ACT Questions and Answers - November 15, 2017

Website Survey - Noridian encourages suppliers to complete the ForeSee Survey on the Noridian website by clicking yes, "I'll give feedback." Noridian values visitors's input and feedback to continue to enhance the website. We review every comment/response sent to us from the website survey and take into consideration any change or improvement we can make to our website, the portal or even our Outreach and Education. Please take the survey every few months to tell us how we're doing.

New Medicare Card Project - Formerly known as Social Security Number Removal Initiative (SSNRI). The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) requires CMS to remove Social Security Numbers (SSNs) from all Medicare cards. A new randomly generated Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards for transactions like billing, eligibility status, and claim status. Beginning April 1, 2018 Medicare cards will be issued without a HICN, and; April 2019 all new and existing Medicare beneficiaries will have been issued a new Medicare card. The transition period for claims processing will begin April 1, 2018 and run through December 31, 2019. During the transition period claims will be accepted with either a HIC number or MBI. View the CMS New Medicare Card Project Milestones Chart that displays the project timeline.

Electronic Supplier Visit (E-Visit) - E-Visits are a free customized educational opportunity that Noridian offers to all suppliers. Suppliers can work directly with an Educational Representative and/or a Medical Review Nurse during this time. This education is scheduled to fit specific needs and takes place electronically through GoTo Meeting allowing continuous open dialogue. Prior trainings have included a review of policy information, specific questions, and discussion of claim denials amongst other things. Supplier's referral sources are encouraged to attend as well. Let us know what you would like to discuss and we can get it scheduled for you. Access the request from the Noridian Educational Forms webpage.

Target Probe & Educate (TPE) - The TPE program is taking the place of the widespread reviews previously conducted by Medical Review. The goal of the TPE program is to improve the claims error rate and reduce the volume of appeals through claim review and education. Suppliers identified for TPE will receive written notification of the review which will include 20-40 claims followed by one-on-one education to address the errors. There will be up to three rounds of review for each supplier in the program. Suppliers with a moderate to high error rate after the first round will continue to the second round, those that maintain a moderate to high error rate will move to a third round of reviews. Suppliers with continued high error rates after three rounds may be referred to CMS for additional action.

Noridian Medicare Portal (NMP)- Self Service Reopenings – These have expanded to include additional options for supplier. It allows real-time adjustments for claim corrections. Visit our NMP webpage for more information.

Electronic Fund Transfer (EFT) - This is the required method of Medicare payment for all suppliers entering the Medicare program for the first time and for existing suppliers that are submitting a change to their existing enrollment record but are not currently enrolled in EFT. Visit the Electronic Funds Transfer webpage for more information.

DME On Demand - There are various topics available to accommodate supplier's learning needs which include an overview of different Local Coverage Determinations (LCDs), various forms that are used in DME such as the Advance Beneficiary Notice of Noncoverage (ABN), Certificate of Medical Necessity (CMN), DME Information Form (DIF) and the CMS-1500 claim form. There is a section dedicated to the use of NMP and several different sessions on documentation requirements. A completion certificate is provided via email following completion of a module and some sessions contain quizzes.

Resources and Reminders

  • Announcements - The POE team will be implementing separate Durable Medical Equipment (DME) and Orthotic and Prosthetic (O&P) Provider Outreach &Education Advisory Group (POEAG) groups. This is effective January 2018. More information to come!
  • Email Updates - Suppliers are encouraged to register for the Noridian listserv which provides informative emails on Tuesdays and Fridays. Users can customize the listserv to their business needs. See the Email List Sign Up webpage for details and registration link.

Q&A Session

Q1. The Knee Orthoses (KO) LCD specifies that certain KOs are covered if the beneficiary has recent injury or surgical procedure on the knee. What is Noridian's definition of "recent" as it pertains to this LCD.
A1. As defined by the medical directors, "recent" is considered within the past 30 days.

Q2. Can a supplier use the positive airway pressure (PAP) sleep study for the replacement reasonable useful lifetime (RUL) that the beneficiary has requested or is the beneficiary required to have another sleep study signed by a Sleep Board Certified doctor that is in practice today? Why doesn't the timely documentation of 12 months apply (Standard Documentation Requirements (A55426))?
A2. A sleep study performed and authenticated by a Physician who is properly licensed and credentialed is still valid today if all current coverage criteria is met.

For beneficiaries who are seeking Medicare coverage of a replacement PAP device outside the 5 year RUL, the Face-To-Face (F2F), 5 element order (5EO), and proof of delivery (POD) must be submitted upon request. The face-to-face evaluation required for an RUL must be completed by the beneficiary's treating physician and should document that the beneficiary continues to use and receive benefit from the CPAP device. There is no requirement for a new sleep test or trial period.

Q3. The Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (Formerly CPAP) LCD allows for a supplier to dispense "not more than a three-month quantity at a time."  Is there a requirement for a narrative note or modifier? 
A3. Suppliers should include a narrative for the three-month supply on the claim. The narrative can be "3-month supply" or "90-day supply." This narrative allows the claim(s) to be processed correctly. There is no modifier for the number of months of supplies delivered/shipped (except National Mail Order (NMO) suppliers who use the KL modifier for shipping diabetic supplies).

Q4. There are times when beneficiaries whose original sleep study was performed before he/she entered Fee for Service (FFS) Medicare. In those studies, hypopneas were scored with a 3% desaturation. One physician states that if the beneficiary's apnea-hypopnea index (AHI) is greater than 5, the AHI is irrelevant and, therefore, a new study is not required. The Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (Formerly CPAP) LCD refers only to "AHI" not "apnea index (AI)." Can a supplier provide services in this case? Does this study meet the Medicare criteria in effect at the time the beneficiary seeks Medicare coverage of supplies or a replacement PAP device?
A4. No. This scenario does not meet current Medicare coverage criteria. A study with only an AI does not meet coverage criteria as stated in the LCD. To meet Medicare coverage criteria, all sleep studies must have a qualifying AHI or a respiratory disturbance index (RDI). Medicare's definition of hypopnea requires interpretation based on a 4% desaturation. The 4% scoring criteria was a part of revisions to the LCD effective January 1, 2006. If a beneficiary had a sleep study prior to Medicare, the sleep study must meet guidelines in effect at the time the beneficiary enters Medicare. If it does not, the beneficiary must have a new study.

Q5. A supplier has had many CURES Act adjustments recouped for HCPCS A7000. They also have a different Remittance Advice (RA) with a large recoupment but the document control number (DCN) is not linked to a specific beneficiary. Is this related to CURES Act as well? When the Supplier Contact Center (SCC) is called, the customer service reps are unable to provide any answers to explain why this is happening. Please address why this is happening and what can be done to fix this issue going forward.
A5. There may be some claims adjusted that result in a potential overpayment from the CURES Act adjustments. These may be due to beneficiaries in a skilled nursing facility (SNF), home health agency (HHA), etc. for the date of service on the claim. Contact the SCC and request the concerns/questions be referred to the recoupment team. Please provide sufficient details in the request. For additional clarification, see the CR9968 CURES Act Fee Schedule Adjustments webpage.

Q6. What documentation is required to justify a custom ankle foot orthosis (AFO), custom back braces, etc. Is this something that the physician must document, or can the fitter document it? Is there any suggested wording?
A6. For custom fabricated orthoses, there must be detailed documentation in the treating physician's records to support the medical necessity of custom fabrication rather than a prefabricated orthosis as described in the Coverage Indications, Limitations and/or Medical Necessity section of the related LCD. This information will be corroborated by the functional evaluation in the orthotist or prosthetist's records and must be available upon request. There is no "suggested wording" as it must be specific to the individual beneficiary's needs.

Q7. Is oxygen ever covered for pneumonia?
A7. Oxygen coverage is not based on diagnosis. The medical records must support that the beneficiary has a severe lung disease or hypoxia-related symptoms or findings that are expected to improve with oxygen. Those conditions must be very clearly documented within the beneficiary's medical record.


Last Updated Jun 19, 2019