ACM Q and A - August 20, 2025 - JD DME

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Meeting (ACM). 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 to one supplier, Noridian addressed it directly with the supplier.

Questions Received Prior to ACM

Q: What documentation and prior authorization request (PAR) information are required for L1832 (knee orthosis)?
A: Required documentation for the L1832 for PAR is as follows: face-to-face (F2F) encounter, written order prior to delivery (WOPD), and any additional medical records providing support for medical necessity.

• Noridian Medicare website > Medical Review > Pre-Claim Review > Required Prior Authorization Programs > Prior Authorization for Orthoses

Q: Should the diagnosis on a clinical visit be the same diagnosis on the DME service?
A: The diagnosis on a clinical visit does not have to be the same as the diagnosis on the DME claim for billing purposes. However, the medical record must support the DME item billed, and the diagnosis billed on the DME claim to receive payment for the DME item.

Q: When a patient requires a high liter flow over 4 liters per minute (LPM) only while ambulating, does Medicare still cover the higher liter flow?
A: Medicare will cover a high flow rate greater than 4 LPM only when there is a qualifying blood gas study completed while the beneficiary is on 4 or more liters. If 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be limited to the standard fee schedule allowance. For more information review the Oxygen and Oxygen Equipment Local Coverage Determination and Policy Article.

Q: Would coverage of a ventilator fall under the definition for Emergency Medicaid Only?
A: Noridian is unable to address questions regarding Medicaid. Please contact your Medicaid contractor for guidance.

Q: Can you provide an update on the coverage criteria and prescription requirements for hospital beds or Group 3 pressure reducing support surfaces (PRSS) for prior authorization (PA) or documentation?
A: There are no new updates to the prior authorization process or policy for hospital beds or the Group 3 PRSS process. The DME MACs will begin to educate when information is available. Please refer to the resources below for more information.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs
• Noridian Medicare website > Medical Review > Pre-Claim Review > Required Prior Authorization Programs > Prior Authorization for Pressure Reducing Support Surfaces

Q: What is the process the supplier and patient should follow when a fraudulent claim for Durable Medical Equipment (DME) is found?
A: If the patient suspects fraud they can contact 1-800-MEDICARE (1-800-633-4227). The supplier should cease submitting claims related to the suspected fraud until the issue is resolved and report the suspected fraud. Notify the Centers for Medicare & Medicaid Services (CMS) 1-800-MEDICARE, and the Office of Inspector General (OIG) 1-800-HHS-TIPS (1-800-447-8477). There is online reporting as well.

• CMS: Crushing Fraud, Waste, & Abuse
• OIG: What is your complaint regarding?

Verbal Questions During ACM

Q: If a claim was denied due to the doctor being retired, do we submit a reopening or a redetermination?
A: A reopening is allowed in this situation.

Q: We receive denials for Q2052 (services, supplies, and accessories used in the home for the administration of intravenous immune globulin (IVIG)) because the drug was not paid prior to submission. When I call Customer Service, I’m told this is because the drug is not on the same claim as the Q code. Can you verify that these codes need to be billed together?
A: The Q2052 can be billed separately and does not need to be administered on the same day. However, the date of service for the administration must be within 30 days of the date of service of the drug. If the Q2052 is billed without the J-code, the claim will be recycled for 15 days and will be denied if no associated J-code is located in the system. If you are receiving denials in this situation, you may call Customer Service to have the claims reprocessed.

Q: Is there a group available to reach out to for assistance with billing Medicare Secondary Payer (MSP)?
A: Noridian does not have a group available. However, since the questions are claim-specific, please call Customer Service for further assistance.

Q: We’ve received different answers regarding the need for a diagnostic sleep study. We have beneficiaries transfer to us, but we are unable to locate the diagnostic sleep study. We’ve been told that as long as Medicare paid for the original machine, one is not required. We’ve also been told that another one would be needed. Can you please clarify?
A: If Medicare originally paid for the device, the medical necessity was met, and another study is not needed. If the beneficiary needs a replacement device, follow the LCD guidelines regarding Reasonable Useful Lifetime (RUL).

Written Questions During ACM

Q: If three types of wound dressings are ordered for a debrided pressure ulcer with moderate drainage, such as collagen as the primary dressing and alginate plus bordered gauze as secondary dressings, are all three covered by Medicare?
A: If the documentation supports what is ordered then these dressings may be covered. Noridian POE is not able to predetermine documentation for medical necessity.

Q: On the L1832 (knee orthosis), the Medicare website states no authorization is required if there is an emergency or after surgery. We give most of these braces to the beneficiary for the provider to put on after surgery. Does this need a prior authorization?
A: Medicare does not cover an orthotic device dispensed to a beneficiary prior to the time at which the beneficiary undergoes the procedure that makes necessary the use of the device. Moreover, the need for the device cannot be clearly established until the procedure that makes its use possible is successfully performed. In the situation where the brace is needed post-operatively, the brace cannot be dispensed to the beneficiary until after the surgery has happened. If it is needed to dispense the brace immediately after surgery, you may bypass prior authorization and bill using the ST modifier to signify it was an emergent need.

Follow-up question: If the provider takes the L1832 to the hospital and puts it on, sizes the brace in the operating room, and places it on the beneficiary, how do we bill for that?
A: If the brace is applied during the hospital stay, it should be billed by the hospital. However, if the supplier provides the brace for fitting and the beneficiary does not use it until discharge, the brace should be billed on the date of discharge.

Q: If we have a sleep study which shows a Medicare 4% Apnea-Hypopnea Index (AHI) of 4, however, the Respiratory Disturbance Index (RDI) is 12.6, no Respiratory Effort-Related Arousal (RERA) are incorporated in the RDI. Is this acceptable? The concern is the fact that the RDI is equal to the 3% AHI listed on the sleep study.
A: That would not be acceptable. The scoring needs to be 4% in order to qualify for coverage.

Q: Are sleep studies required to be in chronological order to show the progression of the sleep-related disease? We have a baseline sleep study from August 2023 which confirms obstructive sleep apnea (OSA) and recommends CPAP. The beneficiary has been on PAP therapy for over one year and the compliance data shows an emergence of central events while on therapy. The doctor has the beneficiary go into the sleep lab for a Bi-PAP Adaptive Servo-Ventilation (ASV) titration and then orders the ASV. Would this beneficiary need to go back into the sleep lab for a CPAP/Bi-PAP titration only or would they need a CPAP/Bi-PAP/ASV titration? Can we use the previous ASV titration study to show improvement on treatment?
A: Medicare does not require sleep studies to be presented in chronological order, but documentation must clearly support the medical necessity of each step in the treatment process. In the case of a beneficiary who had a baseline sleep study in August 2023 confirming obstructive sleep apnea (OSA) and has been on CPAP therapy for over a year, the emergence of central events during therapy may indicate treatment-emergent central sleep apnea (TECSA) or complex sleep apnea (CompSA). If the physician ordered a BiPAP ASV titration and subsequently prescribed ASV therapy, a repeat CPAP or BiPAP titration is not typically required unless there is a clinical reason to reassess those modalities. Medicare guidelines allow the use of a facility-based ASV titration study to demonstrate improvement on therapy, provided the study shows resolution of obstructive events and significant improvement in central events with the prescribed ASV settings. The ASV titration study can be used to support coverage if it meets the criteria for central or complex sleep apnea and documents the patient’s response to therapy. Continued coverage also requires a face-to-face re-evaluation between days 61–90 of therapy, confirming compliance and benefit from the device.

Q: When qualifying a beneficiary for central sleep apnea (CSA) and the sleep study does not indicate the central apnea-central hypopnea index (CAHI), as a rule, we will review the sleep study and calculate the AHI ourselves to ensure the patient meets the LCD (we actually perform calculations to ensure the patients qualify). Should we or should we not continue this?
A: After discussing this situation with the medical review staff, it would not be appropriate for the supplier to calculate and score the sleep study report. This should come to the supplier already scored from the treating practitioner that is interpreting the sleep study.

Q: When gathering documentation for five-year oxygen renewal equipment, I understand no new testing is required. However, notes and an order are needed. What is the time frame for the office visit notes? Should they be within 30 days of delivery of the new equipment or is it acceptable within six months?
A: The policy does not specify a timeframe for a new order. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.

Q: The policy states the RDI can be used as long as the RERA is not incorporated. However, the policy does not state the hypopnea must be scored using 4%. Can you please clarify?
A: Per the LCD: "Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation."

Q: When Medicare is the secondary payer, we were told the claim needs to state "None" in Box 11.  My system just leaves the box blank and does not indicate "None".  Is that acceptable?
A: When Medicare is the secondary payer, it is required that Item 11 on the CMS-1500 claim form be completed with either the insured’s policy or group number (if applicable) or the word "None" if there is no other insurance primary to Medicare. Leaving Item 11 blank is not acceptable and may result in the claim being rejected. Your system should be updated to ensure that "None" is entered in Item 11 when appropriate. This small detail is critical for proper claim adjudication under Medicare Secondary Payer (MSP) rules.

Q: We have a beneficiary who has a K0006 is being ordered. However, she does not meet the weight requirement, but they included her hip measurement of 22 inches. They are stating she needs a 22-inch wheelchair which is a "heavy duty" wheelchair or K0006. Can we qualify her based on the hip measure despite the weight not meeting the requirement?
A: According to the LCD, to qualify for a K0006, at least one of the following must be true:

• The beneficiary weighs more than 250 pounds, or
• The beneficiary has severe spasticity.

If the documentation does not support the criteria, the wheelchair would likely be denied not reasonable and necessary. The beneficiary may meet the requirements of another chair and that may need to be evaluated. We cannot approve extenuating circumstances outside of the policy. If the beneficiary does not meet criteria, and claims are denied, follow the appeals process with supporting documentation.

Q: A power wheelchair was purchased by another insurance company and the beneficiary became Medicare-eligible. Now a repair on the chair is needed. Since Medicare did not initially pay for the chair, a dummy Certificate of Medical Necessity (CMN) was put on file with Medicare for repairs and modifications. Medicare has never paid for a new chair for the beneficiary. Will there be a reasonable useful lifetime (RUL) error or same and similar denial with the new chair if it was purchased less than five years ago? Also, will there be any issues to have Medicare approve a new power wheelchair if the beneficiary meets the clinical qualification and prior authorization is submitted if the same chair was paid for by another insurance in 2022?
A: Medicare does not automatically assume responsibility for items obtained prior to Medicare entitlement. In order for repairs to be paid, the beneficiary must meet the criteria for the DME item. If the beneficiary meets coverage criteria of the DME chair, repairs may be covered up to the cost of replacement. Refer to the Noridian Medicare website for more information: Browse by Topic > Repairs, Maintenance, and Replacement. Regarding a new power wheelchair, the beneficiary can qualify if they now have Medicare as primary if Medicare didn't previously pay for the wheelchair.

Q: Does Medicare require clinician’s signatures and dates be in the same format? For example, the physical therapist evaluation was hand signed and electronically dated.
A: If both signature and date can be authenticated there is no requirement that they both must be in the same format.

Q: For beneficiaries with an ostomy that require extended wear products (HCPCS A4407-A4411), are they required to have a "high-output" stoma, or what is the requirement for these products?
A: Per the Policy Article: "A ‘high output’ pouch (A4412, A4413, A4435) has a capacity of greater than or equal to 0.75 liters, is drainable with a large bore solid spout with cap or plug, and is either part of a 2-piece system (A4412, A4413) or a single-piece system (A4435)."

Q: If a provider orders a 90-day supply of immune-suppressant medication and the beneficiary only wants 30 days, can we fill off this order for the 30 days? If the beneficiary decides the next time to fill for 90 days, will this order still be correct documentation?
A: Yes, the beneficiary can choose to receive a 30 or 90-day supply. As long as the order remains valid, you can fill it for 90 days after the 30-day supply is exhausted.

Q: With regards to the fraudulent claims, how will the supplier know when the "issue is resolved"? Will the supplier or patient receive something in writing?
A: When a DMEPOS supplier is involved in a situation where claims are flagged as potentially fraudulent, the resolution process typically involves formal communication from Medicare or its contractors, such as the MACs or Unified Program Integrity Contractors (UPICs). However, neither the supplier nor the beneficiary will automatically receive a written notice stating that the issue is "resolved" unless the case involves a formal investigation or audit that concludes with a documented outcome. For additional information on Fraud and Abuse please visit the Noridian Medicare website > Browse by Topic > Fraud and Abuse.

Q: The pre-submitted question regarding fraud indicates the supplier should cease submitting claims related to the suspected fraud until the issue is resolved. Can the supplier obtain an Advance Beneficiary Notice of Noncoverage (ABN) and submit claims with a GA modifier to transfer payment obligation to the beneficiary, or would this be a non-covered service and the beneficiary would private pay?
A: No. The liability cannot be transferred to the beneficiary for this reason.

Q: Does Medicare cover DME for an incarcerated beneficiary?
A: No. Medicare does not cover DME or other medical services for beneficiaries who are incarcerated at the time the items or services are furnished. According to CMS regulations (42 CFR §411.4), a beneficiary is considered to be in custody if they are incarcerated in a jail, prison, or similar institution, on medical furlough, or required by law to reside in a mental health facility. While individuals may remain eligible for Medicare during incarceration, Medicare will generally not pay for any medical items or services provided during that time. More information is available on the CMS website.

Q: Is clinical review available for HCPCS E0760 (osteogenesis stimulator) like with CGS?
A: This is not a service provided at this time.

Q: Are there provider relations analysts we can reach out to directly for future questions?
A: Suppliers must call the Contact Center for claim-specific questions and attend our education webinars for policy-specific questions. We also offer Monday Live Chat to ask policy-specific questions. Registration is available on the Noridian Medicare website > Education and Outreach > Schedule of Events.

Q: Where can I find diagnosis guidelines for DME on the Noridian website? I'm noticing a great deal of denials due to unspecified diagnosis.
A: Diagnosis information and requirements are typically housed in the Policy Article related to the Local Coverage Determination for the DME item.

Q: For an E0483 (AffloVest – high frequency chest wall oscillation device), are we required to have a copy of the chest CT scan or can the chart notes reference the CT scan with the month and year (09/2021), rather than a complete date?
A: For Medicare coverage of the AffloVest under HCPCS code E0483, the documentation must confirm a diagnosis of bronchiectasis via a CT scan. However, Medicare does not require a copy of the actual CT scan image to be submitted. Instead, the chart notes must reference the CT scan, and it is acceptable to document the month and year (e.g., "09/2021") rather than the full date, as long as the scan clearly predates the order and supports the diagnosis. The key requirement is that the CT scan is referenced in the medical record and confirms the diagnosis of bronchiectasis. This reference must be part of a comprehensive documentation package that also includes symptoms (e.g., daily productive cough or frequent infections), failed airway clearance therapies, and a treatment plan recommending the AffloVest. You can find additional information in the High Frequency Chest Wall Oscillation Devices – Policy Article A52494.

Q: Under Criterion B, # 2 in the High Frequency Chest Wall Oscillation LCD, if a CT scan is used, does the date have to be month, day and year, or is ok if it has the month and year?
A: Under Criterion B, #2 of the LCD, if a CT scan is used to confirm the diagnosis of bronchiectasis, Medicare does not explicitly require the documentation to include the exact day of the scan. However, the month and year must be clearly documented to establish that the scan was performed prior to the request for the device and is relevant to the current clinical condition. Additional information can be found in the High Frequency Chest Wall Oscillation Devices - Policy Article A52494.

Q: Can you please explain how a skilled nursing facility (SNF) should submit a claim to show that a beneficiary was discharged from a skilled bed to long term care? We need Noridian to reprocess several claims for payment that were recouped from our provider, but the SNF episode is causing an issue. The SNF says they submitted a billing with end date that shows the beneficiary discharged off Medicare services so why does Medicare Part B not show that? What recourse do we have in having payments reprocessed on our claims? Can we provide a copy of SNF billing to show the beneficiary was discharged from Medicare services with them?
A: This information is updated when the SNF bills for their Part A claims. Please call Customer Service for assistance with these claims.

Q: If there is no documented affirmation of testing being reviewed by the treating practitioner, can it be documented later and write a new order? Would the beneficiary have to be re-started after the physician documented affirmation and completed a new order for oxygen?
A: You can continue to bill for the items. In the event of an audit, submit all documentation for initial and any amendments or updates completed. The policy states the evaluation by the treating practitioner needs to be completed prior to ordering the oxygen.

Q: Can a medical assistant in the doctor’s office call in the verbal dispensing order?
A: Yes, a medical assistant can call in a verbal dispensing order to a DME supplier on behalf of the treating physician, as long as the order meets Medicare’s documentation requirements. According to CMS guidance, a verbal dispensing order must include the following elements: a description of the item, the beneficiary’s name, the prescribing physician’s name, and the date of the order.

Q: We can now accept "Mask of Choice" on PAP orders, but do we still have to have the one per three months with it on the standard written order (SWO)? Also, was the update extended to cover other supplies like tubing?
A: That is acceptable for masks and the general description of the item can be used for other accessories. One item per three months is not a mandatory requirement of the SWO. However, Medicare does require that the quantity to be dispensed be listed, if applicable. For more information, refer to the clinician letter on the Noridian Medicare website under Policies > Clinician Resource Letters.

Q: Since Medicare does not cover broken machines, it must be lost, stolen, or irreparable damaged, but with the Philipps being recalled and the machine being broken beyond repair, will Medicare cover a new initial prior to the five-year RUL?
A: If the device was recalled by Phillips, the company would be responsible for replacing it. Medicare would not pay for another device within the five-year RUL for that reason.

Q: A beneficiary was eligible for Medicare on August 1, 2005, but didn’t select Medicare as primary until April 1, 2025. I am requesting documentation after April 1, 2025, but the office is pushing back stating the beneficiary has had Medicare since 2005 and clinical notes are not required. There is no same or similar on file.  Am I correct in asking for these documents? 
A: We require current medical documentation after the Medicare Part B enrollment. Since the beneficiary transitioned to Medicare as their primary payer on April 1, 2025, you are correct in requesting documentation dated after that point to support the claim. Even though the beneficiary has had Medicare since 2005, updated documentation is necessary to establish current medical necessity and ensure compliance with Medicare billing requirements now that Medicare is the primary payer.

Q: For the new hydrophilic intermittent catheter codes effective January 1, 2026, will a new prescription be required if the provider identifies a specific manufacturer part number but has the incorrect HCPCS code?
A: Yes. A new prescription (SWO) will be required if the provider specifies a manufacturer part number (e.g., Coloplast product #1234) but uses the incorrect HCPCS code (e.g., A4351 instead of the new A4295) for hydrophilic intermittent catheters, effective for dates of service on or after January 1, 2026. According to the DME MACs' joint guidance, if the existing SWO lists a specific HCPCS code (like A4351) that will no longer be valid for hydrophilic catheters, a new SWO is required to reflect the correct new code (A4295, A4296, or A4297). The new SWO can include either:

• The correct new HCPCS code, or
• A general description (e.g., "hydrophilic catheter"), or
• A brand name/model number (e.g., "Coloplast 1234") as long as it clearly identifies the product and aligns with the new code.

In the example, if the provider wrote "XXXX-XXXX but incorrectly paired it with A4351, a corrected SWO would be needed to ensure the HCPCS code aligns with the product’s classification under the new 2026 coding structure. You can find additional information by following the path listed here Noridian Medicare website > Policies > Medical Director Articles 2025 > Documentation Requirements for New Urological Supplies Codes.

Q: When billing for repairs of a capped rental E0194 (air fluidized bed), where or how can you get information on a denial with PR-96 remark code N171?
A: The denial message for PR 96, N171 states, "Payment for repair or replacement is not covered or has exceeded the purchase price." If that is the denial message received, the Medicare payment amount exceeds the amount allowed by Medicare according to the fee schedules listed in PDAC. You can find additional information on denials by utilizing the Denial Code Resolution Tool. Noridian Medicare website > Education and Outreach > Tools.

Q: Are the Monday Live Chats now only monthly?
A: Yes. Monday Live Chat is monthly for the remainder of the year. We will re-evaluate again for 2026.

Q: If a beneficiary is on a Group 2 or 3 pressure reducing support surface (PRSS) and is considered healed but the physician wants them to stay on the bed, can the provider continue to bill if the physician puts in the clinicals that there is a continued need?
A: Allowing the equipment to remain with the beneficiary is a business practice decision unless the equipment is beneficiary-owned. The policy is very clear that coverage of the PRSS ends when the wounds have healed. It is up to the physician to document continued need or use. Follow the Local Coverage Determination requirements for continued use: "continued use of a Group 2 support surface is covered until the pressure ulcer is healed". If healing does not continue, coverage may still be allowed if the medical record includes documentation showing that:

• Other aspects of the care plan are being adjusted to promote healing, or
• The support surface remains reasonable and necessary for wound management.

For Group 3 Support Surfaces, such as air-fluidized beds, continued coverage must be supported by monthly documentation from the treating practitioner. Coverage continues until the ulcer is healed, or if healing stalls, documentation must show that:

• The care plan is being modified to encourage healing, or
• The bed remains medically necessary for ongoing wound care.

Q: If billing for repair parts, is it still the same as a regular Medicare claim? Meaning you can only bill that particular part monthly or yearly, or is it based on cost?
A: There is no fixed frequency limit but follow the billing requirements for the item in question. The definition of a repair is found in the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2.A. There are certain items that do not qualify for/as a repair. For details on repairs, modifiers, and payment rates, see the Noridian Medicare website > Browse by Topic > Repairs, Maintenance, Replacement.

Q: If we have a SWO for a E0601 (PAP device) which is renewed annually, may we use this to dispense and bill for a K0462 (temporary replacement for beneficiary-owned equipment being repaired, any type) rental while beneficiary-owned E0601 is being repaired?
A: You may use an existing Standard Written Order (SWO) for E0601 to support the billing of K0462, as long as the documentation requirements are met and the SWO reflects continued medical need for the base item. Medicare allows suppliers to bill K0462 for one month’s rental of a loaner device when a beneficiary-owned E0601 is being repaired, provided the repair takes more than one day. A new SWO is not required specifically for the loaner item, but the supplier must ensure the following documentation is in place:

• Narrative on the claim including:
  • Description, manufacturer, and model of the E0601 being repaired.
  • Description, manufacturer, and model of the loaner device.
  • What was repaired.
  • Why the repair took more than one day.
• Modifiers such as RR (rental) and KX (meets coverage criteria) should be used appropriately.
• Medical necessity for the E0601 must be established and documented within the past 12 months.
• As long as the SWO for E0601 is current and the documentation supports the repair and temporary replacement, it can be used to bill K0462 without needing a separate SWO for the loaner.

Q: Is there a place on the website to show what reimbursement would be on the purchase of K0861?
A: The purchase fee schedule is not publicly available. However, suppliers can estimate the amount they will receive by multiplying the rental rate (RR) by 13 months, which offers a close approximation. Noridian Medicare website > Browse by Topic > DMEPOS Payment Categories > Capped Rental Items.

Q: Are capped rental accessories available for purchase if billed with the purchase of a K0861?
A: Capped rental accessories may be eligible for purchase when billed with the purchase of a K0861 power wheelchair, but there are important conditions to consider. According to Medicare guidance:

• When a Group 3 power wheelchair (K0861) is eligible for purchase, associated accessories (such as cushions, trays, or positioning devices) may also be eligible for purchase if they are medically necessary and billed on the same claim. These accessories must be classified as routinely purchased or inexpensive DME or be part of the custom configuration of the wheelchair.
• If the accessory is normally a capped rental item, it can be purchased only if the base item (K0861) is being purchased and the accessory is integral to the function or use of the wheelchair. However, it's critical to ensure:
  • The accessory is not separately classified as a capped rental item unless Medicare allows purchase in conjunction with the base item.
  • The documentation clearly supports medical necessity for each accessory.
  • The correct modifiers (e.g., NU for a new purchase) are used.

Additional information can be found on the Noridian Medicare website > Browse by Topic > DMEPOS Payment Categories > Capped Rental Items.

Q: Is there any narrative required on a new claim for a glucose monitor or CGM device if it is the initial claim, not a replacement device?
A: No. A narrative is not needed.

Q: For PAP supply A codes, is it still required to have the beneficiary-owned/rented HCPCS for the device and date of service (DOS) of the beneficiary receiving the unit? Is this required for all orders, including recurring? If a beneficiary is a transfer from a different company, do we require the above documentation on all claim line items until the beneficiary has a unit provided by the new supplier?
A: Either a beneficiary-owned or Medicare-paid PAP device is required to be on file in order for Medicare to pay for supplies (A codes). If the PAP device is not on file, then a claim narrative is required.

Q: For HCPCS K0108 (wheelchair component or accessory, not otherwise specified) on an initial claim for a custom manual wheelchair (K0005) that has been approved on Advance Determination of Medicare Coverage (ADMC), at what rate are these being reimbursed?
A: We don't have a specific reimbursement rate.

Q: A K0861 (power wheelchair) has met the RUL and now a new replacement K0861 is needed. There are no changes in the beneficiary’s condition. Is continued need, written order prior to delivery (WOPD) and SWO all that is needed or will they need a new face-to-face (F2F) visit?
A: An order and documentation of continued need would be necessary. More information can be found on the Noridian website > Browse by Topic > Repairs, Maintenance, Replacements.

Q: Are diagnosis codes required in the face-to-face (F2F) and where is it listed in the LCD?
A: The medical record documentation must support the level of care provided. The diagnosis should be clearly documented in a way that supports the items ordered. While the ICD-10 code is not explicitly required in the F2F documentation, there must be diagnosis-related information. The Standard Documentation Requirements Article (A55426) outlines what must be included in the F2F and SWO/WOPD.

Q: Medicare paid 13 months in the past. Now the beneficiary is going to a different provider for PAP supplies. I understand Noridian won't ask for the study, but won't the Comprehensive Error Rate Testing (CERT) or Recovery Audit Contractor (RAC)?
A: We cannot speak directly to their reviews, but ongoing refills for CPAP supplies are covered in Program Integrity Manual (100-08), Chapter 5, Section 5.10.2: "When reviewing claims for replacement of essential accessories for beneficiary-owned CPAP, RADs, and CGMs, the contractor shall review for continued medical necessity of the DME and necessity of the replacement accessory. Contractors are not required to determine that the requirements for provision of the CPAP, RAD, and CGM as when it was originally ordered were met."

Q: Can travel PAP machines be billed as E0601 (PAP device)?
A: For HCPCS coding questions, please refer to the Pricing, Data Analysis and Coding (PDAC) Contactor.

Q: Are physician signatures required to be dated, such as on chart notes and orders?
A: Physician signatures must be dated to meet Medicare documentation requirements. CMS guidelines specify that medical records, including chart notes and prescriptions, must include both the physician’s signature and the date to confirm when the service was ordered or performed. However, for a SWO, only the date of the order is required. Therefore, if the SWO includes a date provided by the supplier, the physician does not need to separately date their signature.

Q: What documents are needed when a beneficiary with an oxygen concentrator is renting with commercial insurance then switches to Medicare Fee-for-Service (FFS) during the rental?
A: We offer a valuable resource on our website specifically for beneficiaries who are entering Medicare. The Beneficiaries Entering Medicare webpage provides comprehensive information about what happens when a beneficiary transitions to Medicare with equipment previously covered by another payer. You can access the page directly by following this path or using the following URL. Noridian website > Billing, Claims, and Appeals > Billing Situations > Beneficiaries Entering Medicare d

Q: Where can I find a policy that goes over what documentation is needed to bill using diagnosis code G47.37 (central sleep apnea in conditions classified elsewhere) for HCPCS E0471 (RAD)?
A: This is addressed in LCD L33800 and Policy Article A52517.

Q: For situations with a beneficiary needing both a commode and a wheelchair, if the beneficiary is wheelchair-bound and unable to propel into the bathroom due to doorway width, would that be acceptable for confinement? For example, the beneficiary returns home from a hospital stay using a wheelchair and needs to utilize the restroom. The Commode DME on Demand says at minute 1:13, "Under coverage guidelines, ‘physically incapable of using toilet facilities or confined to single room, bedridden. Cannot ambulate with cane or walker. Cannot use or be wheeled in wheelchair.’ " Can you help us with what the reference to the ambulation and mobility device is meant to clarify?
A: Documentation must support the level of care provided. LCD L33796 defines the criteria. Medicare covers commodes when:

• The patient is physically incapable of using regular toilet facilities, such as when:
  • They are confined to a single room.
  • They are confined to one level of the home without a toilet.
  • They are confined to the home and no toilet facilities are accessible.

Ownership of a walker or a wheelchair will not disqualify the beneficiary from receiving a commode.