ACM Q and A - November 7, 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: There is lacking details on the new PureWick system (E2001). The National Coverage Determination (NCD) is vague. When is criteria coming out?
A: The only information Noridian has on the PureWick system may be found in the coding and billing article at the path below. This is a joint publication with Noridian and CGS.

Noridian Medicare website > Policies > Medical Director Articles > 2024 > PureWick Urine Collection System – Coding and Billing Instructions - Revised

Q: How does regular Medicare enrollment differ from durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) enrollment?
A: In order to bill Medicare for DMEPOS items, suppliers must enroll with the National Provider Enrollment (NPE) East or NPE West. More information on enrollment and links to the NPE East and NPE West contractor websites may be found at the path below.

Noridian Medicare website > Browse by Topic > Enrollment

Q: Are there any upcoming policy changes for the ventilator policy?
A: There are not any upcoming changes to ventilator coverage. You can learn more about ventilator coverage at the next webinar, scheduled for December 19th at 1 p.m. CT.

Noridian Medicare website > Education and Outreach > Schedule of Events

Q: What kind of documentation is Medicare looking for to justify specialty enteral nutrition formulas (B4149)?
A: The medical records from the treating practitioner must support the level of care provided. If the beneficiary requires a special formula, there must be a determination that a standard formula is insufficient to meet nutritional requirements. While a diagnosis alone is not sufficient to support medical necessity of an item, perhaps the medical records discuss the beneficiary having an allergy or medical condition which prohibits the use of a standard formula or eliminates the standard formula as an option.

Q: We have a patient demanding pickup of equipment that is under the five-year reasonable useful lifetime (RUL). The power wheelchair was purchased 18 months ago and has been repaired, and the reason for pickup is the beneficiary doesn’t like the manufactured chair.
A: The beneficiary owns the wheelchair and therefore is responsible for the item. If the beneficiary is requesting the item to be returned that would be up to your own business practices. However, Medicare will only replace the wheelchair in certain instances such as lost, stolen, or irreparably damaged items. For more information on replacement, review the Noridian Medicare website > Browse by Topic > Repairs, Maintenance and Replacement > Replacement

Q: Could you please show what documentation is required for Therapeutic Shoes for Persons with Diabetes (TSPD) and give suggestions on what information is needed per the 2024 guidelines?
A: Noridian offers a documentation checklist for TSPD that is up to date. It provides guidance on all the documentation needed as well as what information needs to be provided. Please follow the pathway to view the documentation checklist: Noridian Medicare website > Browse by DMEPOS Category > Therapeutic Shoes > Therapeutic Shoes for Persons with Diabetes Documentation Checklist

Q: If the beneficiary has a significant weight loss but has a bariatric wheelchair that has not reached the 5-year reasonable useful lifetime (RUL), can we bill another wheelchair of an appropriate size?
A: If there is a change in medical need a different wheelchair may be billed for payment. Issuing an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary would be appropriate in this scenario. The claim will deny as same or similar, and all documentation requirements can be submitted to redeterminations for review.

Verbal Questions Asked During ACM

Q: What is the best practice for billing Foley catheters and bundled billing when beneficiaries are overutilizing? They are requiring more than one per month but we're getting two bundled codes that populate because we provide, for example, two of the drainage bags, 12 Foleys, and 12 insertion trays.
A:  Only one foley catheter is allowed per month unless there is documentation that supports the need for additional units (e.g., obstruction, sludging, clotting of blood, or chronic, recurrent urinary tract infection). The supplier will bill for the units ordered, which will populate with A4311 and A4314 in this case. After the first denial, the supplier should complete a redetermination to be reviewed by medical review. If the documentation supports it, a note will be put in the system to allow further claims to be processed for payment.

Q: Medicare extended telehealth visits for the face-to-face (F2F) through December 31, 2024. Is there any clarification on if this will be extended past 2024?
A: Yes, valid telehealth visits will continue to be acceptable. Some flexibilities for valid telehealth visits are scheduled through December 31, 2024. CMS has a list of what would be considered a valid telehealth visit.

Q: Is the August 2024 required face-to-face and written order prior to delivery list on the CMS website a comprehensive list?
A: Yes, the complete list is located on the CMS website.

Q: Regarding a positive airway pressure (PAP) mask, it doesn't matter where the fitting happened (such as a doctor's office or another location), the supplier can still bill for it, correct?
A: Correct, the DME supplier who provides the mask must bill for the mask.

 Written Questions Asked During ACM

Q: Can you please review the different role between nurse practitioner, physician assistants and certifying physicians regarding the therapeutic shoes?
A:  There are different ways that these can be the certifying physician. One way a nurse practitioner can be a certifying physician is if they are participating in the Primary Care First (PCF) Demonstration Project. A nurse practitioner and a physician assistant can act as a certifying physician if they are practicing "incident to" a supervising physician (M.D. or D.O.). For "incident to", the supervising physician must sign and date (indicating agreement) the nurse practitioner’s or the physician assistant's records. All billing must be done under the supervising physician’s National Provider Identifier (NPI) for "incident to" requirements to be met.

Q: Can you clarify acceptable addendums to diagnostic testing or medical records, specifically computed tomography (CT) of chest or chest x-ray?
A: All addendums to medical records must be done according to the requirements in the Internet Only Manual, Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.5.

Q: With the ABN, the beneficiaries want to electronically sign and date. I have seen Medicare come back and state that the beneficiary cannot electronically date, handwritten only. The beneficiary has to print it out, sign it, and then scan it back. Is there an easier way that this can be done?  Not all beneficiaries have the equipment to do this.
A: Nothing prohibits electronic signing or dating of the ABN. Electronic issuance of ABNs is not prohibited. If a healthcare provider or supplier elects to issue an ABN that is viewed on an electronic screen before signing, the beneficiary has the option of requesting paper issuance over electronic if that is what s/he prefers. Also, regardless of whether a paper or electronic version is issued and regardless of whether the signature is digitally captured or manually penned, the beneficiary should be given a paper copy of the signed ABN to keep for his/her own records. For more information, see the IOM, Publication 100-04, Chapter 30.

Follow-up Question: I received a denial stating the signature must be handwritten. Can this be looked into?
A: If a claim was denied, the appeals process must be followed.

Q: We have a new Medicare beneficiary who just entered Medicare on October 1, 2024. His F2F visit and testing are all prior to this date. Does he still need a F2F visit after becoming Medicare eligible if he was not set up prior to eligibility?
A: Another F2F visit is not required if this is regarding oxygen or PAP.

Q: We recently received some denials where a clinician is PECOS-enrolled but somehow not for Part B. How can we check for this for DME?
A: PECOS enrollment may be verified on the CMS website.

Q: Regarding power mobility devices (PMDs), do we know if the telehealth F2F and specialty evaluation that was mandated during the health crisis will be extended past December 31, 2024?
A: Valid telehealth visits do continue to be acceptable for PMDs when done by the treating practitioner with the requirement met for both audio and video. A listing of valid telehealth services can be found on the CMS website.

Q: How does Medicare view lumpectomy vs mastectomy? Do chart notes need to specify mastectomy or is a substantial lumpectomy sufficient? If the record stated lumpectomy, but described size (removed measurement, cup size change, etc.) that could be described as partial mastectomy but doesn't state mastectomy, could the beneficiary qualify for breast prosthesis or does the record need to include the word mastectomy?
A: The medical records need to reflect what medical procedure took place. A lumpectomy wouldn't necessarily mean a mastectomy, so the medical records need to be specific. Also, a breast prosthesis and garments are covered for a beneficiary who has had a mastectomy with a diagnosis code that is listed in the Local Coverage Determination (LCD)-related Policy Article. The medical record would need to support the need for a prosthesis.

Q: Is there an LCD or National Coverage Determination (NCD) for urine suction pumps (PureWick)?
A: There is not a policy; however, the Medical Directors discuss the PureWick system and coding guidelines in an article on our website under Policies > Medical Director Articles > 2024 > PureWick Urine Collection System - Coding and Billing Instructions - Revised.

Q: Would having a comment on the physician written order saying "Refer to RT Determination" satisfy the requirement that the treating practitioner has evaluated the results of the blood gas study as long as we have a copy of the testing in the medical records or would we have to prove the provider actually seen the testing?
A: We are unable to provide pre-approval of specific documentation examples. However, we do have a recently published article titled "Treating Practitioner Evaluation of the Blood Gas Study for Oxygen" which describes what may be used to meet this requirement. Examples include notation of the results on the order or reference to evaluation of testing performed on a specific date. In the example provided, "Refer to RT Determination" may not be sufficient in case of review to meet this requirement. This article is found under Browse by DMEPOS Category > Oxygen > Related Articles section.

Q: When will there be training and updated materials (checklists, etc.) for Pneumatic Compression Devices with the change from LCD to NCD?
A: Training materials will be released when more information is available. Thank you for your patience.

Q: If a prior authorization (PA) is needed and the item is dispensed, is the authorization date from the prescription date or is it the approval "affirmed" date on the letter?
A: The prior authorization becomes valid starting on the date the affirmed Unique Tracking Number (UTN) is provided.

Q: Does Noridian do retroactive authorizations?
A: Retroactive prior authorizations are not appropriate except in scenarios where the beneficiary is retroactively eligible for Medicare. More information on prior authorization can be found on the Noridian Medicare website under Medical Review > Pre-Claim Review > Required Prior Authorization Programs. Also, the operational guide can be found on the CMS website.

Q: Can an order have the verbiage of a letter of medical necessity (LMN) and that count as both forms from the provider?
A: A separate order is required unless the supplier is also the treating practitioner. Supplier-prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician. An LMN itself is not enough to meet coverage criteria. The information must come from the medical records.

Q: What happens if a referring physician is no longer with the clinic or hospital and an LMN is needed? Can another provider write the LMN?
A: If the beneficiary has seen this physician, they can write an LMN; however, LMNs are not considered part of the medical record and cannot be used alone to support medical necessity on Medicare claims.

Q: If a beneficiary qualified for oxygen originally under COVID due to no qualifying oxygen saturation testing and is due or coming up due for replacement following the RUL, does the beneficiary need to complete new testing or is the CR modifier good for lifetime and no new testing is required?
A: Suppliers may continue to append the CR modifier if the oxygen remains medically necessary. New testing would not be required if therapy has been continuous. More information is available on our website under Policies > Medical Director Articles > 2023 > Claim Submission Instruction Post-PHE - Continued Use of Modifier CR and COVID Narrative - Revised.

Q: Regarding oxygen saturation testing, if it previously was not signed by the doctor and now it's at the end of the RUL, do we have to have it mentioned in the current F2For order?
A: Mention of the original testing is not required for replacement oxygen following the RUL. There must be a new standard written order (SWO) for the replacement oxygen to demonstrate continued medical need.

Q: For PAP beneficiaries entering Medicare where the beneficiary started the process prior to becoming eligible for Medicare, F2F, sleep study, and order, (equipment not received yet), then becomes Medicare-eligible, does the beneficiary have to be seen again for another F2F and order after the Medicare effective date and before the equipment is delivered?
A: As long as the initial coverage requirements in the PAP LCD have been met, a new sleep study, order, and F2F are not required.

Q: Regarding oxygen for nocturnal use, if the doctor is ordering oxygen for congestive heart failure, chronic obstructive pulmonary disease, etc., and the F2F documents sleep-related symptoms, such as snoring, daytime sleepiness, and fatigue, etc., can the qualifying saturation test come from an overnight oximetry, or does it have to come from a titration study?
A: A titration would only be required if there was documentation of sleep apnea. Otherwise, an overnight oximetry test would be acceptable.

Follow-up Question: Wouldn't the titration be needed to rule out the sleep apnea because the beneficiary has symptoms of sleep apnea?
A: That would be up to the treating practitioner. Medicare only requires a titration for oxygen if the documentation specifically mentions sleep apnea or suspected sleep apnea.

Q: We previously attended a joint webinar from CGS and Noridian for surgical dressings. The educators advised that Medicare will only pay for 12 foam dressings per month but that an ABN would have to be on file if the beneficiary is paying for the additional 18 foam dressings ordered. This advice was upheld through four years of redeterminations, Targeted Probe and Educate (TPE) reviews, Comprehensive Error Rate Testing (CERT) reviews, and post payment claim reviews. We recently had a Unified Program Integrity Contractor (UPIC) review and received our first denials for foam dressings over alginate primary when the doctor recommends daily change, and it has been documented that the facility is providing the 18 extra foam dressings. Was there a change in coverage and frequency?
A: An ABN would be valid for the additional 18 units if the documentation does not support it. For denied claims, a redetermination should be submitted with supporting documentation.