Provider Outreach and Education Advisory Group (POEAG) Minutes - October 23, 2024 - JA DME

Attendees

Members: Cassandra Basham; Wayne Bradberry; Kim Brummett; Dawn Cetti; Patty Donndelinger-Bogyo; Rebecca Erickson; Jason Freeman; Pamela Fritz; Lisa Gannon; Rosa Gomez; Kimberly Hanson; Crissy Hill; Dawn Jorgensen; Tugba Koca; Maria Koehnlein; Carolyn Koster; Jeannette Leon; Marsha Lawrence; Carol Lernihan; Februari Lester; Anna Markiewicz; Marisa Mort; Bill Noyes; Noel Neil; Yvette Nugent; Jan Palmer; Kimberlie Rogers-Bowers; Kristi Sanders; Mary Stoner; Heather Werner; Michelle Wullstein; Jon Shreter

Noridian: Amber Mertz; Ashley DeCoteau; Brenda Swancy; Colleen Harryman; Corinne Medina; Kelsey Slettebak; Mary Reineke-Ferguson; Shelly Carlson; Tracy Schutt

POE Advisory Group Mission and Goals

Mission

• To determine the best methods of providing quality education and training to our supplier community.

Goals

• Develop timely, useful, relevant educational opportunities for our suppliers
• Provide input in the creation, implementation and review of Provider Education and Training
• Determine innovative, cost effective methods of using technology in provider education and training CMS Internet Only Manual (IOM), Publication 100-09, Chapter 6

Standing Items

• Education for practitioners
  • Continue to seek opportunities
• Collaborative MAC education
  • A/B DME Workgroup
    • Lower Limb Orthoses: December 17, 2024, at 11 a.m. CT

Follow-up from Previous Meeting - General

• Level 200 webinars
  • Please send scenarios you would like to see included
    • Send to DME POEAG email (DMEPOS-POEAG@Noridian.com)
• Supplier complaints due to differences between CGS/Noridian processes
  • None currently

Follow-up from Previous Meeting - O&P

Level 200 webinars: Lower Limb Prosthetics (LLPs) scenarios

• Please send scenarios you would like to see included to the POEAG email (DMEPOS-POEAG@Noridian.com):
• Member concern: Education is lacking in modifier use with the prefabricated for custom fit codes without a mirrored off-the-shelf code (the -99 codes), when the code technically requires the KX modifier, but the system doesn't allow this. Can this information be included in upcoming education?
  • When suppliers are utilizing a miscellaneous code for billing, i.e. L2999 or L3999, and laterality is involved, they must append the LT or RT modifier to the claim line. Also, if the policy requires a liability modifier, it must also be appended, i.e. KX for L2999.
  • Webinars and Modifier Lookup Tool were updated with this information
  • Printed articles: Noridian website > Browse by DMEPOS Category > Orthotics > Correct Billing for Custom Fitted Orthotics When No Custom Fitting is Completed with No Off-the-Shelf Equivalent, and Noridian website > Fees and News > Latest Updates > Update for Billing Custom Fitted Orthotics When No Custom Fitting Is Completed with No Off-the-Shelf Equivalent Available (September 18, 2024)

New Items

General

• Ask the Contractor Meeting (ACM)
  • Scheduled for November 7, 2024, 2 p.m. CT
  • General - all topics
• Effective October 1, 2024, through January 6, 2025
  • Capecitabine billed as J8999 (prescription drug, oral, chemotherapeutic, NOS)
    • Include drug name Capecitabine in narrative on claim
  • Dates of service on/after January 7, 2025
    • Capecitabine resumes billing with new HCPCS J8522
    • Discontinue billing with J8999
• Effective October 1, 2024
  • Suppliers discontinue billing HCPCS J1170 (Injection, hydromorphone, up to 4 mg)
  • Bill hydromorphone with HCPCS code J1171 (Injection, hydromorphone, 0.1 mg)
    • J1170 will be removed from HCPCS tables and J1171 will be added
  • Suppliers should utilize HCPCS J1171
  • No changes to the policy requirements for hydromorphone
  • KX, GA, GY, or GZ modifier must be appended to the claim line or will be denied
• Reminder: Methotrexate billed as J8999 effective July 1, 2024, through September 30, 2024
  • Include drug name in narrative
  • On/after October 1, 2024, resume billing Methotrexate with new national drug code (NDC)
    • Discontinue billing with J8999
  • Do not bill with newly established HCPCS codes J8611 (Methotrexate (Jylamvo), oral, 2.5 mg) or J8612 (Methotrexate (Xatmep), oral, 2.5 mg)

DME

• Drugs used as Preexposure Prophylaxis (PrEP) to prevent HIV infection
  • Effective for dates of service on/after September 30, 2024, FDA approved oral or injectable PrEP antiretroviral drugs are a covered DME benefit for the prevention of HIV
  • Practitioner determined beneficiary is at risk for HIV (covered ICD-10 diagnosis)
  • Medical records support
  • Enrolled as DMEPOS supplier
  • CMS website: PrEP for HIV and Related Preventive Services
• Prior authorization suspended for osteogenesis stimulator (OS) codes
  • E0747, E0748, E0760
  • Effective August 28, 2024
  • Suspension due to continued confusion over some noninvasive OSs and whether they comply with three-year expected life requirement
• Retirement of Pneumatic Compression Devices Local Coverage Determination (LCD) and Related Policy Article
  • Effective November 14, 2024
  • Pneumatic Compression Devices Coding and Billing article released
  • Suppliers to utilize the National Coverage Determination (NCD) 280.6
  • Noridian Medicare website > Policies > Medical Director Articles > 2024 > Retirement of Pneumatic Compression Devices Local Coverage Determination (LCD) and Related Policy Article - Effective November 14, 2024

O&P

• Lower limb prosthetics (LLP) LCD and Policy Article changes effective September 1, 2024
  • Claims for all LLP HCPCS codes will be denied/rejected without one of these modifiers appended:
    • KX, GA, GZ, or GY, and LT or RT modifier
  • HCPCS codes L5615 and L5841 will now require K0-K4 modifier
  • Following HCPCS codes can be allowed with K2-K4 modifier and KX modifier (previously had to be K3 or K4 modifier)
  • L5973, L5976, L5979, L5980, L5981, L5987, L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841 (new code effective 04/01/24), L5848, L5856, L5857, L5858
• Reminder: L1833 (knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf) requires prior authorization only for dates of service prior to August 12, 2024
• Reminder: Codes added to the Required Prior Authorization List
  • Effective for dates of service on/after August 12, 2024
    • Knee orthoses: L1843, L1845, L1951
    • Spinal orthoses: L0631, L0637, L0639
• Reminder: L1833 requires a face-to-face encounter and written order prior to delivery only for dates of service prior to August 12, 2024
• Reminder: Codes added to the Required Face-to-Face and Written Order Prior to Delivery List
  • Effective for dates of service on/after August 12, 2024
  • Knee Orthoses: L1845, L1852
  • Spinal Orthoses: L0635, L0636, L0638, L0639, L0640, L0651

General Questions from POE Advisory Members

• I have a claim that keeps getting rejected for HCPCS Code L4387 with the NU, KX and LT modifier. Common Electronic Data Interchange (CEDI) has said it is the modifiers, but we can't figure out what we're doing wrong. Can you advise?
  • NU is not a valid modifier to use for L4387. If you follow the Modifier Lookup Tool, you only need the RT or LT as well as either KX, GA, or GZ.
  • Noridian website > Browse by Topic > Modifiers > Modifier Lookup Tool
• Do you know what the CMS Enrollment Timeliness Standard is for processing the 855S?
  • The average processing times are 45 calendar days for web applications and 60 calendar days for paper applications. However, some of the MACs are able to process applications in advance of these timeframes. You can find this information on the National Provider Enrollment Conference Frequently Asked Questions posting on the CMS website.
• Are there any talks of a National Coverage Determination (NCD) or LCD being established for the newly added HCPCS code E0469 (lung expansion airway clearance)? Do you have any advice as to how to get these covered by Medicare with no coverage guidelines established yet?
  • At this time, we are not aware of an NCD or LCD being established. Once we are given information we will educate at that time.
    • To follow up to the E0469 being recently added to the fee schedule, if there is a fee schedule established by CMS are we able to bill and appeal denials with medical necessity or are these not billable until an NCD/LCD is published?
      • As of October 1, 2024, E0469 is a valid code and can be appealed with medical documentation supporting the medical necessity.
• Was the Pneumatic Compression Devices webinar in November cancelled?
  • This webinar is delayed due to the policy change. It will be scheduled and suppliers can re-register once it is posted to the Schedule of Events.
• Regarding HIV prep, is there a prescription requirement for this?
  • All items billed to the DME MAC require a Standard Written Order and documentation practices must be followed.
• With the change in September regarding the prescription not being considered as part of the medical record, can Noridian comment on any implications?
  • There are no specific changes to policies. The medical records must still substantiate what is on the order.
• When does the hydromorphone code go into effect?
  • This is effective October 1, 2024.
• A member has examples for the LLP L200 webinar. Is Noridian looking for anything specific?
  • All examples are appreciated.
• Some flexibilities are in place in areas affected by natural disasters but they apply only to certain geographic areas. We have shortage issues nationwide due to damage in those certain areas. Is there a way to extend flexibilities beyond the affected areas.
  • Noridian cannot extend flexibilities. Suppliers can reach out to CMS with issues.
• At the end of the PHE in 2023, Medicare extended the telehealth waiver until the end of this year, regardless of the beneficiary location. Do you have information on extending this beyond the end of this year?
  • Noridian has not received additional information at this time but will share as soon as we receive it.

Suggestions from POE Advisory Members

• Can a power wheelchair rental calculator and a purchase price calculator be added to the Noridian website?
• Can the External Infusion Pump calculator be updated to reflect the code changes?
• On the CGS LLP Documentation Checklist, everything is listed so it's all together with quick access. On the Noridian checklist, there are links to each type of documentation so there is flipping between the checklist and the Policy Article. Is it possible to update the checklists so all of the information is listed?
• Can Advance Determination of Medicare Coverage (ADMC) be added to the Noridian Medicare Portal?
• Can a diagnosis tool to identify payable diagnosis codes per policy criteria be created? You could enter a HCPCS with an ICD-10 and it would tell you if it's payable per the policy. This would be particularly helpful for the knee orthosis policy that has so many payable diagnosis codes, many of which are listed in ranges in the policy article so it's difficult to search for them.

Upcoming Meeting

Next Meeting: TBD