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CR9968 CURES Act Fee Schedule Adjustments

CMS has issued Change Request (CR) 9968 This link takes you to an external website. and related contractor instructions to begin mass adjustments for all claims impacted by the extension of the transition to the fully adjusted Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) payment rates under Section 16007 of the 21st Century Cures Act. Noridian started these mass adjustments on 6/26/17 and completed them on 9/12/17.

On this page, view the below information.

Important Facts Regarding the Adjusted Claims

Noridian will conduct adjustments to the fee amounts for certain DME items furnished on or after January 1, 2016, in areas that are not competitive bid areas due to CR 9968 under the 21st Century Cures Act. Claim dates of services are July 1, 2016 – December 31, 2016 and mass adjustments will be conducted to correct claims payment.

There is no need for suppliers to call to see if their claims have been adjusted or when their claims will be adjusted. Noridian will be using  the CMS approved RARC Code ‘N689' to identify claim adjustments with the following Alert Message. Alert: This reversal is due to a retroactive rate change. N689 will be in the 2100.MOA segment of the ERA and in the claim header MIA/MOA section on the SPR.

There may be some claims adjusted that results in a potential overpayment. These may be due to patients in a SNF, HHH, etc. for the date of service on the claim. You will receive an overpayment demand letter.

KE Modifier Reopenings

KE Modifier Adjustments for Transition to the Fully Adjusted DMEPOS Payment Rates

Noridian is ready to accept KE written reopening requests as outlined below for claims with dates of service July 1, 2016 - December 31, 2016 for finalized claims. Addition of KE modifiers cannot be completed during a telephone reopening.

As part of the fee schedule update for the 21st Century Cures Act, the KE modifier was added to the fee schedule for use on items bid under the initial Round 1 of Competitive Bidding but used with non-competitive bid base equipment.

See the HCPCS Applicable to KE Modifier listing [Excel].

Suppliers must request to have the KE modifier added to applicable claims. Follow the below to do this.

  1. Submit written reopening requests, one per beneficiary, on the Medicare DME Reopening Request Form.  You could also attach a spreadsheet if you have a list of claims for this beneficiary.  If you have multiple beneficiaries for which you need to add KE modifiers to their claims, proceed to the next step. Otherwise, go to Step 3.
  2. Suppliers must call Phone Reopenings, see Contact webpage for number, to notify them that they will be submitting a request to have KE modifiers added to claims.
    • The Reopening representative will provide an authentication number for the request. This must be done for each Provider Transaction Access Number (PTAN) for which there are adjustments. You must also get different authentication numbers for JA and JD.
  3. Mail or fax a Medicare DME Reopening Request Form [PDF] using the fax or mailing addresses below.
  4. Spreadsheet must be typed. Hand written documents are not accepted.
  5. JA and JD claims cannot be on same spreadsheet even if under the same PTAN. Separate requests for JA and JD must be submitted.
  6. At the bottom of the form, in the comments section, indicate "Special Project Request – see attached spreadsheet" (indicate total number of pages including coversheet, form and spreadsheet pages).
  7. In the comments section, include the statement "Add KE modifier for all" and supplier authentication number.
  8. On the attached spreadsheet of claim lines, ensure that the font is large enough to be easily read and include the following information.
    • Supplier National Provider Identifier (NPI)/PTAN
    • Authentication Number
    • Beneficiary Full Name
    • Medicare Number
    • Date of Service
    • HCPCS Codes
    • Claim Control Number (CCN) - list each claim number only once on spreadsheet

A Reopening Spreadsheet template [Excel] has been created to assist suppliers with this.

Written reopening requests can also be submitted through the Noridian Medicare Portal (NMP). The portal is limited to submission of 70 megabyte files so check the file size of large spreadsheets before submission.

Note: The claims affected must be finalized, i.e. supplier has received a paper or electronic remittance advice for the claim, before a request for the KE modifier can be submitted.

Fax: 701-277-7886

Mailing Address

Noridian JD DME
Attn: Written Reopenings
PO Box 6727
Fargo, ND 58108-6727

Courier Address

Noridian JD DME
Attn: Written Reopenings
900 42nd St S
PO Box 6727
Fargo, ND 58103-2146

KE Modifier Reopening Reminders

  • Noridian will add KE modifier to claim in appropriate modifier location, based on other modifiers already present on claim, that will allow claim to pay additional fee schedule amount
  • When a claim line requires purchase or rental modifier (NU, UE, RR), a monthly rental modifier (KH, KI, KJ) or a liability modifier (GA, GY, GZ), these modifiers will remain in one of first four modifier locations
  • Adjustments only apply to claims with dates of service July 1, 2016 - December 31, 2016

Claim Processing Education

Suppliers should be aware of the following claims processing items for the CR9968 Cures Act Fee Schedule Adjustments.

  1. Suppliers with oxygen claims covered under these mass adjustments may see miscellaneous code E1399cc on some remittances. Due to system limitations, the code E1399 is being used when previous oxygen CMNs have been deleted and are no longer on file due to a new CMN superseding the previous CMN. Code E1399 was used since it will not impact current or future oxygen claims. The cc modifier also signifies that the HCPCS was changed during processing.
     
  2. Noridian will not be adjusting rented Inexpensive and Routinely Purchased (IRP) items when the first rental month occurred before July 1, 2016. For rented IRP items, Medicare pays rentals up to the purchase price. Since the purchase price is established by the date of service from the first rental month, the purchase price will not change due to these adjustments, as the initial (first rental month) date of service does not fall into the timeframe for these adjustments, 7/1/2016-12/31/2016.
     
  3. Oxygen Concentrators: Some claims adjusted for the Cures Act adjustments are denying with code N370 (Billing exceeds the rental months covered/approved by the payer) rather than paying the last month of rental, i.e. only 35 rental payments were made. Noridian is aware of this system issue and is working with the system maintainer for resolution. In the interim, we will adjust claims brought to our attention. Call the Contact Center to report these instances for correction.
     
  4. Temporary Replacement of Beneficiary Owned Equipment (K0462): Noridian reviews this code to assure that accurate payment has been made by suspending each claim for manual review. If you feel the claim was underpaid or denied in error, the next step is to submit an appeal.
     
  5. Heated Humidifier (E0562): This inexpensive and routinely purchased (IRP) item when billed as a rental, in some cases, did not process appropriately during the adjustment. Any IRP item billed as a rental will pay up to the fee schedule allowance. If the rental began prior to July 1, 2016, no additional payments will be made on claims for July 1, 2016, through December 31, 2016 dates of service because the fee schedule amount was already in effect. Noridian is reviewing the claim adjustments to verify accurate payment. If claims need to be adjusted again, Noridian will handle the adjustments.
     
  6. Wheelchair Accessories: In order to process wheelchair accessories claims adjusted by the Cures Act, in some cases, Noridian may need to change the submitted HCPCS code to E1399 with a "cc" modifier (code change). This step is needed to pay the correct amount. There are various billing and modifier rules that cannot be accommodated with the limitation of four modifiers for pricing and system edits. The best solution is to change the submitted HCPCS to E1399 with a "cc" modifier.
     

Related Articles

Articles Posted
Cures Act Adjustments and Competitive Bidding 08/07/17

 

Frequently Asked Questions (FAQs)

Q1. Can I call the Contact Center to see if my claim will be adjusted?
A1. No, the customer service representatives will not be able to tell you which claims will be a part of the mass adjustment.

Q2. How will I know if my claim was adjusted?
A2. The remittance advice will identify these claims with RARC Code N689 - Alert: This reversal is due to a retroactive rate change.

Q3. Am I able to add the KE modifier once I receive my remittance advice showing the claim was adjusted to allow the new fee schedule?
A3. No, suppliers must wait to request the KE modifier to be added to claims once all claims have been adjusted in the mass adjustment. A listserv will be sent out when a special project reopening can be submitted as well as detailed instructions on how to submit. This was done on 8/25/17.

Q4. Will my claims crossover to the secondary insurance?
A4. Crossover will occur if the supplemental insurer does not exclude adjusted claims from the crossover process. Please work with your supplemental insurers to determine if they accept adjusted claims.

Q5. Will we get separate remittance advices for these CURES Act claim adjustments?
A5. No, these adjustments are processing at the same time as new claims submitted to the DME MACs. Remittance advice statements could include some CURES Act adjustments as well as claims you submitted over the past few weeks.  It is important to review your remittance advice statements for claims that have the remark code N689 associated with them. Similarly, beneficiaries will see these CURES Act adjustments on their quarterly Medicare summary notices with other claims.  As a reminder, beneficiaries can call 1.800.Medicare with any questions they have about their Medicare summary notices.

Q6. Will my claims be expedited through the system?
A6. No, these adjustments will be processed in Medicare's system against all online and common working file edits. This could include inpatient stays in a skilled nursing facility, Medicare advantage plan enrollment, and home health episodes. It is possible that a claim could deny based on these edits. You will receive an overpayment demand letter for these claims. 

ACT Q&As

 

Last Updated Dec 14, 2017