ACM Q and A - May 9, 2024 - JD DME

Questions Received Prior to ACM

Q: How do we bill DME items that do not have a Healthcare Common Procedure Coding System (HCPCS) code assigned to them, and the manufacturer reports no suggested HCPCS code?
A: Review the policy for miscellaneous coding requirements specific to the policy. Additional information can be found on our webpage titled, "Billing Not Otherwise Classified (NOC) HCPCS Code," which will provide NOC code billing guidance. You can find this information on the Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Billing Not Otherwise Classified (NOC) HCPCS Code.

Q: If we are providing continuous positive airway pressure (CPAP) supplies for a beneficiary coming from another company, what documentation is required?
A: If Medicare paid for the CPAP, medical necessity is assumed to have been established. Documentation of continued need is required for ongoing supplies in the form of a recent order or timely documentation in the medical record showing usage of the item. If Medicare did not pay for the CPAP, coverage criteria for the CPAP must be met.

Noridian Medicare website > Browse by DMEPOS Category > Positive Airway Pressure (PAP) Devices

Q: How do I submit a prior authorization request (PAR)?
A: Suppliers can submit a PAR through fax, mail, or electronic submission of medical documentation (esMD) with a coversheet. Suppliers can also submit through the Noridian Medicare Portal (NMP). A coversheet is not required when submitting through the NMP. For more information on PAR submission and documentation requirements, please see the Noridian Medicare website > Medical Review > Pre-Claim Review > Required Prior Authorization Programs.

Q: I have a patient who will be receiving IV Push and the supplies needed to perform this, but the main hydration therapy is provided by the hospital at discharge. How can we bill for supplies? Should the supplies come from the hospital or home health care agency who will oversee the infusion at home?
A: Hydration therapy is not a DME benefit. Please reach out to your Part B contractor for coverage details.

Q: How do we bill the nursing services for intravenous immune globulin (IVIG)?
A: HCPCS code Q2052 is billed for services, supplies, and accessories used in the home for the administration of IVIG. The nursing services billed under HCPCS code Q2052 may be billed separately from, or on the same claim as the IVIG drug. Q2052 should be billed with the same place of service as the related IVIG HCPCS code. Noridian Medicare website > Browse by DMEPOS Category > Intravenous Immune Globulin (IVIG)

Q: How do I bill Medicare Fee-for-Service (FFS) for a claim that was denied from Anthem Medicare Preferred because the patient went into a hospice stay?
A: We cannot speak to Medicare Advantage plans. Medicare FFS does not cover DME services related to hospice conditions. If the items in question are unrelated to the hospice diagnosis, they may be covered by Medicare FFS. Please refer to the consolidated billing tool to learn more about billing during active hospice episodes.

Noridian Medicare Website > Education and Outreach > Tools > Consolidated Billing Tool

Q: Is an approved Unique Tracking Number (UTN) tied to the beneficiary rather than the provider that submitted and obtained the UTN? If yes, does this apply to any DME that requires a prior authorization (PA)? If it applies to all PA DME, and it’s not tied to a specific provider, can a beneficiary take the UTN to whichever provider they wish and have that provider use the UTN on their claim? 
A: A UTN is tied to the beneficiary for any DME that requires PA. A beneficiary can take the UTN to the provider of their choice who can then use it to submit a claim.

Q: Regarding therapeutic shoes for persons with diabetes, do the progress notes from the certifying physician need to be specific to what was indicated on the certification statement?
A: As long as one of the conditions 2a-2f is marked on the certification statement, they do not have to match.

Verbal Questions Asked During ACM

Q: Regarding enteral nutrition, does the beneficiary have to have a face-to-face with a physician or is a qualifying note from a dietician acceptable?
A: There does need to be a face-to-face with the treating practitioner to establish medical necessity; however, the notes from the dietician may be supporting documentation.

Q: We have beneficiaries being discharged from skilled nursing facilities (SNFs) but their files are not updating from status 30. What do you advise suppliers to do in this situation? Also, if the beneficiary needs the equipment right after discharge, we deliver it, bill the claim and it denies, can we file an appeal? Will the appeal be denied because the status has not been updated?
A: Suppliers need to work with the facility to update the beneficiary records. An appeal would deny based on the beneficiary's status in the Common Working File (CWF) if it has not been updated.

Q: Is discharge code 03 (planned to discharge to SNF) a payable status for DME to be provided if no SNF admission is ever billed after that and the beneficiary was at home on the date of service?
A: The supplier needs to work with the facility to have the record updated, because in our system, it appears the beneficiary is inpatient.

Q: Regarding overnight oxygen, does a beneficiary no longer need to sleep for two full hours if the study shows desaturation?
A: The Local Coverage Determination (LCD) states there must be a minimum of two hours of test time, but the requirement of five minutes was removed.

Written Questions Asked During ACM

Q: How do I found out the reimbursement rate for A6583 (accessories for lymphedema items)?
A: There is not a fee schedule for this code since there are a number of accessories that can be used. The DME Medical Directors have indicated claims must include the following for each accessory:

• Description of the item (including quantity represented by each unit of service, such as per inch, foot, or yard for supplies)
• Manufacturer name
• Product name and number
• Supplier price list
• HCPCS of related item (where applicable)

Q: If we have an established lower limb amputee beneficiary in need of new liners and sleeves, does the beneficiary need to have a physician visit to document what is needed and why? Can the supplier deliver the requested liners because they are torn and worn, and a Standard Written Order (SWO) is received and signed by the ordering physician?
A: Socks and liners in the Lower Limb Prostheses (LLP) LCD are covered as refillable items, so the order needs to contain the quantity listed for replacement of those items.

Q: We are running into a situation with a referral source. The beneficiary will have a sleep study and the doctor can see the diagnosis of Obstructive Sleep Apnea (OSA) on the preliminary report and will write an order for the equipment at that time. We receive the graph portion of the sleep study; however, the doctor does not interpret the sleep study until a later date and will sign the study at that time. Often, we receive the signed interpretation after the written order for the equipment. Is this acceptable?
A: Yes, there is no timeline requirement on when the suppliers must obtain the interpretation and Standard Written Order (SWO), other than the requirement that the SWO be obtained prior to claim submission.

Q: There seems to be some confusion as to the time frame for a break in service for PAP equipment. Is the break in service 60 days or 90 days?
A: A break in service that is greater than 60 days plus any days remaining in the last paid rental month would require initial coverage to be met to establish a new period of medical need. For a break in service of less than 60 days, no additional action is required, and billing would resume where it left off. More information is found on the Noridian Medicare website > Browse by Topic > Documentation > Break in Need or Service and Break in Billing.

Q: We have a beneficiary new to our company that has been on Medicare since 2019. The beneficiary has been on PAP therapy for many years and supplies have been billed to Medicare, however Medicare has never paid for PAP equipment. Recently the beneficiary's download shows despite being on therapy for seven hours per night, a high residual apnea/hypopnea index (AHI) which is primarily central in nature. The treating physician did bring the beneficiary in for a new titration sleep study which was a Bi-Pap/ Bi-Pap ASV study. This study does in fact confirm Central Sleep Apnea (CSA) as well as the benefits of Bi-Pap ASV treatment. We received an order to provide the beneficiary with a Bi-Pap ASV, however the original baseline sleep study was scored using the 3% desaturation. Will a new baseline sleep study be needed using the 4% desaturation scoring? If so, will a new titration sleep study be required showing the emergence of CSA and improvement on Bi-Pap ASV?
A: If the study cannot be rescored using the 4% criteria, a new study would be needed. The sleep study must meet the criteria outlined in the LCD, including demonstrating a diagnosis of CSA and significant improvement with the use of the device on the settings that will be prescribed for home use.

Q: What if the interpretation is signed and dated after the order?
A: The LCD states, "The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea." If the interpretation is signed after the prescription, there should be some indication in the medical record that the treating practitioner saw the polysomnography (PSG) results to identify the diagnosis of OSA.

Q: What is the timeframe for a break in use for PAP supplies? If the beneficiary has not been on therapy for 65 days, would he need a new sleep study to re-establish the diagnosis of OSA?
A: Yes, greater than 60 days would be considered a break in need and initial coverage criteria would need to be met to establish a new period of medical need, including a new sleep study. More information is available on the Noridian Medicare website > Browse by Topic > Documentation > Break in Need or Service and Break in Billing.

Q: If we are unable to get providers to document prior to product delivery, are we able to obtain documentation post-delivery but prior to billing?
A: We encourage our suppliers to obtain as much supporting documentation as possible prior to delivery. Not only does this help ensure that coverage criteria have been met, but also ensures that documentation is on hand in case of an audit. The only document that is required prior to billing is the Standard Written Order. Documentation requirements and additional resources can be found on the Noridian Medicare website > Browse by Topic > Documentation.

Q: Do physicians need to document that a wheelchair has enough navigation space inside of the beneficiary's home or is this documentation requirement satisfied by the home assessment?
A: This requirement is satisfied by the home assessment.

Q: Can you please provide any information on the implementation of the Lymphedema Compression Treatment policy with CMS and State Medicaid programs? I am having extreme difficulties right now as Washington State Medicaid has not implemented the new HCPCS codes and is requesting that we use A6549, which according to the Pricing, Data Analysis and Coding (PDAC), no longer works because of the new HCPCS released.
A: We cannot provide education or guidance on requirements for State Medicaid programs.

Q: Are there any products that are excluded from the 10-day early pick up rule?
A: For delivery of refills, the supplier must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. There are no exceptions to the refill requirements. More information is found in the Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.6.

Q: If a beneficiary has an ostomy but is rarely seen by their primary care physician for it because they go to wound care nurses, would notes from the nurses count towards the documentation requirements? They are the ones that are documenting what the LCD and Policy Article ask for.
A: The beneficiary's medical record is not limited to the physician’s office records. It may include hospital, nursing home, or HHA records and records from other health care professionals. The nurse's documentation in the record would support continued need. See the Noridian Medicare website > Browse by Topic > Documentation > Medical Records for more information.

Q: Can the SWO for a thoracic-lumbar-sacral orthosis (TLSO) be written with generic descriptions of the accessories, such as "2 lateral pads," "1 sling," "2 extensions," along with the TLSO?
A: The SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or require an upgraded code (list each separately). The description may be listed as either a general description (e.g., sling, lateral pads), a HCPCS code, a HCPCS code narrative, or a brand name/model number. General descriptions are allowed per the Standard Documentation Requirements Policy Article A55426 found on the Noridian Medicare website > Policies > Active LCDs.

Q: Regarding general description on the SWO, can we use a general description for items that have different HCPCS codes? For example, a TLSO is ordered, and different pads are needed for a proper fit, but they have different HCPCS codes. Can the order state something like "TLSO contour pad" and that will cover all pads that are billed?
A: A general description like 'TLSO contour pad' could be used. Per the Standard Documentation Policy Article A55426:

• General description of the item: The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number
• For equipment - In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
• For supplies - In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately).

Q: If there are multiple items on a SWO, but the DME supplier does not provide all items i.e., custom orthotics, does the supplier need to get a new SWO with just the items they billed or is the original SWO fine?
A: As long as the SWO includes the item you are providing and billing Medicare for, a new SWO is not needed.

Q: If a beneficiary has a physician visit and a SWO was written, then needs to have another visit because the first one didn't support medical necessity, is a new SWO required, or can we use the original SWO? Can you provide a source for this?
A: This depends on the item being provided. Some policies require a visit prior to the order and other policies are more general. Please refer to the applicable Local Coverage Determination or Policy Article for specific criteria.

Q: Medicare used to have a statement that said changes to a DMEPOS order after signature required the prescriber to date and initial the change. I can't find this now that Certificates of Medical Necessity (CMNs) are no longer needed. Is this still a requirement and can you provide a different source we can send to prescribers?
A: Any changes need to follow the recordkeeping principles outlined in the Program Integrity Manual, Chapter 3, Section 3.3.2.5.

Q: If a beneficiary-owned K0884 (power wheelchair), not paid by Medicare, needs repair, do we need to have documentation showing the coverage for the base item was met, or just documentation and orders that support the beneficiary continues to use and need the chair?
A: There are two documentation requirements when it comes to beneficiary-owned equipment. The treating practitioner must document that the DME item being repaired continues to be reasonable and necessary; and, either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary.

For additional requirements for repairs, please review the Standard Documentation Requirements Policy Article.

Q: Do you have a link that shows what HCPCS codes a skilled nursing facility (SNF) or long-term care facility can and cannot provide?
A: Please refer to the Consolidate Billing Lookup Tool on our website: Claims, Billing, and Appeals > Billing Situations > Consolidated Billing.

Q: For annual prescriptions on ongoing PAP supplies, our system generates an auto-service date of the initial date it was ordered. When we send the prescription for the following year, we must change that date manually. However, I'm finding orders that were not manually changed so may have a service date of 2021, but the practitioner signed and sent it back to us in 2024. Considering that the SWO date is defined as being the date that the order was communicated to us, is it ok to use these or do we need to request a new one with the service date changed to 2024?
A: Annual orders are not required by Medicare for PAP. A recent order for supplies may be used to support continued medical need, but the date would need to be timely (within 12 months prior to any date of service under review).

Follow-up question: For timely date, do they go by the date signed by the practitioner or received by the supplier versus the service date that was auto generated?
A: This is based on the order date. If the order does not specify "order date," the date communicated to the supplier may be used. When multiple dates are included on the order, like in the example given, a reviewer may not consider the order to be timely if a 2021 date is indicated. In this situation, the supplier is encouraged to get a new order.