial; can he/she purchase the PAP device? What if the beneficiary meets > 70% two months later with a F2F, can supplies be billed with the KX modifier? If the beneficiary returns the PAP, can he/she requalify and what is required?
A20. Purchase of a PAP device cannot be submitted to Medicare because it is a rental only. If the beneficiary chooses the billing option on the ABN, it must be a rental. Supplies are not covered by Medicare for a beneficiary owned machine because compliance was not achieved within the allotted trial time. If the beneficiary subsequently becomes compliant, an appeal could be filed; however, any supply claim will deny. The best avenue is to continue working with the beneficiary to become compliant, then the fourth month can be billed and the continuity of therapy would be shown.
Last Updated Feb 10, 2020