ACT Q and A - November 11, 2021 - JA DME
ACT Questions and Answers - November 11, 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. Are there any exceptions for an E0482 (cough stimulating device) during the public health emergency (PHE)?
A1. During the PHE, the clinical indications for coverage are not being enforced for the E0482 per CMS-1744-IFC and CMS-5531-IFC. If a claim is being affected due to the pandemic, suppliers can bill with the CR modifier and narrative COVID-19 on the claim line.
Q2. I received a CO-261 denial. The provider side cannot help me, and the beneficiary cannot see the claim. How do I resolve this for payment?
A2. For all claim specific questions please contact the provider call center at the numbers provided here.
- Jurisdiction A: 866-419-9458
- Jurisdiction D: 877-320-0390
Q3. Have updated PureWick billing and coding guidelines been published?
A3. For the most up-to-date information, see the PureWick Urine Collection System- Coding and Billing Instructions article which was published by the medical directors on October 7, 2021: Noridian Medicare website > Policies > Medical Director Articles > 2021 > PureWick Collection System-Coding and Billing Instructions.
Q4. In regard to five-year oxygen renewal, when a beneficiary has an oxygen concentrator (E1390) or a portable gas oxygen system (K0738), does the face-to-face (F2F) need to be within the last six months or 12 months?
A4. There is no requirement for a F2F or physician visit for replacement of oxygen equipment due to reasonable useful lifetime (RUL), however, there must be evidence of on-going medical need within the past 12 months. Currently that can be accomplished with obtaining a new initial CMN.
Q5. Can you provide information regarding the upcoming changes in the oxygen National Coverage Determination (NCD)?
A5. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) are in the process of revising the Oxygen and Oxygen Equipment Local Coverage Determination (L33797) and the related Policy Article (A52514) to reflect the national CMS policy changes to NCD 240.2 and the removal of NCD 240.2.2. If there are any further updates we will tailor our education to reflect these changes. Keep in mind that while CMS has published their decision memo, these changes are not yet in effect. Please see the updated oxygen decision memo.
Q6. How do suppliers get doctors to make note of foot deformities such as bunions, hammertoes, etc.?
A6. Suppliers can send practitioners the clinician resource letters and clinician checklists or refer the practitioner to the Noridian website where these are located. These resources will help the practitioner understand what is needed in order for Medicare to cover what they have ordered for their patient: Noridian Medicare website > Clinicians Corner.
Q7. Can you get an exception to a piece of Durable Medical Equipment (DME) that falls under same or similar?
A7. Same and similar denials can be appealed with documentation to support change in medical need, lost, stolen, or irreparable damage etc. For policy-specific information on when an item can be replaced within the RUL, refer to the policy-specific Local Coverage Determination (LCD) and policy article which can be accessed from the Noridian website under Policies > Active LCDs. If there is reason to believe that an item will deny for same and similar, and there has been no change in condition, suppliers can obtain an Advanced Beneficiary Notice of Non-coverage (ABN).
Q8. How do we bill quantities of Durable Medical Equipment (DME)?
A8. The best place to start for suppliers that are new to billing Medicare is the New Supplier Training Opportunity and Checklist located on the Noridian website under Education and Outreach > New Supplier New Biller > New Supplier Training opportunity and Checklist.
Billed quantities depend on the policy, refer to the policy-specific LCD and policy article which can be accessed from the Noridian website under Policies > Active LCDs.
Q9. When will there be more clarification available regarding oxygen billing under CR COVID-19 and actual Certificates of Medical Necessity (CMNs) under same and similar?
A9. CMS published an oxygen decision memo detailing changes to the oxygen NCD effective September 27, 2021. However, CMS has not provided guidance on implementation of those changes to date. As a result, while the changes are effective, they have not been implemented. When we receive directive from CMS, education will begin.
Verbal Questions Asked During ACT
Q10. The question I have is in regard to a newly designated K code, K1027(oral appliance) (October 1, 2021, First Biannual Coding Cycle, page 100-101, Request number 21.034) for oral appliances for the treatment of snoring and mild to moderate sleep apnea. Will this code be reimbursed going forward? Will the same criteria be required as described in A52512 as E0486 for diagnosis? Will the LCD L33611 be updated to reflect the K1027 code and when might that be? I did not see this code in the DMEPOS October 2021 fee schedule.
A10. This new code is not a part of the oral appliance for the treatment of sleep apnea LCD at this time. Only the E0486 (oral appliance) has been approved for coverage under that LCD. To be covered by Medicare the code must have PDAC approval and meet the definition of a Medicare device. The LCDs are reviewed annually by the durable medical equipment medical directors for potential updates and there is also the option for interested parties to file for LCD reconsideration.
Written Questions Asked During ACT
Q11. I have heard conflicting information on the positive airway pressure (PAP) recall. Is the supplier responsible to replace or is the manufacture required to? The cap was met.
A11. Suppliers are still required to provide replacement devices within the five-year RUL. See this article for more information: Frequently Asked Questions - Phillips Respironics Respiratory Products Recall - Revised
Q12. If a below the knee or above the knee amputee needs new prosthetic liners or sleeves, for example L5679, L5673, L5685, etc., does the beneficiary need to have a F2F with their doctor or can they simply obtain a new prescription from their doctor for those items?
A12. For liners, socks, and sleeves if the quantity is listed on the original standard written order (SWO) a new SWO would not be required. If the quantity is not listed on the SWO, a new SWO would be required.
Q13. When a beneficiary needs new therapeutic shoes and inserts, and they had their foot exam with their Doctor of Podiatric Medicine (DPM), what proof do I need to obtain from the primary care physician (PCP) showing that they are treating the beneficiary for their diabetes? Is the A1C test result sufficient from their PCP? What other methods would suffice?
A13. A new certification statement is required for a shoe, insert, or modification provided more than one year from the most recent certification statement on file. There must be information in the medical records of the certifying physician that documents the management of the beneficiary's diabetes and detailed information about the condition that qualifies the beneficiary for coverage: Therapeutic Shoes for Persons with Diabetes (TSPD) - Policy Article.
Q14. Can you please describe when to and when not to only use the HCPCS that shows on Pricing, Data Analysis and Coding (PDAC) for items? Which items are required to be on PDAC? Example: wheelchair accessories that do not show on PDAC as coded but by description fall into a HCPCS category? Manufacturers tell us they can only suggest a code.
A14. HCPCS codes approved and published by PDAC are the codes required to bill Medicare and if a code exists for the item that is the code that must be billed. If there is not an established HCPCS code for an accessory, the supplier may use a not otherwise classified (NOC) code and coverage determination will be made when the claim is billed. Please see the PDAC webpage for more information.
Q15. Regarding coding, if the manufacturer suggests a code, for example, L1812 for a hinged knee brace, but they do not have it coded on PDAC, may the supplier use the L1812 code listed on the manufacturer's website and product?
A15. Suppliers cannot use a manufacturer's suggested HCPCS code where that item has not been approved by PDAC. If the code is not approved and published by the PDAC then a not otherwise classified (NOC) code can be used. Refer to the LCD and Policy Article for the policy-specific NOC codes. Please see the PDAC webpage for more information.
Q16. Is is true that if a beneficiary changes insurances from a Medicare replacement back to Medicare fee-for-service that the supplier needs to have a new assignment of benefits/payment agreement if they are a supply-only beneficiary, even though an agreement was signed while the beneficiary was enrolled in the Medicare Replacement?
A16. That is correct because they are assigning benefits to a new payor.
Q17. What exactly are you looking for to make sure an Assistive Technology Professional (ATP) was directly involved in selection of the wheelchair? They attend the licensed/certified medical professional (LCMP) mobility assessment with it documented they were present. Additionally, the ATP provides measurements. Would that be sufficient?
A17. ATP involvement can be shown in a variety of ways. Documentation in the LCMP evaluation that the ATP was present is one way, providing documentation of an assessment of a beneficiary by the ATP is another. The requirement is that documentation shows in-person ATP involvement in the wheelchair selection.
Last Updated Mon, 06 Dec 2021 14:04:51 +0000