ACT Q and A - November 10, 2022 - JA DME
ACT Questions and Answers - November 10, 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
Q1. What is CMS requiring since the Certificate of Medical Necessity (CMN) is going away? What is the official date the CMN will no longer be required?
A1. The CMN will no longer be required for dates of service January 1, 2023, and after. Medical necessity will be required and will need to be established in the medical record.
Q2. Does the beneficiary need to meet Medicare coverage criteria for the base item to qualify for the repairs to beneficiary-owned equipment?
A2. The beneficiary-owned base item must be medically necessary for the beneficiary to receive the service or any associated supply. One of the requirements for repair to beneficiary-owned equipment is the item must meet continued medical need. For more information, see our website on the Browse by Topic tab > Repairs, Maintenance and Replacement > Repairs.
Q3. When billing for seat lift mechanisms, can we collect payment for the chair portion on the day of delivery?
A3. Per the Seat Lift Mechanisms Policy Article, "When providing a seat lift mechanism that is incorporated into a chair as a complete unit at the time of purchase, suppliers must bill the item using the established HCPCS code for the seat-lift mechanism. In this situation, the supplier may bill the seat lift mechanism using E0627 or E0629, and bill A9270 for the chair." Collecting payment for the chair will be up to your company's business practices as Medicare only covers for the seat lift mechanisms.
A4. Are there any updates regarding when the new Oxygen Local Coverage Determination (LCD) will be released?
A4. The oxygen LCD that will be effective January 1 can be accessed under the Policy section of the Noridian websites. This LCD was released on November 17.
Q5. A beneficiary wants more than the two allowed contacts after post cataract surgery. How do we bill for more than two boxes?
A5. For beneficiaries with pseudophakia, coverage is limited to one pair of eyeglasses or contact lenses after each cataract surgery with insertion of an intraocular lens (IOL). Replacement contact lenses would be denied as noncovered. You would not need an Advance Beneficiary Notice (ABN) to receive a beneficiary liable denial for additional lenses, however you may want to offer a voluntary ABN.
Q6. Does Medicare require a signature date from the practitioner for a polysomnography (PSG) test?
A6. If there is a date the PSG was completed, the practitioner's signature would be acceptable on its own. If the test is not dated the practitioner would need to date it as well.
Q7. If a beneficiary moves to a different jurisdiction after the capped rental period of positive airway pressure (PAP), E0601, and their device requires a repair, who is responsible for that repair?
A7. If as the supplier, you were paid for the full 13 month capped rental period, it is your responsibility to provide a working device for the full five-year reasonable useful lifetime (RUL). This means that if a repair is required, you are responsible to make that repair regardless of where the beneficiary lives or help the beneficiary get a repair done in their current area or jurisdiction.
Q8. Please provide the exact requirements or policy that includes elements for a telehealth visit that DME may accept post Public Health Emergency (PHE)?
A8. At this time, we have not received any information from CMS as to what requirements will be enforced post PHE. As soon as we have any information on the post PHE requirements, we will begin to educate on them.
Q9. How do we bill supply fees for immunosuppressive drugs to Medicare Part B for transplant beneficiaries?
A9. Transplant beneficiaries must be eligible for and entitled to Part B DMEPOS Medicare prior to billing for DME. In order to receive payment for immunosuppressive supply fees (Q0510, Q0511 and Q0512), the associated immunosuppressive drugs must be covered by Medicare. Please refer to the following path for more information: Noridian Medicare Home page > Browse by DMEPOS Category > Immunosuppressive Drugs.
Q10. I am a non-participating provider. Can a supplier submit claims non-assigned for certain DME?
A10. Suppliers who chose to be non-participating may submit claims non-assigned. Participating vs. non-participating supplier information can be found on the National Provider Enrollment (NPE) contractors' websites:
Q11. How do we bill infusion pumps when the pump is only used for one infusion per month?
A11. The medical records must support the coverage criteria. Regardless of the number of days of use per month (whether it be one or 30), Medicare would require the coverage criteria be met for payment. Please refer to the following path for more information: Noridian Medicare Home page > Browse by DMEPOS Category > External Infusion Pumps.
Q12. Why do the multi-function ventilators (E1399) continue to deny out for need each month in Jurisdiction D when Jurisdiction A pays?
A12. Education is not able to speak to why individual claims are denying. Please reach out to the Contact Center for claim specific questions.
Verbal Questions Received During ACT
Q13. We received a denial and are appealing because the clinic failed to bill with the discharge date. What do we need to include? Does the clinician need to document anything regarding the two-day rule in their notes? Do we as the supplier need to document that we delivered within the two-day rule?
A13. Suppliers should bill with the date of discharge. The discharge information does need to be in the facility's medical records. Suppliers may want to confirm with the beneficiary that discharge actually occurred.
Q14. We have beneficiaries going into the clinic when they are in a skilled nursing facility (SNF) and when we run eligibility, it doesn't show a SNF stay. There is a rule for custom items that if an item is ordered prior to a SNF stay, we can bill with the order date. Where is that located?
A14. The order date cannot be used as the date of service for billing. However, the Medicare Claims Processing Manual Chapter 20 Foreword states: "The DME, prosthetic/orthotic devices (except customized devices in a SNF), supplies and oxygen used during a Part A covered stay for hospital and skilled nursing facility (SNF) inpatients are included in the inpatient prospective payment system (PPS) and are not separately billable." So, if you receive a denial when billing the custom item on the actual DOS, we suggest you appeal.
Q15. When Medicare Advantage Plans aren't following Medicare guidelines, what should we do?
A15. Noridian is a Fee-for-Service (FFS) Medicare Administrative Contractor (MAC) and are unable to respond to other insurance company policies, including Medicare Advantage Plans.
Q16. Regarding high frequency chest wall oscillation devices, is there anything in writing that shows what is considered well documented treatment?
A16. The treating practitioner will need to document clearly what has been tried and why the beneficiary has a need for this device.
Q17. We appealed an overutilization denial and it was dismissed because we didn't appeal the original denial of CO-16 due to a name mismatch. Have the guidelines changed in which claim is appealed?
A17. There is no change in claims processing. Claims that deny with an appealable denial such as reason code 16 and remark codes N264, N575, and MA13 must be appealed within 120 days. Even if a claim was reopened or resubmitted, the time limit for filing an appeal is still 120 days from the initial claim determination.
Q18. Medical records no longer need to be updated every 12 months if medical necessity was established originally. If we've been servicing a beneficiary for five years and the initial medical records support the need, we understood that a denial would not occur. Is that correct?
A18. There are some policies this affects, such as ostomy supplies and urological supplies. For these items, the initial justification for medical need establishes that the condition necessitating the item is permanent. As a result, once the benefit category is met (or continues to be met), ongoing documentation of medical need is not required for those specific policies.
Q19. We are a paperless office. We like to make sure the reviewer can pinpoint where the medical necessity is in the notes and were told we cannot put an arrow in the documents. Is this correct?
A19. Suppliers can add a latter or note to indicate where the information is; however, medical records should not be altered.
Q20. If a physician indicates a beneficiary needs a ventilator permanently and the beneficiary is ordering supplies, that proves they are using it. Do we still need the physician to document they need the supplies?
A20. Continued medical need is still a requirement for most policies. The only policies that do not require the continued medical need are ostomy and urological supplies. All of the other policies must still follow the continued medical need guidelines in the Standard Documentation policy.
Q21. When was the requirement for continued need for urological supplies removed and is it by date of service?
A21. This was changed on July 26, 2020, and it is by date of service. Once the permanency has been established, medical records are not needed every 12 months unless there is a change in the beneficiary's condition.
Q22. We faxed an Advance Determination of Medicare Coverage (ADMC) on October 21 and only three pages were received but I faxed 32. When I called to verify it was received, the recording said it was. Now I received a denial because it was missing paperwork, but it was a fax issue. I don't want this beneficiary to wait another 20 days, so I refaxed this packet. Is there anything I can do in the future to prevent this from happening again?
A22. Suppliers can call our Supplier Contact Center around three days after faxing to speak to a representative to verify how many pages were received.
Written Questions Received During ACT
Q23. Due to a recent update to the respiratory assist device (RAD) policy, when qualifying a beneficiary for a RAD device for the diagnosis of Central Sleep Apnea, am I correct in assuming a home sleep study may be used to qualify the beneficiary for coverage?
A23. Home sleep testing is accepted under the respiratory assist device (RAD) policy.
Q24. What is the formula used for determining the allowable amount for L7510 (prosthetic repair) and L5999 (lower extremity prostheses, not otherwise specified)? Is it based off manufacturer's suggested retail price (MSRP)/ or cost invoice?
A24. When there is no fee schedule, gap-filling is utilized. This methodology takes into the account fee schedule amounts of other DME MACs, supplier price lists, and manufacturer wholesale pricing. This information can be found on our website > Education and Outreach Tab > Supplier Manual > Chapter 12. When billing add the Supplier Price List (PL) to the narrative of the claim. For more information see the article Billing Not Otherwise Classified (NOC) HCPCS Code on our website.
Q25. For code L7510 is there a price threshold that automatically generates a denial? We have been getting denials for that code and we are following the line description Medicare is requiring.
A25. There is not a price threshold that generates a denial for L7510. Because we cannot see the denials, you would have to do a redetermination with all documentation to support the item ordered. You should contact the Provider Contact Center for your Jurisdiction to look at those specific claims.
Q26. When submitting claims to Medicare as a secondary payor the first code on the claim is being paid as if Medicare is primary. The additional codes are being processed correctly as the secondary payor. Why is this happening?
A26. Please reach out to our Contact Center for your Jurisdiction to review the claim.
Q27. We have been receiving oxygen orders for cluster headaches. Can we accept these orders before January 1, 2023?
A27. Under the current LCD, treatment of cluster headaches with oxygen is only payable if the beneficiary is enrolled in a clinical trial.
Q28. We have a beneficiary that has been unable to use his PAP device for a year due to the recall. He is not eligible due to same/similar. The provider has documented that up until the recall, he was consistently using the machine for years. Where is the written policy that shows we do not have to have the beneficiary retest?
A28. We do encourage the documentation to be thorough, justifying the break in use due to the recall. Billing may resume once they have and are using the replacement device.
Q29. I thought that the E0986 (push-rim activated power assist option) was a purchased item when provided with a K0005 ultralightweight wheelchair. I understood that the K0005 is considered a complex wheelchair but noticed in the Pricing, Data Analysis and Coding (PDAC) this is a rental only. Is this correct?
A29. Correct, the E0986 is only a rental item. However, the K0005 can be purchased or rented.
Q30. If Medicare retracted their money for rental oxygen and the denial states patient responsibility, can we choose to not bill the beneficiary and just add another month onto the end of the billing cycle?
A30. An additional rental month may be billed at the end of the rental period. For claim specific questions contact our Supplier Contact Center.
Q31. If the beneficiary elects to have a Group 3 power chair as a purchase, can we bill out for single lump sum payment or do we bill it as a rental?
A31. Complex rehabilitative power wheelchairs (HCPCS codes K0835-K0843 and K0848-K0864) and options/accessories furnished for use with a complex rehabilitative power wheelchair can be either rented or purchased. For more information on power mobility devices (PMDs) see our website > Browse by Topic > DMEPOS Payment Categories > Capped Rental Items.
Q32. We are having issues with K0005 and E1161 custom chairs. The base code is paid and all the accessories to the chair are denied. We have called several times and get a different answer every time. Some say add the KU modifier and others say add the KY modifier. I hate just resubmitting many times with different configuration. Can you tell me what modifiers need to be on a custom wheelchair in order to be paid?
A32. The KU and KY modifiers have a listing of accessories that require the modifier. More information on which codes require this is on our Modifiers page listed under Browse by Topics.
Q33. For the multi-function ventilators that have less than the five options, the E1399 (miscellaneous DME) continues to deny out each month after it was deemed payable. It is a monthly rental and the beneficiary is not required to show continued need prior to a year so we continue to send in the same documentation over and over each month but it keeps denying. Region B and C do process for payment without having to appeal each month. The contact center tells me this is how the system is set up.
A33. Because the issue appears to be claims specific, and because jurisdictions process claims differently based on their interpretations of the policy, we would again encourage the supplier to call the contact center. If they are needing more information than they receive from the contact center, please escalate the concern.
Q34. When is the next round of competitive bid going to be announced?
A34. CMS has not announced future rounds of competitive bidding at this time. Please watch our website for updates.
Q35. A prescriber orders an initial polysomnogram (PSG) for a beneficiary. During the PSG, a titration is conducted, and the beneficiary's apnea-hypopnea index (AHI) decreases to a point that the obstructive sleep apnea (OSA) is resolved/adequately treated. However, the beneficiary continues to desaturate. Can that beneficiary be simultaneously qualified for PAP therapy and oxygen, or must the beneficiary use the PAP compliantly for 90 days and then get qualified for the oxygen?
A35. If the beneficiary meets the coverage criteria for both policies (oxygen and PAP), they would quality for both.
Q36. For an E0483 (high frequency chest wall oscillation device), is chest percussion therapy being ruled out due to not having a caregiver available to provide the therapy alone enough to hit the criterion 4 requirement of well-documented treatments to mobilize secretions?
A36. Not having a caregiver available would not meet criterion 4.
Q37. After the beneficiary goes in for their re-evaluation with the doctor, has something changed in the PAP/RAD policy which requires the beneficiary to go back every four months in order to get new supplies?
A37. The LCD requires a re-evaluation between the 31st and 91st day which documents symptoms are improved and objective evidence of adherence. Following the trial period, the requirement is for on-going medical need to be documented every 12 months.
Follow-Up Question: After that four-month re-evaluation, is that the only time the beneficiary needs to go back to the doctor for re-evaluation? Did anything change in the policy stating the beneficiary has to go back when they need new supplies?
Answer: Yes, that is the only re-evaluation required by the PAP LCD. The only other thing to keep in mind is having timely (within 12 months) documentation on file to support continued medical need.
Q38. I was told on a few other webinars that the reorder of supplies from the beneficiary would suffice to show continued medical need. Is this correct?
A38. Correct, a new order is an option listed in the Standard Documentation article to show continued medical need.
Q39. Can you provide information on where to find the process to reactivate a DMEPOS supplier?
A39. For information on renewing DMEPOS supplier enrollment, see the CMS revalidation website.
Q40. Your website says repairs can be completed by any DMEPOS supplier and that the initial supplier is not required to do the repair. This seems to conflict with your pre-submitted Q&A.
A40. The supplier that issued and was paid for the equipment must ensure the equipment is in good working order for reasonable useful lifetime of the item. If the beneficiary requires repair, the original supplier should either complete the repair or help the beneficiary find another supplier to help repair the item. For more information, see CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15.
Q41. Can a home health agency perform an oxygen qualifying test in the beneficiary's home?
A41. The qualifying blood gas study must be performed by a treating practitioner or by a qualified provider or supplier of laboratory services while the beneficiary is in a chronic stable state of health. With the exception of overnight oximetry, unsupervised or remotely supervised home testing does not qualify as a valid test for the purpose of Medicare reimbursement of home oxygen and oxygen equipment.
Q42. If an old sleep study was scored at 3%, is it ever acceptable to be calculating total apneas/total sleep x60 to check what the score would have been at 4%? Is the beneficiary's only option a resleep if the original study did not include 4% scoring?
A42. Only sleep studies that are scored at 4% are considered acceptable for coverage criteria to be considered met. If the sleep study can be rescored that would be acceptable. If not, the beneficiary would require a new study that meets the Medicare requirements.
Q43. Can you clarify if for a refill request for consumable supplies that the quantity remaining must be less than 10 days remaining at the time of the reorder or may they have 14 days remaining and we do not deliver until at least four days later so they would have 10 days remaining at the time of delivery?
A43. For consumable supplies, contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the expected end of the current utilization period. For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. You can find that information under the Policies tab > Medical Director Articles > 2021 > Items Provided on a Recurring Basis and Request for Refill Requirements - Annual Reminder - January 2021.
Q44. Is oxygen considered a drug under the mandatory assignment for covered drugs billed to Medicare?
A44. Yes, oxygen is considered a drug. A Medicare participating supplier is one who voluntarily enters into an agreement to accept assignment for all services furnished to Medicare beneficiaries during a 12-month period, beginning January 1 of each year. Suppliers who choose not to sign the participation contract are referred to as nonparticipating suppliers. Nonparticipating suppliers may choose to accept assignment on a claim-by-claim basis except where CMS regulations require mandatory assignment (i.e., Medicare covered drugs, Indian Health Services). Accepting assignment means accepting the Medicare approved amount as payment in full.
Q45. Can a supplier dispense an L1833 (knee orthosis) prior to receiving a prior authorization decision?
A45. In the case of an emergency need for the brace, where a two-day prior authorization (PA) request is not feasible, the orthoses maybe dispensed without getting a PA. The supplier must append the ST modifier to the claim for the orthoses. The claim with the ST modifier will be stopped for medical review and the supplier will receive an additional documentation request letter asking for documentation to support the emergent need of the brace and medical necessity of the brace. In instances where the brace is not needed emergently, PA is required, a brace cannot be provided until PA is obtained.
Q46. Does the physical exam need to include objective measurements of strength, endurance, etc., to support a beneficiary is unable to self-propel a standard manual wheelchair (MWC) but can self-propel a lightweight wheelchair or can a simple statement of this be sufficient?
A46. Objective information regarding ability to propel should be included in the exam of the beneficiary. The evaluation should be tailored to the individual beneficiary's conditions. The history should paint a picture of the beneficiary's functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the beneficiary's activities of daily living difficulties or what impact on the beneficiary's abilities.
Q47. A beneficiary now has Medicare, but his/her current wheelchair was covered/paid for by another insurance (that he/she had prior to Medicare). This beneficiary needs repairs to his/her current wheelchair now. We cannot determine whether this beneficiary qualifies for a wheelchair per Medicare policy. In order for Medicare to cover the repairs on this beneficiary-owned wheelchair, what information do we need to have on file/submit to Medicare to prove that this beneficiary qualifies for wheelchair repairs?
A47. Repairs to items that a beneficiary owns are covered when necessary to make the items serviceable. Beneficiary-owned equipment must be medically necessary, the wheelchair would need to meet the requirements of the LCD through the medical records. For more information on beneficiary-owned equipment see our website under Browse by Topic > Repairs, Maintenance and Replacement > Repairs.
Last Updated Tue, 20 Dec 2022 19:53:01 +0000