Article Detail - JD DME

Posted December 20, 2012

Event Summary

On October 30, 2012 The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) conducted a Webinar on External Breast Prostheses. During this Webinar, information was provided to assist suppliers in understanding the medical policy for External Breast Prostheses and Medicare's requirement for documentation.

Suppliers are strongly encouraged to review available resources on each of the DME MACs Web sites, including the medical policies:

•  Jurisdiction A - NHIC, Corp.: http://www.medicarenhic.com/dme
•  Jurisdiction B - National Government Services: http://www.NGSMedicare.com
• • Jurisdiction C - CGS Administrators LLC.: http://www.CGSMedicare.com
• • Jurisdiction D - Noridian Administrative Services: https://www.noridianmedicare.com/dme

 

Question and Answer Summary

The following questions were asked via the chat feature for this Webinar. These questions are ones that were unable to be addressed during the Webinar. Please note that questions and answers may have been rewritten for clarity.

Enrollment/Assignment of Claims

 

Are ordering physicians required to be enrolled into the internet-based Provider Enrollment Chain & Ownership System (PECOS)?

Answer: The Centers for Medicare & Medicaid Services (CMS) is expanding claim edits for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS). As a result, in the near future, implementation of specific edits will occur that will restrict DMEPOS suppliers from receiving payment from Medicare for items that you order if you do not have a current enrollment in the Medicare PECOS.

Furthermore, for any DMEPOS item to qualify for coverage by Medicare it must be ordered by a physician or a practitioner who is eligible to order such item. Physicians or practitioners must be enrolled in PECOS and must be registered in the system and have a specialty that is eligible to order DMEPOS items for Medicare beneficiaries.

 

Is a supplier required to accept assignment on a specific amount of bras or may they all be submitted as nonassigned?

Answer: A non-participating supplier may choose to accept assignment or submit the claim as non-assigned. A supplier may not attempt to circumvent the Medicare allowed amount limitation by "fragmenting" his/her bills. Bills are "fragmented" when a supplier accepts assignment for some services, and claims payment from the enrollee for other services performed at the same place and on the same occasion.

A Participating supplier must accept assignment for all items and services furnished to Medicare beneficiaries.

 

Is nonassigned acceptable for each claim or for each day?

Answer: Suppliers who are nonparticipating with the Medicare program are able to choose assignment or nonassigment for claims submitted to Medicare on a claim by claim basis.

 

May a nonparticipating supplier accept assignment on a prosthetic and nonassignment on bras if they are delivered on the same day?

Answer: No. A supplier may not attempt to circumvent the Medicare allowed amount limitation by "fragmenting" his/her bills. Bills are "fragmented" when a supplier accepts assignment for some services, and claims payment from the enrollee for other services performed at the same place and on the same occasion.

 

If a physician orders a total for the year of six bras and the beneficiary wishes to purchase from a participating supplier a 7th bra, can the supplier collect payment for the 7th bra from the member as self pay?

Answer: Per the CMS Internet-only Manual (IOM) Publication 100-04 Medicare Claims Processing Manual, chapter 1, §70.8.8.6, per Section 1848(g)(4) of the Social Security Act, suppliers are required to submit claims to the DME MAC for services furnished. Suppliers who fail to submit a claim are subject to sanctions. CMS is responsible for assessing sanctions and monetary penalties for noncompliance.

Suppliers who have knowledge of an individual that is on Medicare should submit all items/services to the DME MAC for consideration of payment.

Note: Suppliers will not violate mandatory claims submission rules under Section1848 of the Social Security Act when a claim is not submitted to Medicare at the beneficiary's request by their choice of Option 2 on the revised Advance Beneficiary Notice of Noncoverage (ABN).

 

What certification does a fitter require to provide these items?

Answer: Medicare does not require a certification however; suppliers should verify if their state requires a license to fit and provide these services.

 

Does fitting require a licensed person?

Answer: Currently, Medicare does not require a licensed person to perform fittings.

 

If a supplier does not accept assignment on a claim, then the beneficiary pays in full, how does the supplier notify the secondary insurance in order to not receive the payment?

Answer: Suppliers will need to verify with the requirements from the secondary payer. Once Medicare processes the claim, information will appear on the Medicare remittance advice.

 

If a supplier is nonparticipating and doesn't accept assignment, is accreditation still required?

Answer: Yes. All DMEPOS suppliers who serve Medicare beneficiaries and meet the supplier standards listed in this chapter must enroll and obtain a Provider Transaction Access Number (PTAN) with the National Supplier Clearinghouse (NSC).

Before enrolling with the NSC, you must obtain a National Provider Identifier (NPI). Applying for an NPI is a separate process from enrollment with the NSC. This information will be found under the supplier enrollment chapter of your supplier manual. This chapter outlines the enrollment requirements that you must meet in order to receive payment in the Medicare program as a DMEPOS supplier.

 

For nonparticipating suppliers who submit all claims as nonassigned, does the beneficiary pay the supplier upfront for all charges?

Answer: Yes, then Medicare provides payment to the beneficiary.

 

If a supplier chooses to switch to nonparticipating, does the supplier have the right to bill Medicare on a claim-by-claim basis of accepting assignment?

Answer: Yes, nonparticipating suppliers have the option of accepting assignment on a claim-by-claim basis except where CMS regulations require mandatory assignment (i.e., Medicare covered drugs).

 

Are there any "negative" consequences of being a nonparticipating supplier?

Answer: Nonparticipating suppliers are not included in the Medicare Participating Suppliers Directory (MEDPARD) prepared by the NSC. This directory serves as an aid to the beneficiary in selecting a supplier who accepts assignment as the beneficiary will have less out-of-pocket costs.

 

If non par and customer wants a bra for $75, do they pay the full amount up front and then Medicare billed and payment sent to them. Or do we collect difference at the time of delivery?

Answer: Nonparticipating suppliers billing as nonassigned can collect payment in full from the beneficiary who will then receive reimbursement directly from Medicare for the allowed amount.

 

How do suppliers switch to nonparticipating status?

Answer: Open enrollment forms (CMS-460, Participation Agreement Form) are mailed to all active suppliers every November. If an existing non-participating supplier wants to become participating, then the agreement form must be received during open enrollment and postmarked before December 31 of that year.

If a participating supplier wants to become nonparticipating, they can request to become non-participating by sending the request to the NSC on their company letterhead. The request must be postmarked before December 31 of that year to become non-participating effective January 1 of the next year

 

What is the purpose of revalidation when accreditation is required every three years?

Answer: CMS requires that all DMEPOS suppliers with Medicare billing privileges re-enroll with the Medicare program every three years through the NSC.

 

When suppliers revalidates their application, are they are able to switch their status to nonparticipating?

Answer: Suppliers can change their participation status annually. To switch from participating to nonparticipating, a supplier just needs to submit a request to the NSC on their company letterhead, postmarked before December 31 for the change to take effect January 1 of the following year.

 

If a company chooses not to be a Medicare supplier, is a Medicare beneficiary able to go to that company and submit their own claim for reimbursement?

Answer: Beneficiaries are strongly encouraged to receive DMEPOS items from Medicare suppliers. If a beneficiary opts to receive DMEPOS items from a non-Medicare supplier, they are able to submit their own claim for reimbursement however; they are only able to receive reimbursement from Medicare one time per DMEPOS item. If a beneficiary opts to receive DMEPOS items from a non-Medicare supplier, they are able to submit claims to Medicare for reimbursement by completing the Patient's Request for Medical Payment CMS-1490S Form.

 

Do mastectomy suppliers have to be enrolled in PECOS as well as the ordering physicians?

Answer: In order to submit claims to any of the four DME MACs, a supplier of mastectomy products must be enrolled with the NSC. CMS is currently providing warning messages with claims that are processed when the ordering physician is not in PECOS. Suppliers should work with these physicians in order to avoid claim denials when CMS announces the start date for warning messages to switch to denials.

 

Coverage

 

If a beneficiary requires a new prosthesis due to weight gain or loss, will Medicare allow reimbursement?

Answer: An external breast prosthesis of a different type can be covered at any time if there is a change in the patient's physiological condition necessitating a different type of item. If the patient's medical condition changes, this should be documented in the patient's medical record. The patient's ordering physician would also be required to submit a new order which explains the need for a different type of breast prosthesis. The order must be kept in the supplier's files but need not be submitted with the claim.

 

What is Medicare's reasoning for not covering custom breast prosthetics?

Answer: The medical necessity for the additional features of a custom fabricated prosthesis (L8035) compared to a prefabricated silicone breast prosthesis has not been established, and therefore, if an L8035 breast prosthesis is billed, it will be denied as not reasonable and necessary.

 

If a beneficiary receives a foam form may they receive reimbursement from Medicare for a silicone prosthetic in six months?

Answer: The useful lifetime expectancy for silicone breast prostheses is 2 years. The useful lifetime expectancy for nipple prostheses is 3 months. For fabric, foam, or fiber filled breast prostheses, the useful lifetime expectancy is 6 months. Replacement sooner than the useful lifetime because of ordinary wear and tear will be denied as noncovered.

 

May a beneficiary be fitted for a L8015 prior to surgery and delivered after the surgery?

Answer: Yes. An external breast prosthesis garment, with mastectomy form (L8015) is covered for use in the postoperative period prior to permanent breast prosthesis or as an alternative to mastectomy bra and breast prosthesis.

 

How many bras may a beneficiary receive per year?

Answer: The policy does not identify a specific quantity. These items are paid based on medical necessity evidenced in the patient's medical record.

 

Can a Medicare beneficiary receive mastectomy bra if she does not have a need for full breast prosthesis?

Answer: Yes, a Medicare beneficiary may receive bras if a partial prosthesis is needed.

Is a beneficiary required to receive a L8015 prior to a L8030 or may a beneficiary receive the items at any time?

Answer: No, a beneficiary is not required to receive a L8015 prior to a L8030. However, L8015 may be covered as an alternative to mastectomy bra and breast prosthesis.

 

May beneficiaries switch between an L8020 and L8030 if the Reasonable Useful Lifetime (RUL) has expired for each?

Answer: Yes a beneficiary may switch between both prostheses as long as the RUL has expired.

 

With the Women's Cancer Act, is there a way to get the mastectomy sleeves covered by Medicare?

Answer: The policy article (PA) states the Mastectomy Sleeve L8010 does not meet the definition of a prosthesis therefore is denied as noncovered.

 

When providing prosthesis is the medical record from the surgery required or will a follow-up visit note be sufficient?

Answer: A breast prosthesis is considered for coverage for a patient who has a mastectomy, ICD-9-CM diagnosis V10.2, V45.71, 174.0-174.9, 198.81, 233.0, 457.0. During a review it would be expected the medical record would contain sufficient detailed information to justify coverage.

 

Are suppliers able to deliver a L8020 and L8030 at same time?

Answer: No. The L8020 is the fabric, foam, or fiber filled prosthesis and has a RUL of 6 months; the L8030 the silicone or equal mastectomy form with a RUL of 2 years. The local coverage determination (LCD) tells the supplier the Medicare Program will pay for only one breast prosthesis per side for the useful lifetime of the prosthesis. Two prostheses, one per side, are allowed for those persons who have had bilateral mastectomies. More than one external breast prosthesis per side will be denied as not reasonable and necessary.

 

Does Medicare consider reimbursement for breast prosthesis due to a congenital malformed breast?

Answer: Coverage is included for the conditions listed in the medical policy. If a potentially covered condition is missing, an LCD reconsideration should be submitted explaining the need and justification for the proposed addition. Suppliers may use the DME MACs Web sites for further information on submitting an LCD reconsideration.

Why must a beneficiary wait until the surgery is completed in order to receive their post-op camisole?

Answer: The medical necessity for the items listed in the medical policy cannot be established until after mastectomy. The beneficiary may be fitted for their post-op mastectomy bra or external breast prosthesis garment, with form, prior to surgery but the delivery of the item(s) may not take place until the surgery has been completed.

 

May a beneficiary receive more than one L8015 in a lifetime?

Answer: Yes, the medical policy for External Breast Prostheses does not specify the quantities of bras or external breast prosthesis garment, with form, which are covered. This is determined by the medical necessity and what is reasonable and necessary for the individual patient. Medical records from the physician should reflect and support what is dispensed to the beneficiary.

Will Medicare consider payment for a breast prosthesis for the other side non-mastectomy side to even the beneficiary out?

Answer: No, Medicare will only pay for the affected side.

 

If a beneficiary receives a L8020 after surgery then 4-6 weeks later is able to tolerate a L8030, will the supplier receive reimbursement for the L8030 due to progression in medical need?

Answer: All prosthetic devices are determined to be or not be reasonable and necessary by means of the medical records provided from the physician. The RUL of the L8020 is 6 months.

 

For the L8015, if the camisole is sold prior to surgery but the date of service on the claim is after the surgery, is the acceptable?

Answer: The L8015 (external breast prosthesis garment, with form, post) is not payable if dispensed prior to surgery (medical necessity for the L8015 cannot be established until after completed surgery). The date of service on the claim must match the date the beneficiary received the item so a supplier cannot dispense the item on one date and bill for it on a later date.

 

Are beneficiaries able to receive a breast prosthesis and a nipple prosthesis on the same date?

Answer: If a beneficiary receives a breast prosthesis for one side and the nipple prosthesis for the other, yes this can be considered for reimbursement. If the beneficiary is receiving a breast and nipple prosthesis for the same side, this would not be considered for coverage on both prostheses.

 

What process should a supplier follow if the beneficiary wants a camisole after her healing period?

Answer: The L8015 (external breast prosthesis garment, with form, post) is covered prior to a permanent breast prosthesis being dispensed or as an alternative to a breast prosthesis and mastectomy bra. Once the breast prosthesis and bras are dispensed, Medicare will no longer cover the camisole. Prior to this, a supplier can continue to dispense camisoles under the original order.

 

Medical Documentation/Signature Requirements

 

What information should be present in the medical records to justify the quantity and frequency of mastectomy bras?

Answer: The LCD does not specify a usual quantity of bras. The number provided should be sufficient to accommodate daily wearing and a usual laundering interval. As a durable supply, they may be replaced when they are no longer able to provide sufficient support.

 

Are the medical records required to specify what type of breast prostheses the beneficiary should receive?

Answer: No. The LCD does not require the medical records to specify the type of prosthesis.

 

What resources are available for suppliers to provide to ordering physicians in regards to stamp signatures are not acceptable for Medicare purposes?

Answer: Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in Program Integrity Manual, Pub. 100-08, Chapter 3, §3.3.2.4.

On a Certificate of Medical Necessity (CMN) the physician's name and credentials are listed in Section A. If the signature on the CMN is not legible does the physician need to print their name under their signature?

Answer: Medicare does not have an official required CMN for external breast prosthesis. Supplier-created CMNs are classified as supplier created documentation and therefore are insufficient to justify reimbursement. Medicare discourages the use of such documents and encourages suppliers to work closely and collaboratively with the prescribing physician to ensure that sufficient information is included in the actual medical record to justify payment.

 

If a supplier has a signature log however; the physician's signature is different, what recourse does a supplier have?

Answer: The supplier may want to obtain an attestation statement from the physician.

Additional information regarding CMS' signature requirements, including signature logs and attestation statements, can be found in MLN Matters article MM6698.

 

What constitutes a designee for signature purposes?

Answer: A designee is someone other than the beneficiary who signs for the beneficiary. Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the document. The signature of the designee should be legible. Below are the acceptable designees for each piece of documentation:

• ABN
  • Notifiers are responsible for determining who may act as a beneficiary's authorized representative for the purposes of ABN issuance under applicable State or other law. An individual who may make health care and financial decisions on a beneficiary's behalf (e.g. the beneficiary's legal guardian or someone appointed according to a properly executed "durable medical power of attorney") is an authorized representative. If the beneficiary has a known, legally appointed representative, the ABN must be issued to the existing representative. If a beneficiary does not have an existing representative and one is necessary, an authorized representative may be appointed for purposes of receiving notice following CMS guidelines and as permitted by State and Local law.
  • An individual authorized under state law to make health care decisions
  • An individual exercising explicit legal authority on the beneficiary's behalf, may be the authorized representative of the beneficiary with respect to receiving notice
  • The spouse, unless legally separated
  • An adult child
  • A parent
  • An adult sibling
  • A close friend (defined as "an adult who has exhibited special care and concern for the patient, who is familiar with the patient's personal values, and who is reasonably available")
• Assignment of Benefits
  • Legal guardian
  • Representative payee - a person designated by the Social Security Administration or other governmental agency to receive an incapable beneficiary's monthly cash benefits
  • Authorized representative - acts on behalf and in best interest of the beneficiary and is usually a parent, legal guardian of minor, or legal guardian of an adult who has been declared incompetent
  • Relative
  • Friend
  • Representative of an institution providing care or support
  • Governmental agency providing assistance
• Proof of Delivery o Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary

Suppliers should review the supplier manuals available on the DME MACs Web sites.

 

What does the clinical course in the medical records section entail?

Answer: The term "clinical course" is not used in this medical policy. In general the term "clinical course" refers to the history or progression of a medical condition. This information was provided in the presentation as additional information that may appear in the medical records for the beneficiary.

 

What is deemed as a medical necessity for product eligibility after reconstruction surgery?

Answer: If after a beneficiary has received reconstructive surgery and a breast prosthesis is required, Medicare will consider payment for the prosthesis and bras. If after reconstructive surgery a prosthesis is not required, bras would not be covered since there is not a prosthesis.

 

Since mastectomy is a permanent condition, may medical documentation stating the diagnosis be from years back?

Answer: Yes, the medical records may advise a diagnosis that is beyond the seven year time frame Medicare advises for medical records. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the medical policy.

 

For medical record information, may this be documented by the supplier or is it required to be documented by the ordering physician?

Answer: Medical information collected by the supplier is deemed insufficient, by itself, even if signed by a physician, to justify payment. Information from the medical record is the primary source used to justify reimbursement.

 

How should functional levels be documented in the medical records?

Answer: Functional levels are not a requirement for the external breast prostheses medical policy. This information was provided in the presentation as additional information that may appear in the medical records for the beneficiary.

 

Who is responsible for maintaining a signature log?

Answer: A publication titled "Signature Requirements" is now available in downloadable format from the Medicare Learning Network® on the CMS Web site. This fact sheet is designed to provide education on Signature Requirements to healthcare providers, and includes information on the documentation needed to support a claim submitted to Medicare for medical services. Ultimately, all documentation requirements affect the suppliers claim; on behalf of a health care provider, you may create a signature log at any time, and Medicare Contractors will accept all submitted signature logs regardless of the date when they were created.

 

Are suppliers required to send their notes to the ordering physician?

Answer: No, suppliers are not required to send their notes to ordering physicians.

 

For mail order suppliers, what information should be noted in the medical records in order to determine skin condition, balance and posture?

Answer: These are not elements of any reasonable and useful criteria contained in the LCD. This information was provided in the presentation as additional information that may appear in the medical records for the beneficiary. Medicare expects suppliers of prosthetic items to maintain sufficient detailed information in their records to demonstrate that the item provided was properly fit and able to be used by the beneficiary.

 

For a lost or stolen prosthesis, what documentation is required to support the replacement prosthesis?

Answer: Suppliers will need to follow the documentation requirements specified in the medical policy for a new item along with documentation of current usage/need. For documentation of lost or stolen, suppliers may include the following documentation:

• Reason for replacement
• Medical records
• Police reports
• Written explanations from the beneficiary

 

Can the typed printed name of the ordering physician be above the illegible signature?

Answer: A publication titled "Signature Requirements" is now available in downloadable format from the Medicare Learning Network® on the CMS Web site. This fact sheet is designed to provide education on Signature Requirements to healthcare providers.

 

In order to support medical necessity, what information should be in the medical records?

Answer: There must be sufficient information to demonstrate that the applicable coverage criteria are met.

 

If a form from the ordering physician has an illegible signature, may the ordering physician circle their name if there is a listing of physicians or are they required to print their name below their signature?

Answer: The preferred would be the printed name below the signature, although the name within the letterhead circled is also acceptable. A publication titled "Signature Requirements" is now available in downloadable format from the Medicare Learning Network® on the CMS Web site. This fact sheet is designed to provide education on Signature Requirements to healthcare providers

 

If a medical entry or documentation contains written and typed information, is this acceptable for valid documentation?

Answer: A partially typed and partially handwritten record is a valid part of the medical record if it is properly authenticated.

 

Does there need to be a face to face visit associated with the prescription?

Answer: Medicare payment policy does not require a specific face-to-face visit but it is required that the beneficiary's medical records support medical necessity.

 

Will a photo of the patient's status (post-mastectomy) serve in the event physician medical records are not obtainable?

Answer: A photograph in the supplier's records is not an acceptable or adequate substitute for documentation in the beneficiary's medical record to support medical necessity. A photograph may be part of the comprehensive medical record.

 

Coding

 

Would a form L8020 or L8030 and bras L8000 be covered for a beneficiary who has a diagnosis of 174.9 and had a lumpectomy vs a mastectomy?

Answer: This is possible for reimbursement. A breast prosthesis is covered for a patient who has had a mastectomy, ICD-9-CM diagnosis codes V10.3, V45.71, 174.0-174.9, 198.81, 233.0 or 457.0. A mastectomy bra (L8000) is covered for a patient who has a covered mastectomy form (L8020) or silicone (or equal) breast prosthesis (L8030) when the pocket of the bra is used to hold the form/prosthesis.

 

What garments are classified under Healthcare Common Procedure Coding System (HCPCS) L8002?

Answer: Codes L8001 and L8002 describe a bra with integrated breast prosthesis, either unilateral or bilateral, respectively. Products described by codes L8001 and L8002 may be constructed of any material (e.g., cotton, polyester or other materials), with any type or location of closure, any size, with or without integrated structural support (e.g., underwire).

 

Can a V code be the primary diagnosis when billing?

Answer: Yes. A breast prosthesis is covered for a patient who has had a mastectomy, ICD-9-CM diagnosis codes V10.3, V45.71, 174.0-174.9, 198.81, 233.0 or 457.0.

 

Have the accepted diagnosis codes been expanded?

Answer: The diagnoses for a breast prosthesis to be covered are: ICD-9-CM codes V10.3, V45.71, 174.0-174.9, 198.81, 233.0 or 457.0.

 

Does "shelf" camisole pertain to a specific style of camisole or does it mean an "over the counter" item that can be purchased at a department store?

Answer: Code L8015 describes an external breast prosthesis garment, with mastectomy form, used post mastectomy. For additional information regarding coding refer to the Pricing, Data Analysis and Coding (PDAC) Contractor's Web site.

 

What is diagnosis code 457.0?

Answer: The diagnosis code of 457.0 is Postmastectomy Lymphedema Syndrome.

 

For Medicare to reimburse on a claim, is a diagnosis code required?

Answer: Yes. The ICD-9 diagnosis code must be included on each claim for the prosthesis or related item.

 

What modifier should be reported when billing for replacement items?

Answer: The RA modifier is used for replacement items that have met the RUL or due to irreparable damage, theft, or loss.

If a new item was provided due to a change in physiological condition, a different HCPCS code would be billed and this would not be considered a "replacement" of the original item. The RA modifier would not be used in this situation.

All other applicable modifiers per the medical policy are also required to be submitted on the claim.

 

In the event that a pocketed bra (L8000) is not available in the needed size (e.g.: G, H, I cups) are suppliers able to modify the bra with a pocket and bill it as a pocketed bra?

Answer: To be covered under the Medicare DME MAC the item must be pocketed; the PA states products described by code L8000 may be constructed of any material, with any type or location of closure, any size, with or without integrated structural support. Although there are manufacturers that provide the larger sizes one is to assume this can be provided in this manner at no extra cost to the beneficiary.

 

Is the shelf camisole billed as L8015?

Answer: No. Medicare's description of the L8015 is an external breast prosthesis garment, with form used post mastectomy; so the shelf style camisole without breast form should not be coded with HCPCS code L8015.

If a beneficiary has a dual mastectomy how does a supplier bill the prostheses to receive reimbursement?

Answer: The assumption here is "dual" meaning bilateral, the right (RT) and left (LT) modifiers must be used with these codes. When the same code for bilateral items (left and right) is billed on the same date of service; bill for both items on the same claim line using the RTLT modifiers and 2 units of service. Claims billed without modifiers RT and/or LT will be rejected as incorrect coding. Bras and similar inherently bilateral items (L8000 - L8002, L8015) are exempt from the RTLT requirement.

 

Are suppliers required to report the V diagnosis code on the claim first?

Answer: No, suppliers of these products are not required to report the V diagnosis code as the first diagnosis code; however, suppliers should report the primary diagnosis code first.

 

Are suppliers able to bill a camisole with integrated shelf bra as a L8000?

Answer: No. Medicare's description of the L8000 is breast prosthesis, mastectomy bra.

 

Are compression garments for lymphedema billed as HCPCS L8015?

Answer: Code L8015 describes an external breast prosthesis garment, with form used post mastectomy. Mastectomy sleeves used for the treatment of lymphedema can be billed using code L8010 (but are noncovered by Medicare).

 

Dispensing and Detailed Written Orders

 

If a dispensing order specifies a number of bras that the supplier does not see is medically necessary, may the supplier reduce the dispensing due to not medically necessary. For example, the dispensing order specifies 12 bras however; it is determine the beneficiary should only receive 3?

Answer: A supplier can obtain an ABN in this situation and bill only for the items that are believed to be reasonable and necessary. However, there is not a set number of bras a beneficiary can receive. It is based upon the treating physician's order and the medical record. A supplier is able to dispense a number lower than what is written on the dispensing order.

 

What is the definition of dispensing?

Answer: Dispensing is when a supplier receives an order from a treating physician and provides items/services to a Medicare beneficiary.

 

If a beneficiary presents a valid detailed written order to the supplier, is the supplier required to contact the ordering physician for a dispensing order?

Answer: No. If the supplier has the detailed written order (DWO), a dispensing order would not be necessary. The supplier may dispense the item based on the DWO and submit a claim to Medicare.

 

If the beneficiary wants a different bra style number then previously dispensed, is a new order required?

Answer: No, all mastectomy bras without integrated prosthesis are coded as L8000, Changing from one manufacturer or style to another does not change the coding or the medical necessity therefore a new order is not needed. Changing from an L8000 to an L8001 or L8002 would require a new order.

 

Are the quantity and the frequency required to be on a DWO?

Answer: Frequency is not applicable for this medical policy. The quantity is required on the DWO along with the following:

• Beneficiary's name
• Prescribing Physician's name
• Date of the order and the start date of the order, if the start date is different from the date of the order
• Detailed description of the item(s)
• Physician signature and signature date

For items provided on a periodic basis, including drugs, the detailed written order must also include:

• Item(s) to be dispensed
• Quantity to be dispensed
• Number of refills

 

When is a new DWO required?

Answer: A new DWO is required when:

• A new order is required when there is a change in the item(s), frequency of use, or amount prescribed.
• A new order is required on a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy.
• A new order is required when an item is replaced.
• A new order is also required when there is a change in supplier.
• A new order is required if there is a change in length of need or a previously established length of need expires.
• Also when required by any state or federal laws

 

For how long is a prescription for bras valid?

Answer: For Medicare purposes, a prescription (DWO) is valid for as long as the prescription indicates, consistent with applicable laws. Suppliers should verify with their state regulations if a new prescription is required at certain intervals.

 

Is it sufficient for the detailed written order to specify the quantity of bras or is it required to be on the start order (dispensing order) and obtained before delivery of mastectomy bras?

Answer: Quantity is not required on the dispensing order but is required on the DWO.

 

Are supplies able to have a valid lifetime DWO?

Answer: A DWO must follow all federal and state guidelines. CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, §5.2.4 will provide further guidelines. Medicare requires a new DWO:

• A new order is required when there is a change in the item(s), frequency of use, or amount prescribed
• A new order is required on a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy.
• A new order is required when an item is replaced.
• A new order is also required when there is a change in supplier.
• A new order is required if there is a change in length of need or a previously established length of need expires.
• Also when required by any state or federal laws

A new order is required when an item is being replaced because the item is worn or the patient's condition has changed. Your records should also include beneficiary-specific information regarding the need for the replacement item. This information should be maintained in your files and be available to the DME MACs or other review contractors upon request. Failure to provide the appropriate documentation or providing documentation that contains broad, nonspecific explanations will result in claim(s) denial.

A new physician's order is required before replacing lost, stolen, or irreparably damaged items to reaffirm the medical necessity of the item. Proof of loss or damage through documentation such as a police report, picture, or corroborating statement should be submitted with the claim.

 

If a beneficiary contacts a supplier may the supplier contact the physician in order to receive a dispensing or DWO?

Answer: Yes, once the beneficiary makes contact with the supplier you may then document that contact, and the detailed written order will be provided to the physician for concurrence and signature.

 

When requesting a dispensing or DWO from a physician because the beneficiary has contacted the supplier, is it acceptable for the supplier to advise what the beneficiary is eligible for?

Answer: A supplier can assist the physician in determining what item will work best for a particular beneficiary (and will often complete the detailed description on the detailed written order) but the physician must initiate the dispensing order after evaluating the beneficiary.

 

Does the dispensing order alone have to have quantity or can the detail written order clarify the quantity in amount of time?

Answer: The detailed written order should clearly indicate a quantity and duration for the mastectomy bras. This is not a requirement for dispensing orders.

 

If a prescription states 6 bras but no refill information, is the order valid for one year or does it need to specify one year on the order?

Answer: Because the order is unclear, it should be sent back to the physician for clarification, preferably requesting a new, replacement order to minimize confusion; both frequency/duration and quantity should be specified on the detailed written order.

 

Are diagnosis codes required on a DWO?

Answer: A diagnosis code is not required on the detailed written order but must be supported by documentation in the beneficiary's medical record.

 

May nurses sign a dispensing order?

Answer: Nurse practitioners, clinical nurse specialists and physician assistants can order DMEPOS items if they meet the conditions listed in CMS publication 100-08, Medicare Program Integrity Manual, Chapter 5, §5.5-5.6.

 

Is it a Medicare requirement for the number of bras to be dispensed to appear on the DWO?

Answer: Yes, for items dispensed on a periodic basis (including mastectomy bras), a quantity must be included on the detailed written order.

 

Advance Beneficiary Notice of Noncoverage/Upgrades

 

When completing an ABN, what dollar amount is reported in section F?

Answer: Notifiers must make a good faith effort to insert a reasonable estimate for all of the items or services listed in Blank (D) of the ABN. In general, it is expected that the estimate should be within $100 or 25% of the actual costs, whichever is greater; however, an estimate that exceeds the actual cost substantially may still be acceptable, since the beneficiary would not be harmed if the actual costs were less than predicted.

 

Are suppliers able to submit breast prostheses bras as upgrade billing? If so, what are the appropriate steps to take to ensure correct billing?

Answer: Upgrades involve situations in which the upgraded item or component is more than what is medically necessary. For items with a different HCPCS code than the item that will be covered by Medicare, this distinction between products is easy to determine. Differing products contained within the same HCPCS code generally are considered as equivalent to one another. A difference in pricing for items classified within the same HCPCS code is not sufficient to justify an upgrade. For bras coded within the same HCPCS code, upgrade billing is not permitted. Please refer to CMS IOM Pub 100-04, Medicare Claims Processing Manual, Chapter 20, §120 for information on billing procedures for ABN upgrades.

 

How should a supplier execute an ABN when medical records cannot be obtained or the medical records are insufficient?

Answer: An ABN should be issued prior to dispensing a DMEPOS item expected to be disallowed for the following reasons:

• Services are not medically reasonable and necessary
• Prohibition on unsolicited telephone contacts
• Supplier number requirements not met
• Advance Determination of Medicare Coverage (ADMC) denial
• Noncontracted suppliers in a competitive bidding area (CBA)

 

If the beneficiary refuses to sign an ABN when the situation warrants one, do suppliers have the option to deny services or tell the beneficiary they are unable to bill Medicare?

Answer: If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN indicating the refusal to sign and may list witness(es) to the refusal on the notice although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the notifier should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option. If the supplier chooses to dispense the item, the claim should be submitted with the GZ modifier if the ABN was not properly executed.

 

Who can witness a refusal to sign an ABN and does it apply to all DMEPOS products?

Answer: If the beneficiary refuses to choose an option and/or refuses to sign the ABN when required, the notifier should annotate the original copy of the ABN indicating the refusal to sign and may list witness(es) to the refusal on the notice although this is not required. If a beneficiary refuses to sign a properly delivered ABN, the notifier should consider not furnishing the item/service, unless the consequences (health and safety of the patient, or civil liability in case of harm) are such that this is not an option.

 

If a supplier is submitting a nonassigned claim, is an ABN required in order to hold the beneficiary liable for the full amount of the supplier charges of service?

Answer: No, an ABN is not required to hold the beneficiary liable for the full charge if Medicare makes payment on the claim. If the claim is expected to be denied, yes the supplier will need to execute an ABN to hold the beneficiary liable for the charges.

 

If a supplier mails an ABN via certified mail, follows up with phone calls, and the records indicate this information, are suppliers able to bill the beneficiary if the ABN is witnessed by supplier staff?

Answer: When a beneficiary refuses to sign an ABN, two members of the supplier would be required to sign the ABN. One will sign the ABN annotating the beneficiary refused to sign and the other will sign and annotate they witnessed the first signature.

 

Are suppliers able to bill items as upgrades due to the item the beneficiary received costs more than what Medicare allows?

Answer: No. Cost is not sufficient to justify an upgrade.

 

Are suppliers able to collect the difference in what Medicare allows and what the supplier charges for a L8000 if an ABN has been properly executed?

Answer: Mastectomy bras are not eligible to be billed as upgrades so an ABN is not applicable. The Medicare allowed amount is all a participating supplier can receive as payment in full when billing for the L8000. Nonparticipating suppliers have the option to bill mastectomy bras as nonassigned claims in order to receive full payment directly from the beneficiary - in these cases, an ABN is not required.

 

Request for Refills

 

If the ordering physician does not indicate refills on the dispensing order or in the medical record, but just ordered four bras, are suppliers to interpret this as to dispense four bras, no refills or one bra every three months?

Answer: Yes either is acceptable.

 

Are suppliers required to inspect the beneficiary's bras prior to dispensing additional bras as refills?

Answer: For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement, the supplier should assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function properly. Document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

 

Are suppliers permitted to contact beneficiaries with a signed consent and request to be notified when eligible for the next three month supply of bras?

Answer: Yes the suppliers may contact their existing customers in order to provide continued services.

 

How soon can shipping occur for refills?

Answer: For subsequent deliveries of refills, suppliers should deliver the DMEPOS product no sooner than ten calendar days prior to the end of usage for the current product.

 

What documentation must a supplier have in order to meet the request for refill documentation?

Answer: A refill request must include:

• Beneficiary's name or authorized representative if different from the beneficiary
• A description of each item that is being requested
• Date of refill request
• For consumable supplies i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.) - The Supplier should assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
• For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., Positive Airway Pressure and Respiratory Assist Device supplies) - The supplier should assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. Document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

 

Proof of Delivery

 

If the beneficiary picks up the items in the store, should the delivery address be our store address?

Answer: Yes the store address would be used.

 

If a supplier is mailing items to a beneficiary is it acceptable to send a delivery ticket and a self-addressed stamped envelope along with the items so the beneficiary may sign the delivery ticket showing that they received the items?

Answer: Yes this is an acceptable practice in order to show a valid proof of delivery.

 

When using proof of delivery, method 2, if the receipt clearly states the date of service is the shipping date but the beneficiary signs it several days later due to shipping delays, is the proof of delivery valid?

Answer: Yes, the proof of delivery would be valid to show the items have been received by the beneficiary.

 

When using proof of delivery, method 2, what date should be used when submitting the claim to Medicare for reimbursement?

Answer: When delivering DMEPOS via a shipping service, the date of service on the claim should be the shipping date.

 

All Other Questions

 

If a beneficiary comes into the shop and asks us to get her prescription for her, is that considered solicitation?

Answer: This is not considered solicitation since contact was made by the beneficiary to the supplier. When the supplier contacts the physician's office they should be clear that the beneficiary has requested for them to contact their physician for an order.

 

Is the prosthesis two year replacement by date of service or by calendar year?

Answer: The replacement timeframe starts the day the prosthesis was delivered to the beneficiary.

 

What does Medicare consider the RUL for the L8000?

Answer: Medicare does not have a RUL specified for the L8000.

 

Are suppliers able to deliver and receive reimbursement when a beneficiary is in a skilled nursing facility?

Answer: For beneficiaries who are currently in a Part A covered stay, within their 100 days, all items/services are considered part of the consolidated billing of the skilled nursing facility. If the 100 days have been exhausted and Medicare Part A has received a claim for "no pay stay" the bras and prostheses can be considered for coverage by the DME MAC.

 

Are suppliers able to charge Medicare or the beneficiary a fitting fee?

Answer: No, suppliers may not charge a fitting fee.

 

Should the mastectomy bra be given and billed the date of surgery?

Answer: The delivery of a mastectomy bra would be dependent upon the beneficiary and their treating physician. Items delivered during a Medicare Part A stay should not be billed to the DME MAC.

 

When are narratives necessary?

Answer: A narrative description is used when providing documentation of a process, measurements, HCPCS codes on a delivery slip etc. there are far too many uses for a narrative description to give all the possible uses. For the claim form the narrative will help to provide information about cause or reason for the item you may have provided; or it may explain the use and reason for a not otherwise classified code. Suppliers will use a narrative on the ABN when applicable.

 

If a beneficiary receives a L8030 and returns to receive a L8020 due to the L8030 is too heavy, will Medicare reimburse on the L8020?

Answer: No, it will deny Same or Similar; the RUL for the L8030 is 2 yrs. The supplier is expected to have properly fit the product prior to delivery. All additional costs for fitting, adjustments changes etc. that are necessary in the 90 days after delivery are covered by the payment for the original item.

 

Are follow-up phone calls acceptable or must a follow-up be performed in person?

Answer: Proof of continued use and continued medical need are both needed for ongoing supplies or rental items. The specific requirements for each can be found in the LCD and each DME MAC has "dear physician" letters available on their web sites that further describe each requirement.

 

How are suppliers notified of future training sessions?

Answer: Each DME MAC posts upcoming trainings (webinars and face-to-face events) via their email listservs in addition to publishing the information on their respective Web sites.

 

When will suppliers be able to use self-service tools to check for same/similar with prosthetic codes?

Answer: This is not currently an option and there is no estimated timeframe whether or when it will become an option.