ACT Questions and Answers - August 13, 2020

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.

Pre-submitted Questions

Q1. We provided a beneficiary with oxygen on March 16, 2020. The beneficiary was a hospital discharge and the diagnosis code on the Certificate of Medical Necessity (CMN) was chest pain. We used a GA modifier. Can we change this to a CR modifier?
A1. To change a GA modifier, a redetermination must be submitted. Per CMS-1744-IFC and CMS-5531-IFC, the clinical criteria are not being enforced during the COVID-19 public health emergency (PHE) for dates of service March 1, 2020, until the end of the COVID-19 PHE. However there remains a requirement that the medical records reflect why the item/service provided is medically necessary.

Q2. Are there any updates on the PHE protocol? How do we bill after the pandemic?
A2.The DME Medicare Administrative Contractors (MACs) have been directed to resume condition of payment prior authorization requirements for power mobility devices (PMD) and pressure reducing support surfaces (PRSS) which was effective August 3. In addition, lower limb prosthetics (LLP) will be added in four demonstration states on September 1, 2020. In Jurisdiction A, the demonstration state will be Pennsylvania and in Jurisdiction D, it will be California. The DME MACs have no direction at this time for billing requirements when the PHE has ended.

Q3. Where are the correct intake forms that I need to submit claims with located?
A3. Medicare does not have required intake forms. Noridian does offer a suggested intake form [PDF] on our website.

Q4. Can an employee who is an Assistive Technology Professional (ATP) and physical therapist (PT) do both the PT and ATP evaluation and create the Letter of Medical Necessity (LMN) for the physician to sign for wheelchairs?
A4.No. Per Local Coverage Determination (LCD) L33789 Power Mobility Devices, the PT, occupational therapist (OT), or practitioner performing the specialty evaluation cannot have any financial relationship with the supplier.

Q5. Can a beneficiary receive both a power wheelchair and a knee-ankle-foot orthosis (KAFO)?
A5. In order for this to occur, the medical necessity requirements of both the power mobility LCD and the Ankle-Foot (AFO)/Knee-Ankle-Foot Orthosis LCD (L33686) would have to be met.

Q6. Can we take an oxygen beneficiary off service if they refuse a new setup after 60 months?
A6. If a beneficiary elects not to receive new equipment after the end of the five-year reasonable useful lifetime (RUL) and if a supplier chooses to transfer title of the oxygen equipment to the beneficiary, maintenance, accessories, and repair are statutorily non-covered per LCD L3397 Oxygen and Oxygen Equipment.

Q7. Could I use the CR and RA modifiers when I have a replacement product prescribed by the beneficiary’s doctor through telemedicine during the PHE?
A7. During the COVID-19 PHE, the CR modifier is to be utilized whenever standard requirements are unable to be met as a result of the PHE. This would include when replacing items due to loss, theft, or irreparable damage as well as oxygen replacement which all require the use of the RA modifier.

Q8. When can we expect the audits to fully resume?
A8. CMS has directed the DME MACs to initiate post-payment review beginning August 17, 2020, for dates of service prior to March 1, 2020. There is no indication at this time when the Targeted Probe and Educate (TPE) review program will resume.

Q9. Has the one-time mass adjustment for claims with a date of service (DOS) between March 6 and April 22 for 75/25 rates been completed and do suppliers need to take any action?
A9. The fee schedule adjustments for dates of service March 6 through April 22 as a result of the CARES Act have not yet been completed. The DME MACs are currently awaiting information from CMS. Suppliers do not need to take action on these dates at this time.

Q10. When two E0467 (multi-function ventilator) are billed, they both deny as a CO151. Why?
A10. When two ventilators are billed on the same day, there will be a denial for duplicate equipment. In this case, with CO151 (Payment adjusted because the payer deems the information does not support this many/frequency of services).

Q11. Do multiple contradictory items (disposable and non-disposable filters) invalidate a Standard Written Order (SWO)?
A11. In the absence of specificity for supplies on the SWO, reviewers will look to the medical record for supporting documentation of the items billed. While an SWO may have a generic description, such as “filters”, suppliers are reminded that the specific type being provided will need the support of the medical record.

Q12. Please clarify the frequency of intermittent catheter coverage. It is understood that Medicare will allow up to 200 intermittent catheters per month. If the beneficiary needs to catheterize more than four times per day, do we need additional documentation from the physician as to why five or six times per day is needed (not just that they need five or six times per day but why more than four times a day)? We have gotten audit denials in the past and were educated that more than four times per day is usually not medically necessary unless the doctor justifies why in the medical records.
A12. Over-utilization of any supply beyond what is considered reasonable and necessary would require clinical documentation in the medical record supporting the need for the additional supplies.

Questions Asked During ACT

Q13. I have a couple of beneficiaries that have a same or similar AFO within the five-year RUL. They want to get a new brace, we have an Advance Beneficiary Notice of Noncoverage (ABN) on file, and bill with the GA modifier. Even though we have all the correct documentation on file, we are getting payment on these and then we receive a Recovery Audit Contractor (RAC) audit several years later saying the RUL has been met and we will get automatic denials. It takes years to get to the Administrative Law Judge (ALJ). We would rather have the claims denied up front. The only part the RAC is looking at is the RUL and even though a beneficiary has had surgery, for example, even though we’ve submitted documentation from the physician that there was a change in condition. We’ve gone through discussion period, redeterminations, reconsiderations, and now we are waiting for the Administrative Law Judge (ALJ).
A13. Use of the GA modifier does not guarantee a beneficiary-liable denial because there may be information in the claims processing system that show the claim is payable. If there’s been a change in condition, that is justifiable. We recommend calling the Contact Center on some recoupment cases and ask for a Tier II representative. The Contact Center doesn’t have the authority to override a RAC recoupment, but they can connect with our RAC liaison and perhaps help with prevention of this circumstance. Also, you may be able to resolve these at the reconsideration level with a formal telephone discussion with Maximus, the reconsideration contractor. Suppliers can present their clinical documentation as to why the claim should be paid and they have nearly the same authority as the ALJ. In the future, you can request a formal telephone discussion on the reconsideration form, prior to submitting it.

Q14. A beneficiary comes on to service that wasn’t on Medicare and is already on a continuous glucose monitor (CGM). If we receive documentation from the physician but we don’t have any of the logs/readings, can we use a narrative statement from the medical record to show they meet the testing requirements?
A14. The logs would be ideal to show the beneficiary is actively using the CGM. However, if the physician summarizes that the beneficiary is actively using their CGM in the medical records, it would be acceptable.

Q15. A beneficiary goes to their primary care physician, discusses symptoms, and then refers the beneficiary for a sleep study. The initial visit notes show the beneficiary may have sleep apnea and the sleep study is completed. Is another face-to-face (F2F) required? Medlearn Matters 8304 shows the F2F is required for positive airway pressure (PAP) devices.
A15. Currently, no, there is not another F2F requirement. There were requirements surrounding the Affordable Care Act (ACA) that there had to be a F2F within six months of the order. CMS has a master list associated with direction in the Federal Register from which they will select a “required list”. That list will clarify policies that will return to the requirement for F2F visits and SWO prior to delivery. CMS was intending to publish the required list this past spring but with the PHE, it has not yet been published. Medlearn Matters 8304 is regarding the ACA, which is no longer in effect. When the SWO (Special Edition (SE) 20007 and SE20011) came out on January 1, 2020, any other kind of order (detailed written order, five-element order, seven-element order, etc.) was eliminated. The only order that is applicable is the SWO and it does not have a requirement of being within six months of the most recent F2F at this time.

Q16. We have a beneficiary who lives in our jurisdiction, but his address is listed in another one because of the power of attorney (POA). I have a denied claim that we cannot appeal because we are not in the correct jurisdiction. If I bill a claim to our jurisdiction, it gets paid, but if a claim gets denied and I try to appeal it, I’m not able to due to the incorrect jurisdiction. Which jurisdiction should I be billing since he is living in one but the POA is in another one.
A16. When there is a POA on file, the claim will read the address entered on the claim. However, the state code registered with Social Security needs to match. The beneficiary can contact Social Security to have the state code updated to where he lives.

Follow-up Question: The POA will still receive the mail, even with the updated state code?
Answer: Yes.

Q17. A beneficiary has a commercial primary insurance with Medicare as secondary and Medicaid as tertiary. The primary pays a majority of the claim and Medicare pays the remaining amount. If the same item is billed again and the commercial insurance does not pay, will Medicare look at it like it’s the first time paying those codes since originally, just the balance was paid?
A17. No, Medicare looks at the claim in the same manner for the RUL of the item regardless of whether Medicare was primary or secondary. Once Medicare pays anything, the guidelines follow the RUL.

Q18. The LLP prior authorization is not in effect until December 1 nationwide. Is there going to be a webinar to show suppliers what needs to be submitted?
A18. Webinars were held on August 27 and September 10. There will be additional webinars scheduled as December 1 approaches. Suppliers can register on our website under Education & Outreach > Schedule of Events once the webinar dates are determined. Suppliers who do not already receive our email notifications each week should register now to be notified when these webinars are scheduled.

Q19. A beneficiary owns their CPAP that was purchased by Medicare but it broke. It meets RUL and the documentation shows the beneficiary was using it, but it is now broken. It’s been approximately four months since it broke. Is a new sleep study needed because the beneficiary hasn’t used the machine in four months?
A19. Technically, Medicare ceases the medical necessity if the period of time exceeds 60 days plus the days remaining in the month in which usage stopped. Ideally, it would be less than 60 days; however, in an audit circumstance, looking at the totality of the medical record, seeing the continued medical need, etc., all of that would be taken into consideration.

Follow-up: Is this answer because of the PHE?
Answer: The Medical Review nurses can use clinical review judgement and totality of the medical record to make their determination. Reviewers would take all factors into consideration.

Q20. We are a podiatrist office and also a DME supplier. What are the guidelines if the podiatrist writes the order for the diabetic shoes and inserts? Does he have to be in the suite at the time of dispensing?
A20. No, the podiatrist does not have to be in the suite at that time.

Q21. Was the SWO change prior to COVID-19?
A21. Yes, the new SWO requirements were effective January 1, 2020.

Q22. Regarding the SWO, can I create and provide a SWO, including the beneficiary information, the prescription, HCPCS codes, diagnosis codes, and physician information to the physician?
A22. Yes, suppliers can take the basics provided by the ordering practitioner, making sure it has all the elements of the SWO and submit to the ordering practitioner for review and signature. Note: Diagnosis codes are not a requirement for SWO but can be included.

Follow-up Question: If a beneficiary walks into our store and wants a brace, can I give the beneficiary a SWO to take to their physician to complete?
Answer. No, the practitioner needs to initiate the order so you would need to tell the beneficiary to go to their doctor and have their doctor contact you because it requires an order. Then you can create the SWO and send it back to the doctor. Unless the beneficiary wants to sign an ABN and purchase the item as self-pay because they do not have an order.

Follow-up Question: If I create a website and I market to the general public, when people are interested in a product and respond with their name, phone number, and email address, they have to go to their doctor first?
Answer: Yes, you can advertise, but you are not able to initiate contact for the order, the practitioner needs to initiate contact with you as the supplier to order Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS).

Written Questions During ACT

Q23. Is “FWW” instead of “front wheeled walker” acceptable on the SWO?
A23. The SWO can be a general description of the item, a HCPCS code, a HCPCS code narrative, or a brand name/model number. Even though the description can be generic, it would be in the supplier’s best interest to be sure that the item ordered was identifiable rather than simply an acronym.

Q24. What is specifically required in a beneficiary’s medical record when the beneficiary wants to switch from a CGM to a blood glucose monitor (BGM)? We have had numerous beneficiaries switch and when we obtain the medical record, we see a lot of records indicate they do not trust the CGM and prefer to go back to the BGM. We submit the medical record and the denial is not overturned. Does the reason have to be a medically necessary reason for the switch? Can the beneficiary switch back to a BGM after five years?
A24. There must be a medical need to switch from a CGM to BGM. Beneficiary preference would not be sufficient. After the five-year RUL, the beneficiary can switch back to a BGM.

Follow-up Question: Does that means the beneficiary is responsible for the cost of the BGM and the strips for the remainder of the five-year term after the dispense date of the CGM?
Answer: If a beneficiary chooses to return to use of a standard BGM due to preference, yes, they would be responsible for the five year RUL. If there is a clinical reason to change back to a BGM from a CGM, for example, if the beneficiary cannot tolerate the CGM, this should be documented within the medical record. The initial claim returning to BGM will deny and an appeal would need to be filed to support the change back to the BGM. If medical necessity is not addressed in the medical documentation, the beneficiary should be offered an ABN.

Q25. I have received denials from Redeterminations stating that we did not provide all of the documentation for the power wheelchair that the beneficiary had and since we did not prove the necessity, the ventilator would not be covered since Medicare was not the company that paid for the power wheelchair. As a respiratory provider, is this correct that we have to prove necessity of a wheelchair when the physician writes in the notes that they are wheelchair dependent?
A25. For a ventilator for use with a power wheelchair, there would need to be a power wheelchair on file with Medicare. Add a narrative on the claim with the HCPCs code of the base equipment that it is beneficiary-owned along with the date the beneficiary obtained the equipment. This will ensure the wheelchair is noted in the system to allow for the ventilator to be used with that wheelchair.

Follow-up Question: The review department was asking for all of the documentation for the wheelchair meeting Medicare criteria, not the purchase information. Why are we being held responsible to provide all of the documentation for a power wheelchair medical necessity?
Answer: Any time a claim is taken to a redetermination, all documentation supporting the need (or lack thereof) is required to be submitted with the request.

Q26. I’d like to clarify working between different lifespans, not medical necessity. A beneficiary receives a knee brace HCPCS L1812 (lifespan one year) on February 1, 2019. On January 20, 2020, it is determined that a different type of knee brace is needed and HCPCS L1851 is ordered. Since L1812 (original brace) had a lifespan for one year, does the beneficiary have to wait until after February 2, 2020, to receive L1851?  Would there be a denial for same/similar since they are both knee braces even though they have different lifespans?
A26. There is a potential for a same/similar denial since there is some overlap for the RUL L1812 and L1851. If suppliers receive a same/similar denial, a redetermination should be filed with documentation showing the change in condition.

Q27. Regarding Advance Determination of Medicare Coverage (ADMC), is this something we can do routinely for our beneficiaries for all high-end knee braces, which are not custom made (example: HCPCS L1851 or L1852)?
A27. ADMC is available only for certain manual wheelchairs. Knee braces are not eligible for ADMC. Eligible HCPCS may be viewed on the Noridian website.

Q28. To bill Medicare for a PAP machine, we are required to obtain a copy of the F2F record that occurred prior to the sleep study. If this F2F is conducted via qualifying telemedicine, do we need to append the CR modifier and a COVID-19 narrative to the PAP claim?
A28. Telehealth visits are acceptable during the COVID-19 PHE. Suppliers providing services resulting from telehealth visits should append the CR modifier and a COVID-19 narrative on the claim.

Q29. If a beneficiary is due for a new CPAP, it's been over five years, they are with a different company and want to switch to another CPAP, do they need a new sleep study or just get all the medical records from the doctor and send in the claim? Is another F2F required?
A29. If Medicare paid for the first machine, the RUL criteria would apply. For replacement due to RUL there must be an in-person evaluation by their treating practitioner that documents the beneficiary continues to use and benefit from the PAP device. There is no requirement for a new sleep test or trial period.

Q30. Can a supplier provide DME supplies to his parents or close family?
A30. Yes, but no one with a financial interest with the supplier can accept the item on behalf of the beneficiary. The beneficiary or someone without a financial interest must sign for the delivery of the item.

Q31. Can a beneficiary get CGM Freestyle libre if he is not on insulin?
A31. One of the criteria for a continuous glucose monitor is that the beneficiary is insulin-treated with multiple daily injections of insulin or on a Medicare-covered insulin pump.

Q32. For diabetic shoes/ inserts, is it true that either visit can be done first as long as it is within the six-month/ three- month time frame, or does the beneficiary need to see the certifying provider first? Does the provider who ordered the shoes/inserts need to be in the suite when the shoes/inserts are dispensed? Does the beneficiary need to be seen when the orders are placed for shoes/inserts or can the orders be placed days after the visit with the podiatrist?
A32. The office visit with the certifying physician showing that the beneficiary’s diabetes is being managed must occur within six months prior to the delivery of the shoes/inserts. In addition, there must be an office visit within the six months of delivery of shoes that describes one of the qualifying conditions of feet/foot. The certification statement should be signed on/after the date of the in-person visit and within three months prior to the delivery of the shoes/inserts. The supplier should have an in-person evaluation with beneficiary prior to the selection of the items includes: an examination and measurements of the beneficiary’s feet.

Q33. During the COVID-19 PHE, is an order for oxygen enough to support medical necessity?
A33. In addition to the order, the beneficiary’s medical record needs to show the item is medically necessary.

Q34. Regarding telehealth, if the visit is noted as telephone-only, and it does note medical necessity for an item, will this work under the COVID-19 PHE or does it still have to be audio and video?
A34. Under the waivers and flexibilities for the COVID-19 PHE practitioners may conduct telephone only visits. Suppliers will need to append the CR modifier and COVID-19 narrative to a claim generated as a result of a telephone visit. Additionally, please note that there is not instruction at this time for what will be required following the end of the pandemic for circumstances such as this.

Q35. What is the correct modifier to use when billing an ankle-foot orthosis (AFO) when there is a same or similar item recently received? We have an ABN on file and the beneficiary will be self-paying for the brace.
A35. If an ABN is obtained, the GA modifier would be appropriate to append on the HCPCS being billed.

Follow-up Question: Will the GA cause the claim to be automatically denied?
Answer: Not necessarily, the claim will go through all claims processing edits and then the liability assignment will be determined.

Q36. The beneficiary was on a bi-level without back up (BIPAP) in 2015 and later stopped using the equipment. Now the doctor is ordering a new BIPAP. The beneficiary has had a new sleep study to prove medical necessity. In 2015, the CPAP was tried and proven ineffective. Will the beneficiary need to be tried now on a CPAP and it be proven ineffective or will the documentation from 2015 be valid?
A36. Our assumption is this is under the obstructive sleep apnea (OSA) diagnosis for the PAP policy. Regardless of what happened in 2015, the fact that the beneficiary has not used a device in five years, would require a F2F indicating there is still need and a new diagnostic sleep study. There is no requirement under the PAP policy for the CPAP to be tried and failed before moving to the BiPAP. If it is the practitioner’s determination through work with the beneficiary that they need to be on a Bilevel and it is clinically documented, the beneficiary can begin therapy on the Bilevel for OSA.

Q37. A beneficiary using a CGM is inherently testing four times per day and would meet the testing requirement for an insulin pump. If a customer is on a CGM prior to Medicare coverage, could we use the CGM to meet the testing requirement or what do we need to show the customer satisfied the testing requirement of four times per day?
A37. Testing results can be used from a CGM device. There are times when a beneficiary comes onto Medicare after already having a CGM. To meet the medical necessity of the four times or more, data from the CGM could be used to support testing requirements.


Last Updated Fri, 08 Oct 2021 12:37:30 +0000