ACT Q and A - May 13, 2021 - JD DME
ACT Questions and Answers - May 13, 2021
The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for one supplier, Noridian addressed directly with the supplier. This session included Medicare program updates, pre-submitted questions, and questions posed during the event.
- If a beneficiary requires parenteral nutrition three days a week and hydration four days a week, can B4193 and B9999 be on the same DME Information Form (DIF)?
Response: Question number six on the DIF requires that days per week be specified. When administration differs, two DIFs would be required.
- Clarify DMEPOS delivered to a beneficiary within two days of discharge for fitting or after surgery to home.
Response: Medicare allows DMEPOS items to be delivered up to two days prior to hospital discharge for training and fitting purposes. Items are not to be utilized in the hospital for physical therapy or any other purpose. For detailed information please see the DMEPOS and Inpatient Stays information on the website.
- For E0601 (positive airway pressure (PAP) device) reasonable useful lifetime (RUL) replacement, can new PAP supplies be included as part of the RUL and/or is refill documentation required?
Response: In the case of replacement of the PAP for RUL, refill documentation for supplies would still be necessary to determine that the previous supplies required replacement. Additionally, suppliers will want to be aware of the utilization schedule to avoid denials for providing replacement supplies too soon.
- Can a physician who has a provider transaction access number (PTAN), order and supply beneficiaries with competitive bid (CB) items without winning the competitive bidding area (CBA) contract?
Response: Practitioners enrolled as DMEPOS suppliers may provide competitive bid items to their own patients incident to a professional service visit on the same day. See the Competitive Bidding Program website for more information.
- Can we bill the beneficiary for Cathflo?
Response: Research indicates that this is a preventive drug and would not be covered under the DMEPOS benefit. There may however be coverage under Part B or Part D Medicare.
- If a beneficiary is in a skilled nursing facility (SNF) for the initial wheelchair date of service (DOS) and now needs repairs at home over one year later, can the wheelchair be placed on file as payable for repairs?
Response: A wheelchair provided during a SNF covered stay should have been reimbursed by the SNF. If the beneficiary now owns the wheelchair, repairs may be covered if the beneficiary meets the current coverage criteria for the wheelchair.
- If a sleep study prior to Medicare Fee-for-Service (FFS) enrollment does not state that hypopneas were scored at 4% and a new is study done, is there a need for new compliance for supplies only?
Response: The requirements for beneficiary’s entering Medicare on a PAP device are that they have a face-to-face (F2F) visit confirming obstructive sleep apnea (OSA) and use of the device along with a sleep study that meets the Medicare requirements at the time the beneficiary enters Medicare. There is not a requirement for a compliance period. Please see the PAP Local Coverage Determination (LCD) on our website under Policies > Active LCDs.
- Is severe edema/lymphoma an acceptable deformity for custom shoes when in conjunction with diabetes?
Response: Noridian is unable to pre-approve specific diagnoses in relationship to coverage. The entirety of the medical record will determine coverage eligibility including diagnosis. A reference listing of diagnosis codes is included in the therapeutic shoes for person’s with diabetes local coverage determination (LCD) which can be found on our website under Policies > Active LCDs.
- Can you clarify billing for prosthetics for a beneficiary in a Part A SNF stay at a rehab facility?
Response: Please visit Chapter 6 of the Noridian Supplier manual on the website for information on consolidated billing. Prosthetics are an exception allowing coverage while a beneficiary is in a SNF.
- When equipment is being repaired, can the beneficiary be charged for shipping the equipment to/from the manufacturer?
Response: Suppliers may not charge the beneficiary for shipping.
- Do multiple conflicting items on a standard written order (SWO) invalidate the order for themselves or other items?
Response: A SWO may have multiple items listed as the general description for provision of the item. However, unless there is specific guidance in the medical record, there must be a SWO obtained prior to billing that confirms the exact items provided.
- What are examples of change in condition to avoid denials?
Response: Noridian is unable to provide examples of change in condition. It is up to the treating practitioner to determine the medical equipment that is necessary for treatment of the Medicare beneficiary’s condition and to document that need in the medical record.
- Has sequestration been extended?
Response: The 2% sequestration suspension has been extended to December 31, 2021. Information is available on the CMS website.
- How do we bill COVID-19 beneficiaries out of the hospital for oxygen?
Response: As of the date of the published ACT Q&A, the oxygen coverage criteria are not being enforced during the public health emergency (PHE). There must be evidence of the medical necessity of the items ordered and claims may be billed with the CR modifier.
- Are there updates and information regarding custom fit orthotics?
Response: The DME Medical Directors (DMDs) of all four jurisdictions published two articles on March 11, 2021. These are Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code – Correct Coding and Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Correct Coding – Revised. Additionally, the outreach and education team published an article entitled Correct billing for Custom Fitted Orthotics when no Custom Fitting is Completed with no Off the Shelf Equivalent on May 7, 2021.
- What are the diagnosis codes that are covered for spinal orthosis?
Response: A spinal orthosis may be covered for the following conditions. 1) To reduce pain by restricting mobility of the trunk; 2) to facilitate healing following an injury to the spine or related soft tissues; 3) to facilitate healing following a surgical procedure on the spine or related soft tissue; or 4) to otherwise support weak spinal muscles and/or a deformed spine. It is up to the treating practitioner to record the proper diagnosis code which is supported by the condition documented in the medical record.
- How can we recertify an oxygen customer if he refuses to have a F2F?
Response: Under normal circumstances the F2F visit with the treating practitioner is required within 90 days of recertification. If the beneficiary refuses, the supplier may offer an Advance Beneficiary Notice of Noncoverage (ABN). During the PHE if the reason that the F2F cannot be accomplished is due to the PHE, the relaxed telehealth guidelines may be utilized, and the claim billed with the CR modifier.
- Does each state require a separate DME credential or will an out of state DME credential work with out of state Medicaid License?
Response: Please refer to the regulations for the applicable state Medicaid program.
- What is the rule regarding Nurse Practitioners (NPs) and Physician Assistants (PAs) working incident to Medical Doctors (MDs) to act as the certifying physician for diabetic shoes/inserts?
Response: NPs and PAs may act as the certifying physician and sign all documentation, however that documentation must be reviewed and signed off by the supervising practitioner. Please refer to the Medical Director article addressing this issue. It is entitled Nurse Practitioners and Physician Assistants as Certifying Physicians for Therapeutic Shoes and Inserts and was published November 5, 2020.
- Are there post PHE updates?
Response: At this time, CMS has not issued any additional guidance to the DME MACs on the PHE.
Verbal Questions Asked During ACT
- We’ve been billing Medicare for the L0642 (lumbar orthosis) with modifier KV but are still being denied based on Medicare guidance. Why are these denying? We are a physician’s office.
Response: Physicians are exempt from CB but still must follow the rules for off-the-shelf spinal and knee braces. Physicians and practitioners can provide these with modifier KV modifier, however the items must be provided to the beneficiary on the same date of service as the office visit. This information is located under Browse by Topic > Competitive Bid.
Follow-up: Our appeal was denied as not covered by Medicare.
Response: Please call Noridian’s Provider Contact Center for assistance on this specific claim; however, the next step is to send it to reconsiderations.
- How do I bill for refractive lenses upgrades? The frame costs $200, our cost is $100, and Medicare allows $75.
Response: When billing claims for deluxe frames, use code V2020 for the cost of the standard frames and the second line item using code V2025 for the difference between the charges for the deluxe frames and the standard frames.
- Regarding CB, we are an orthopedic office and we aren’t always able to provide the brace on the same day as the visit. What do we do in these situations?
Response: In a CBA, the rule states that a physician/practitioner has to bill with the same DOS. If the OTS brace can’t be provided that day, you’ll need to send the beneficiary to a CB supplier.
- We are a PAP supplier and we have some beneficiaries that do not meet initial compliance, then they do a titration study. What is the next step if they do not become compliant? Is there a timeframe?
Response: Neither a PAP device nor supplies are billable until the beneficiary becomes compliant. You can continue to work with them or offer an ABN because they haven’t met the compliance standard in the LCD, and then charge the beneficiary. There is no timeframe, once compliance is met, you pick up billing at month four.
- Regarding code L1845 (custom orthosis), the changes made to achieve individualized fit of the item requires expertise of a certified orthotist or an individual who has specialized training in provision of orthotics and compliance with all applicable federal and state licensure and regulatory requirements. Who can sign off on L1845?
Response: The DME Medical Directors (DMDs) provided instructions in the article stating for more than minimal self-adjustment, the requirements are as noted in the question. We have been asked if a custom fitter can do this and the answer is yes if he/she is an individual who has specialized training in provision of orthotics and compliance with all applicable federal and state licensure and regulatory requirements. One of the most important things to do, if custom fitting has been completed, is to ensure everything is documented.
- Why are physicians and practitioners exempt from CB when DME suppliers are held to these standards?
Response: CMS developed this guideline. You can reach out to the Competitive Bid Implementation Contractor (CBIC) for assistance.
- If several months after initiation of PAP, a beneficiary meets PAP compliance, the supplier can start billing at the fourth month. My understanding is that during that first three months, the download compliance must be met. If they don’t meet that, it must be started over. The F2F can be done months later but the download must be met during the first three months.
Response: That is correct. To be successful in the trial, compliance must be achieved in the first 90 days. The F2F may occur after the 90th day and when that happens, billing may resume at the time of the F2F. When the beneficiary fails the compliance trial period and had a F2F and repeat sleep study, there is no timeframe to meet compliance when going through the second trial. When the first trial is failed, the beneficiary must have the F2F and repeat sleep study in a lab and become compliant. Once compliant, month four can be billed.
- The Noridian LCD has more definition on RDI versus the National Coverage Determination (NCD). You require sleep studies to be interpreted by an accredited practitioner who is certified by American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA) yet your policy directly forces them to score against guidelines. The scoring guideline indicates respiratory disturbance index (RDI) = Apneas + Hypopneas + respiratory effort related arousals (RERAS) yet you do not want RERAS included. REI is what you want which is defined as apneas + hypopneas/monitoring time. Three letters change the policy to allow physicians to follow the guideline of American Academy of Sleep Medicine (AASM) of which they are supposed to be bound. Why has this not been changed?
Response: The NCD is the ultimate source and the guidance we follow comes from the durable medical equipment medical directors (DMDs) who update the LCDs. Provider Outreach and Education (POE) has been instructed by them that RERAS are not included as noted in the PAP LCD. We have also been instructed that until the NCD addresses REI, then REI is not acceptable. You are welcome to submit an LCD reconsideration:
- There must be a clinical need documented in the medical record. When we tell physicians that, we receive a lot of difficulty. Is this written anywhere?
Response: Interim final rule with comment period (CMS-1744-IFC and CMS-5531-IFC) address the non-enforcement of clinical coverage requirements for certain policies, including the need for the item to be “reasonable and necessary”.
Written Questions Asked During ACT
- For a hospital bed to be covered by Medicare, must the documentation in the medical records include that pillows and wedges were ineffective?
Response: The LCD does not specify that pillows or wedges must be tried. Depending on which criteria the beneficiary meets, the use of those items may help provide support for the hospital bed.
- For an E0165 (commode chair with detachable arms) to be covered, must the beneficiary meet the criteria in the LCD just for the E0165 (to facilitate transferring or needing extra width) only or must the beneficiary meet the criteria for both the E0163 (commode chair with fixed arms) and E0165?
Response: The beneficiary would have to meet criteria for the L0163:
- The beneficiary is confined to a single room, or
- The beneficiary is confined to one level of the home environment and there is no toilet on that level, or
- The beneficiary is confined to the home and there are no toilet facilities in the home.
- We noticed that fees/allowables in the second quarter, more specifically for dates of services in April 2021, have increased for some items however Medicare paid according to the previous fee schedule. Will Medicare be correcting the claims automatically and making additional payments to providers?
Response: Noridian is waiting on direction from CMS for the processing of the April 2021 fee schedules. Once direction has been issued, notification will go out to suppliers on the next steps.
- Why are we getting unfavorable decisions on redeterminations for same or similar orthotics when there is no documentation in the supplier’s notes that talk about an adjustment being attempted on the old orthosis? Same or similar coverage within the five-year RUL states there only needs to be detailed documentation that there has been an anatomy change necessitating a new device. We will have detailed documentation for an anatomy change, but Medicare will deny stating the supplier did not document an adjustment was attempted. There is nowhere in the section regarding same or similar denials on orthotics that state we are mandated to put this in our note, or it will deny. We should not have to follow any repair/replacement documentation requirements when that is not why the physician is sending the beneficiary to us. They are referring the beneficiary to us for a new orthotic due to an anatomy change and the current one is no longer acceptable.
Response: If there is another orthotic within the same category that has been paid for within the last five years, it will deny by the system as a same/similar item and a redetermination needs to be filed if it has met criteria for a replacement item. The definition of replacement is found in the Medicare Benefit Policy Manual (CMS Publication 100-02), Chapter 15, Section 110.2.C. That section generally defines replacement as the provision of an entirely identical or nearly identical item when it is lost, stolen, or irreparably damaged. If you have received a denial for a specific claim and are not understanding, we would not be able to address specific claims during the webinar, but you can call the Contact Center to clarify the decision.
- Can a beneficiary do a telehealth visit with the physician to get a prescription for her initial prosthesis?
Response: Keep in mind that there are specific requirements of telehealth, but for the prescription of the device itself telehealth should be acceptable as the need for the prosthesis can be identified with video interaction along with the audio.
- In discussion with another company this morning we were told that we, as a DME supplier, can bill for both an oxygen concentrator base unit as well as the portable oxygen concentrator unit simultaneously. Can we bill E1390 with E1392 and if yes, where is the criteria located?
Response: A portable concentrator (E1392) and stationary concentrator (E1390) can be billed at the same time, however the beneficiary would need to meet policy criteria for each item billed. See the Oxygen LCD on our website under Policies > Active LCDs.
- Does the ordering provider have to be the same physician who signs the Certificate of Medical Necessity (CMN) or DME Information Form (DIF)?
Response: A DIF is completed and signed by the supplier. It does not require a physician's signature. The physician/practitioner that signs the CMN can be different from the ordering provider.
- Is there a link that shows which items are included in competitive bid minus what was excluded because of the PHE?
Response: Items subject to competitive bid can be found on the Competitive Bid Implementation Contractor (CBIC) website. Competitive bid and the COVID-19 Public Health Emergency (PHE) are unrelated. You can find information on COVID-19 waivers and flexibilities on the home pages of our website.
- For capped rentals, what are parameters for collecting coinsurance? Can the entire estimated coinsurance over the rental period be collected at time of delivery?
Response: Capped rentals are a monthly payment. Suppliers are only able to bill the beneficiary the patient responsibility (PR) at the time of billing. It would be inappropriate to request full 13-months of coinsurance at the time of initial rental.
Follow-up Question: Can the first month be collected at the time of delivery or can it only be collected after the claim is billed?
Response: Coinsurance for the first month, may be collected at time of delivery
- If a client had their power mobility device (PMD) authorized via Prior Authorization Request (PAR) with another vendor, but no longer wants to use that vendor, does the new vendor need to secure another PAR approval or does the auth follow the client?
Response: An affirmed PAR decision follows the beneficiary. For more information, please contact the pre-claim hotline at 701-433-3041. You will need to leave a voicemail and include the beneficiary name, supplier name, phone number, and availability.
- For a capped rental item in which client doesn’t meet criteria, can the claim be filed with NUGA or NUGY modifiers (depending on the client’s specific situation) and be properly denied as patient responsibility (PR be able to bill the secondary funding source for purchase of the item as authorized or will the CMS claim be denied for invalid modifier?
Response: Items classified as capped rental by Medicare must be billed as a rental. The GY would be inappropriate, though a GA may be utilized with a properly executed ABN. When executing the ABN and billing, rental is still required.
- We are intending to provide an Abbott Freestyle 2 Continuous Glucose Monitor, but I don’t know if it is a Class III medical device. If it is, I believe I need to use the KF modifier. Where is this located?
Response: Class III CGM devices are listed on the PDAC website.
- How often do we need a new prescription for PAP supplies? If we get a prescription from the doctor saying lifetime need, do we need to get another prescription on some frequency?
Response: When the prescription for PAP supplies indicates a lifetime length of need, there no requirement to obtain a new one on a regular schedule by Medicare. You would need a new prescription if there is a change. Also, note that you would want to follow all applicable state requirements.
- When billing sensors for a continuous glucose monitor monthly, we see that reimbursement is $259.72 on the fee schedule. Is that per unit? Most beneficiaries need two per month and I'm not sure how to bill it.
Response: The K0553 is a 30-day supply allowance which includes all supplies and accessories required within that 30 days. The reimbursement is not based on individual items.
- If someone goes off hospice, is there a specific amount of time required before DME can be provided? Do we need some sort of documentation from the member to prove they are no longer receiving hospice?
Response: Once the beneficiary is discharged from hospice, they could be eligible for full coverage. Always check beneficiary eligibility on the Noridian portal to ensure proper coverage.
Follow-Up Question: What if a member goes off hospice for two weeks, can DME be provided during that time period?
Response: For questions on consolidated billing, please use our Consolidated Billing/SNF/Home Health/Hospice Lookup Tool. This will assist you in knowing which supplies are covered under hospice episodes:
- A beneficiary has surgery in the hospital and requires an ankle/foot orthosis (AFO), spinal orthosis, or non-OTS orthosis and it's delivered within two days of discharge but is kept on the beneficiary after fitting/training. Can the supplier still bill this or is the hospital responsible?
Response: In this case, the facility would be responsible for the brace if it was used within that facility for more than training. As Chapter 5 of our Supplier Manual states: Supplier delivers the item to the beneficiary in the facility solely for the purpose of fitting the beneficiary for the item, or training the beneficiary in the use of the item, and the item is for subsequent use in the beneficiary's home. Please refer to the Noridian website > Claims and Appeals > Billing Situations > Inpatient Stays.
- I see that A7020 (Interface for cough stimulating device) is billable after the purchase of the cough assist; however, additional information was just added to the code stating it is for replacement only. It must not be billed at the time of initial use. Is the interface allowed for payment after the initial one?
Response: Reimbursement may be made for replacement of A7020 only if the beneficiary owns or is purchasing the mechanical in-exsufflation device.
- A beneficiary signs an ABN because they failed PAP compliance. If we bill E0601 for months four through six with the ABN and the beneficiary becomes compliant at month seven, would Medicare pay rentals seven through 13?
Response: The months billed to the beneficiary do not count toward the thirteen months Medicare will pay. Medicare billing would still resume at month four when the beneficiary becomes compliant.
- Can you provide the exact date the custom codes went into effect? We are getting audited for claims back in 2018, so I was wondering when Medicare started requiring documentation with the custom code.
Response: If custom fitting has been completed, there must be documentation in the medical record of what was completed at time of delivery for fitting and has been the rule since the codes split. As part of the 2014 and 2015 HCPCS code update, codes were created describing certain off-the-shelf (OTS) orthotics. Some of these codes’ parallel codes for custom fitted versions of the same items.
- Are DME providers able to distribute a three-month supply of PAP supplies via an in-person office visit?
Response: Yes, PAP supplies are allowed for a three-month supply always.
- Are DME providers required to obtain an updated CMN every 12 months to continue CPAP resupply (mask, cushions etc.)?
Response: The PAP policy does not have a CMN requirement. It is a SWO that must be obtained. There is no scheduled timeframe for a new SWO, however a new order must be obtained if the length of need expires or there is a change in the items ordered.
- Our billing system caused CMNs to be created with the outdated 484.5 form after its expiration date. The 484.3 form is no different in terms of required information. Are we required to obtain a doctor’s approval a second time with the current form because of the mistake?
Response: The correct/current CMN form for the date of service would be required in the event of a records request or audit.
- An existing PAP beneficiary entering Medicare has a need for a new PAP machine, because we don’t have 13 months billed and paid through Medicare, we must prove medical necessity. Sometimes we get stuck because they had a sleep study 10 years ago, but we can’t get F2F notes prior to that study as it was so long ago. Is there any way to get around sending them to the lab to get a new study? Seems like more money for Medicare.
Response: A beneficiary entering Medicare on PAP therapy must follow the “Beneficiaries Entering Medicare” portion of the LCD. This requires a F2F visit following Medicare eligibility and a sleep study that meets the Medicare criteria at the time the beneficiary enters Medicare. There is no requirement to access the original F2F prior to the sleep study in this case. Beneficiaries would be eligible for a PAP device and/or supplies. For beneficiaries who have long been Medicare, qualification is established at the time of initial provision of the device. When 13 months are paid, supplies will be covered without obtaining the original documentation.
- Is there any discussion going on with Medicare to re-institute competitive bidding for PAP devices and oxygen?
Response: Competitive Bid Round 2021 goes through December 31, 2023. We have not received any direction on what Competitive Bid will include after December 31, 2023. Please refer to the CBIC website on future rounds on Competitive Bid and what will be included.
Last Updated Mon, 14 Jun 2021 15:20:22 +0000