Collaborative Post PHE FAQ - JD DME

Q1: Are beneficiaries required to meet the current coverage criteria for ongoing DMEPOS rentals and supplies billed with dates of service on or after May 12, 2023, if the base item was initially provided under a COVID-19 PHE waiver?
A1: For items that were initially provided under the waiver, Medicare will continue to cover ongoing rentals, supplies, and accessories. When applicable, continue to append the CR and KX, CG, and/or N-modifiers.

As a reminder, there must be an order and documentation to confirm medical necessity for all items dispensed during the PHE. Standard documentation requirements for continued use/need apply.

For continued coverage of CGMs, a treating practitioner visit must be conducted within six months after the end of the PHE (May 11, 2023) and every six months thereafter, to assess beneficiary adherence to their CGM regimen and diabetes treatment plan.

Q2: Should we stop using the CR modifier and COVID-19 narrative for ongoing DMEPOS rentals or supplies billed with dates of service on or after May 12, 2023, if the base item was initially provided under a COVID-19 PHE waiver?
A2: For items that were initially provided under the waiver, Medicare will continue to cover ongoing rentals, supplies, and accessories, for dates of service on or after May 12, 2023.  The CR Modifier and COVID-19 narrative can continue to be used for any DMEPOS item (ongoing rentals) and related supplies/accessories where the base item was initially dispensed, rendered or otherwise impacted by the PHE (dates of service on March 1, 2020 through May 11, 2023) or specifically excluded from enforcement of the clinical indications of coverage referenced in Interim Final Rules CMS-1744-IFC and CMS-5531-IFC.

As a reminder, regardless of how the PHE impacted the base item, treating practitioners and suppliers need to provide a standard written order (SWO), ensure items are reasonable and necessary, document medical necessity for all services, and make this documentation available, upon request.

Q3: Should we continue to use the KX modifier for ongoing DMEPOS rentals or supplies billed with dates of service on or after May 12, 2023, for beneficiaries who do not meet current coverage criteria if the base item was initially provided under a COVID-19 PHE waiver?
A3: Yes, after the PHE, for dates of service on or after May 12, 2023, suppliers should continue to bill the CR and KX, CG, and/or N-modifiers as applicable, for any DMEPOS item or related supply/accessory dispensed on dates of service between March 1, 2020 through May 11, 2023, where the base item was initially dispensed, rendered or otherwise impacted by the PHE or specifically excluded from enforcement of the clinical indications of coverage.

Q4: Will Medicare-approved telehealth visits still be allowed after the PHE has ended, even for a policy that requires a face-to-face examination or in person visit?
A4: Yes, Medicare has always allowed Medicare-approved telehealth visits. The Consolidated Appropriations ACT of 2023 extended many telehealth flexibilities through December 31, 2024.

It is in the supplier’s best interest to confirm with the treating/prescribing practitioner the telehealth visit is a Medicare-approved telehealth visit and meets CMS guidelines.

CMS Telehealth Guidance: https://www.cms.gov/about-cms/agency-information/emergency/epro/current-emergencies/current-emergencies-page

Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency: https://www.cms.gov/files/document/frequently-asked-questions-cms-waivers-flexibilities-and-end-covid-19-public-health-emergency.pdf

Q5: Does the telehealth visit have to be both video and audio to replace an in-person or face-to-face visit?
A5: The telehealth visit must be considered a Medicare-approved telehealth visit. Please refer to Answer 4.

Q6: Is there any notification we need to put on the claim that a telehealth visit was utilized?
A6: DMEPOS suppliers are not required to append any modifiers on the claim or add a claim narrative to indicate a Medicare approved telehealth visit was performed. This information should be documented in the beneficiary’s medical record.

Q7: What are the coverage requirements for repairs of patient-owned equipment issued during the PHE under waivers for non-enforcement of clinical indications of coverage?
A7: If Medicare initially paid for the base item, medical necessity for the base item has been established. There are 2 documentation requirements:

1. The treating practitioner must document that DMEPOS item being repaired continues to be reasonable/necessary and,
2. The treating practitioner or supplier must document that the repair is reasonable/necessary.

The supplier must maintain detailed records, describe the need for and nature of all repairs, including a detailed explanation. Justify components, parts replaced, and labor time to restore the item to its functionality.

Q8: Do we continue to bill the CR modifier for ongoing supply claims in situations where the CR modifier and COVID-19 narrative were used only because a signature was not obtained on the proof of delivery (POD) for the base item?
A8: No, the CR modifier and COVID-19 narrative are not required for ongoing supply claims in the situation described. Ongoing supply claims would be required to have their own valid proof of delivery which meets the requirements of Method 1, 2, or 3 deliveries as outlined in the Standard Documentation Requirements for All Claims Submitted to the DME MACs Policy Article (A55426).

Q9: Do we need to obtain a new POD for an ongoing DMEPOS rental if a signature was not obtained on the POD for the base item during the PHE?
A9: No, a new POD does not need to be obtained for an item still being rented following the end of the PHE.

As a reminder, for items delivered directly to the beneficiary for dates of service on or after May 12, 2023, signature and proof of delivery requirements have been reinstated.

Q10: During the PHE, a beneficiary qualified for a CGM under COVID-19 waivers and the CR modifier was used because the insulin regimen was less than 3 times a day., The Glucose Monitors LCD has since been revised and the beneficiary now meets coverage criteria. Can we drop the CR modifier on the claim?
A10: Since the PHE impacted the CGM device claim, the provider may choose to use the CR modifier and "COVID-19" narrative. However, since the beneficiary meets the existing coverage criteria for the CGM now, adding the CR modifier and "COVID-19 narrative" is not mandatory; it is at the supplier’s discretion.

Q11: What protocol needs to be followed for beneficiaries who initially qualified for a CGM based on insulin usage but no longer require insulin within six months to a year due to improvements in their glycemic control. They also do not have a history of severe hypoglycemia. Do we stop servicing these non-insulin patients as soon as we become aware of it? If so, what information or guidelines do we provide to patients to ensure there is no negligence on our end pertaining to their diabetic care?
A11: If it was during the PHE when clinical indications were not being enforced, continue to append the CR modifier and COVID-19 narrative after the end of the PHE.

For CGM continued coverage, the Glucose Monitors LCD states, "Every six (6) months following the initial prescription of the CGM, the treating practitioner conducts an in-person or Medicare-approved telehealth visit with the beneficiary to document adherence to their CGM regimen and diabetes treatment plan."

There is no requirement for the treating practitioner to reconfirm that the initial coverage criteria are met for continued coverage. Therefore, coverage would continue if the treating physician documented that the beneficiary is adhering to their CGM regimen and diabetes treatment plan at the 6-month follow-up visit.

Q12: We have a claim for oxygen that was billed with the CR modifier and "COVID-19" narrative. The oxygen has now capped. Since all rental claims were paid with the CR modifier and "COVID-19" narrative during the PHE for the oxygen, would the maintenance and service claim also need the CR modifier?
A12: Yes, the CR modifier and "COVID-19" narrative would continue to be billed in addition to the MS modifier and the KX or N-modifier as applicable.

Q13:  If we were using the CR modifier during the PHE only because we were unable to obtain a CMN or DIF (the SWO and other policy requirements were met) and we have obtained a new SWO after January 1, 2023, can we remove the CR modifier on rentals after May 11, 2023?
A13: The CMN/DIFs are no longer applicable. Therefore, after the PHE, the CR would no longer be necessary if all other coverage criteria were met when the equipment was first provided.

Q14: How should suppliers bill for oxygen rentals with a start date on or after April 1,2023 through May 11, 2023, where a COVID-19 PHE waiver applies? The KX modifier can no longer be billed for new rental periods and the N1, N2, or N3 may not be applicable.
A14: For oxygen claims that were initially dispensed, rendered or otherwise impacted by the PHE (dates of service on March 1, 2020 through May 11, 2023), or specifically excluded from enforcement of the clinical indications of coverage referenced in Interim Final Rules CMS-1744-IFC and CMS-5531-IFC, suppliers may continue to use the KX modifier or may use the N-modifiers for claims with dates of service on or after April 1, 2023. This is in addition to the CR modifier and "COVID-19" narrative.

Suppliers may continue to use the CR modifier and "COVID-19" narrative without appending an N modifier if none of the N modifiers are applicable.

For initial claims for oxygen or new 36-month oxygen rental periods with dates of service on or after April 1, 2023, suppliers must use the N1, N2 or N3 modifier.

Q15: When providing supplies to beneficiaries who switched suppliers, how will we know when to append the CR modifier and "COVID-19" narrative? Do we need to obtain the clinical information and determine ourselves if the CR modifier and "COVID-19" narrative should be used?
A15: It is in the supplier’s best interest to ensure you have access to the beneficiary’s medical records to determine if the items were provided during the COVID-19 PHE and under an approved waiver for continued use/continued need.

Q16: How long can the CR modifier be used after May 12th, 2023, for items initially dispensed during the Public Health Emergency (PHE)?
A16: The CR modifier can be used if the item continues to be reasonable and necessary.