Medical Director Articles - 2018

Title Brief Description Last Updated
Correct Coding - RT and LT Modifier Usage Change Effective 3/1/19, suppliers must bill bilateral item on two separate claim lines using the RT and LT modifiers and 1 UOS on each claim line. 12/06/18
Correct Coding - 2019 HCPCS Code Annual View changes to Level II Healthcare Common Procedure Coding System (HCPCS) codes for 2019. 12/06/18
Correct Coding - U 500 Insulin for Use in External Insulin Infusion Pumps Recently the PDAC was notified by Lilly, the manufacturer of Humulin® R U-500 insulin, that its use in external insulin infusion pumps is considered "off-label." 12/06/18
Correct Coding and Coverage - Panzyga® (Immunoglobulin Intravenous (Human), 10%) Panzyga®is covered for claims with dates of service on or after August 2, 2018 when specific criteria are met. 11/29/18
Dear Physician Letter - Documentation of Artificial Limbs and Braces (O&P) - November 2018 [PDF] A recent amendment to the Social Security Act states that documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record to support documentation created by physicians and certain other non-physician practitioners for artificial limbs and braces. 11/13/18
Expanded Coverage of Blincyto® The expansion of Blincyto is outlined in this article which will revise the External Infusion Pump LCD 11/08/18
LCD Revisions Summary for November 1, 2018 Changes to the Lower Limb Prostheses LCD regarding weight range information related to L5859. 11/01/18
Topical Oxygen Therapy Used for Wound Care - an Update On April 03, 2017, CMS revised Section C of Hyperbaric Oxygen (HBO) Therapy National Coverage Determination (NCD 20.29) to remove non-coverage language addressing topical oxygen therapy (TOT), allowing the DME MACs the discretion to determine coverage which this article will summarize. 10/04/18
Topical Oxygen Request for Information Bibliography In the fall of 2017, the DME MACs posted a Request for Information (RFI) regarding topical oxygen therapy for wound care that ran from September 14 through October 30, 2017 (45 days) with a total of thirty-six articles for analysis. 10/04/18
LCD and Policy Article Revisions Summary for September 27, 2018 The principal changes to the DME MAC Local Coverage Determinations (LCD) for High Frequency Chest Wall Oscillation Devices, Mechanical In-exsufflation Devices, and Wheelchair Seating as well as Policy Articles (PA) for Oral Anticancer Drugs and Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) are outlined. Please review the entire LCD and related PA for complete information. 09/25/18
Revised Billing Instruction - Oxygen "Q" Modifiers and Medical Documentation For beneficiaries with a single prescribed flow rate that doesn't encompass a full 24 hours, an average is NOT required using "0" for the unaccounted for portion of the 24 hour period. 09/25/18
Clinician Resource Letters - Prior Authorization Condition of Payment for Certain Power Mobility Devices [PDF] Effective for power wheelchairs with dates of delivery on or after September 1, 2018, claims to Medicare must be associated with a prior authorization request as a condition of payment.    09/13/18
Policy Article Revisions Summary for September 13, 2018 The principal changes to the DME MAC Policy Article (PA) are outlined. 09/13/18
Policy Article Revisions Summary for August 23, 2018 The principal changes to the DME MAC Policy Article (PA) that has been revised and posted are outlined. 08/23/18
Correct Coding - A9286 - Hygienic Item or Device, Disposable or Non-Disposable, Any Type, Each In November 2017 the DME MACs published an article, Correct Coding - Hygienic Items Wash Cloths and Cleansing Wipes, explaining the correct coding for hygienic items. 08/16/18
Correct Coding - Porta-Lung Negative Pressure Ventilator - Revised This article has been updated to include a change in HCPCS code assignment for billing the Porta-Lung® negative pressure ventilator.      08/16/18
Correct Coding - Q9994 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH) Coverage Indicator Changed Effective for dates of service on or after July 13, 2018, the Medicare coverage indicator administrative field has been changed for code Q9994. Healthcare Common Procedure Coding System (HCPCS) code Q9994 (IN-LINE CARTRIDGE CONTAINING DIGESTIVE ENZYME(S) FOR ENTERAL FEEDING, EACH) was added to the Level II HCPCS code set effective July 1, 2018. 07/27/18
Policy Article Revisions Summary for July 19, 2018 The principal changes to the Policy Article for Positive Airway Pressure (PAP) Devices for Treatment of Obstructive Sleep Apnea are outlined.  07/19/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for a Drive Wheel Gear Box Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for a drive wheel gear box. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for a Wheelchair Headrest Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for a wheelchair headrest. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Battery Charger Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for a battery charger. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Battery Replacement Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for battery replacement. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Replacement of Wheelchair Seat and Back Upholstery Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for replacement of wheelchair seat and back upholstery. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Wheelchair Tray Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for a wheelchair tray. 07/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Wheelchair Ventilator Tray Recent reports have identified that suppliers are billing Healthcare Common Procedure Coding System (HCPCS) code K0108 (WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED) for a wheelchair ventilator tray. 07/05/18
Correct Coding - Replacement Cecostomy Tube A cecostomy is a surgery that makes an opening in the cecum. A non-latex tube or catheter is then placed in cecum in order to give an antegrade enema. 07/05/18
Dear Clinician Letter - Respiratory Assist Devices (RAD) for Restrictive Thoracic Disorders - June 2018 [PDF]

Medicare provides reimbursement for bi-level positive airway pressure (PAP) devices, with and without back-up rate, for the treatment of restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities) when certain specified coverage criteria are met.

06/28/18
Dear Clinician Letter - Respiratory Assist Devices (RAD) for Hypoventilation Syndrome - June 2018 [PDF]

Medicare provides reimbursement for bi-level positive airway pressure (PAP) devices, with and without back-up rate, for the treatment of hypoventilation syndrome when certain specified coverage criteria are met.   

06/28/18
Dear Clinician Letter - Respiratory Assist Devices (RAD) for Chronic Obstructive Pulmonary Disease (COPD) - June 2018 [PDF]

Medicare provides reimbursement for bi-level positive airway pressure (PAP) devices, with and without back-up rate, for the treatment of chronic obstructive pulmonary disease (COPD) when certain specified coverage criteria are met.

06/28/18
Dear Clinician Letter - Respiratory Assist Devices (RAD) for Central Sleep Apnea or Complex Sleep Apnea - June 2018 [PDF] Medicare provides reimbursement for bi-level positive airway pressure (PAP) devices, with and without back-up rate, for the treatment of Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA) when certain specified coverage criteria are met. 06/28/18
Dear Clinician Letter - Continuous Glucose Monitor - June 2018 [PDF] As of January 12, 2017, Medicare covers continuous glucose monitor (CGM) devices that are classified by CMS as "therapeutic CGMs." 06/21/18
Continuous Glucose Monitors - Use of Smart Devices Effective for claims with dates of service on or after June 7, 2018, the DME MAC Glucose Monitors LCD and related Policy Article is being revised. 06/21/18
Policy Article Revision Summary for June 21, 2018 The principal changes to the Glucose Monitor Policy Article is outlined. 06/21/18
Lower Limb Prostheses - Draft LCD and related PA - Retired The DME MACs have retired the draft Lower Limb Prostheses Local Coverage Determination (DL33787) and related Policy Article (A54517). 06/21/18
Policy Article Revisions Summary for June 14, 2018 The principal changes to the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea and Respiratory Assist Devices Policy Articles are outlined. 06/14/18
LCD and Policy Article Revisions Summary for June 7, 2018 The principal changes to the External Infusion Pumps and Oxygen and Oxygen Equipment LCD and PA are outlined. 06/07/18
Billing Reminder - Immunosuppressive Drugs - Delivery to Inpatient Hospitals The DME MACs have jurisdiction for the Fee-For-Service Medicare program's coverage, coding and reimbursement for immunosuppressive drugs following transplant. 05/24/18
Correct Coding - Submitting Oxygen Claims with Modifiers KX, GA, GY and GZ There are instances where a supplier possesses information that a beneficiary does not meet Medicare "Reasonable and Necessary" requirements for oxygen as specified in the Oxygen and Oxygen Equipment LCD. 05/10/18
Dear Clinician Letter - Knee Orthoses - May 2018 [PDF] Knee orthoses have consistently been one of the highest sources of errors in medical reviews performed by the DME MACs and the CERT contractor.  05/03/18
Policy Article Revision Summary for May 3, 2018 The principal changes to the Standard Documentation Requirements for All Claims submitted to DME MACs PA has been revised and posted. 05/03/18

LCD and Policy Article Revisions Summary for April 26, 2018

The principal changes to the DME MAC LCD and PA for Therapeutic Shoes for Persons with Diabetes are outlined. 04/26/18
Billing Instruction - Oxygen CMN Question 5 - Revised On February 15, 2018 the DME MACs published an article entitled "Billing Instruction - Oxygen CMN Question 5" with supplier guidance on use of new oxygen "Q" modifiers and the CMN.  04/26/18
LCD and Policy Article Revisions Summary for April 19, 2018 The principal changes to the External Infusion Pumps, Glucose Monitors, Oxygen and Oxygen Equipment, Seat Lift Mechanisms and Spinal Orthoses: TLSO and LSO LCDs and PAs are outlined. 04/19/18
Policy Article Revisions Summary for April 12, 2018 The principal changes to the DME MAC Policy Articles (PAs) that have been revised and posted are outlined. 04/12/18
Dear Clinician Letter - Immunosuppressive Drugs - April 2018 [PDF] Immunosuppressive drugs are covered by Medicare Part B for beneficiaries who have had organ transplants. 04/05/18
Policy Article Revisions Summary for April 5, 2018 The principal changes to the DME MAC Policy Articles (PAs) that have been revised and posted are outlined. 04/05/18
Continuous Glucose Monitor (CGM) Use - Alternative Testing For Fingerstick Testing Requirements For Insulin Pumps A beneficiary using a CGM is inherently testing more than the 4x/day glucose monitoring requirement outlined in the DME MAC External Infusion Pump LCD and related Policy Articles. 04/05/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Transit System and Associated Bracket Recent reports have identified that suppliers are billing HCPCS code K0108 for transit system and related components. 03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Front Riggings: Shoe Holder or Shoe Holder Replacement Straps Recent reports have identified that suppliers are billing HCPCS code K0108 for a shoe holder or replacement straps. 03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill For a Wheel Lock Brake Extension for Manual Wheelchairs Recent reports have identified that suppliers are billing HCPCS code K0108 for wheel lock brake extension handle used on manual wheelchairs. 03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Anti-Tip Devices for Manual Wheelchairs Recent reports have identified that suppliers are billing HCPCS) code K0108 for anti-tip devices used on manual wheelchairs. 03/22/18

Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Labor Charges

Recent reports have identified that suppliers are billing HCPCS) code K0108 for labor charges. 03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for Front Riggings: Calf Pad or Calf Support Recent reports have identified that suppliers are billing HCPCS code K0108 for a calf pad, calf support or for differing sizes of these items. 03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for a Privacy Flap Recent reports have identified that suppliers are billing HCPCS code K0108 for a privacy flap.  03/22/18
Correct Coding - Incorrect Use of HCPCS Code K0108 to Bill for an Actuator Recent reports have identified that suppliers are billing HCPCS code K0108 for a wheelchair actuator.   03/22/18
Billing Instructions - LSO and TLSO The DME MACs have claims data showing that spinal orthoses are often replaced at a frequency greater than the allowed 5-year reasonable useful lifetime (RUL). 03/22/18
Dear Clinician Letter - Insulin for Insulin Infusion Pumps - March 2018 [PDF] The DME MAC contractors were made aware of an issue with pharmacies billing Medicare Part D for insulin used in a DME external insulin infusion pump. 03/08/18
Correct Coding - Custom Fabricated Wheelchair Seat and Back Cushions This article will discuss the information necessary for coding of custom fabricated wheelchair seat and back cushions. 02/22/18
RETIRED - Billing Instruction - Oxygen CMN Question 5 Article retired on 04/26/2018. New article posted on 04/26/2018. 02/15/18
Correct Coding - Warranty, Reasonable Useful Lifetime and the Minimum Lifetime Requirement for Durable Medical Equipment Warranty, RUL, and MLR information are often cited interchangeably in response. This article reviews the applicable Medicare definitions and payment rules related to these topics. 02/08/18
Correct Coding - Inserts Used with Therapeutic Shoes for Persons with Diabetes (A5512, A5513, K0903) Inserts used with therapeutic shoes for persons with diabetes coded as A5512, A5513, and K0903 must meet certain specifications outlined in the Therapeutic Shoes for Persons with Diabetes LCD and related PA, as well as the requirements for custom fabrication set out in the DMEPOS Quality Standards, Appendix C.   02/01/18
Policy Article Revision Summary for February 1, 2018 The principal changes to the DME MAC Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) PA are outlined. 02/01/18
Dear Clinician Letter - Completion of Certificates of Medical Necessity - Annual Reminder [PDF] Certificates of medical necessity, commonly known as CMNs, are documents used by the DME MACs to assist in gathering information about the medical necessity of an item 01/25/18
Items Provided on a Recurring Basis and Request for Refill Requirements - 2018 Annual Reminder For all DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. 01/25/18
Dear Clinician Letter - Negative Pressure Wound Therapy (NPWT) Pump - January 2018 [PDF] The Durable Medical Equipment Medicare Administrative Contractors The DME MACs process claims and perform medical review for DMEPOS provided to Medicare beneficiaries. 01/11/18
Dear Clinician Letter - Positive Airway Pressure (PAP) Devices Replacement - January 2018 [PDF] There are two scenarios in which your patient diagnosed with OSA may qualify for a replacement PAP device and/or supplies. 01/11/18
Dear Clinician Letter - Positive Airway Pressure (PAP) Devices - Revised - January 2018 [PDF] Data from the CERT program projects that $500M in inappropriate payments are made each year for PAP devices used to treat obstructive sleep apnea. 01/11/18

 

Last Updated Dec 06, 2018