ACT Q and A - September 8, 2021 - JD DME
Mini ACT DME Supplies Questions and Answers - September 8, 2021
The following questions and answers (Q&As) are cumulative from the mini Ask the Contractor Teleconference (ACT) on DME supplies. 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.
Questions Asked Prior to ACT
Q1. What do we do when a beneficiary comes to us from another vendor, unhappy with the device they received?
A1. That would be a business decision. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) cannot advise. Rather, our role is to provide education on coverage requirements, documentation, billing and to process claims.
Q2. Where do we bill for Durable Medical Equipment supplies?
A2. Suppliers must bill the DME MAC jurisdiction that includes the state where the beneficiary's address is on file with the Social Security Administration. Additional information can be found on the Noridian Medicare website under Claims and Appeals > Claim Submission > Common Working File (CWF) and the Medicare Claims Processing Manual 100-04, Chapter 27 (Medicare Claims Processing Manual).
Q3. Do you need a DME number if you are not billing to the DME MAC?
A3. Suppliers that are not billing Medicare do not need to enroll as a Medicare DME supplier. Suppliers that are going to submit Medicare claims must be enrolled as a Medicare DME supplier. To register, go to the National Supplier Clearinghouse website at Palmetto GBA.
Q4. Does the medical necessity establish when a nebulizer is purchased at 13 months like it does with a continuous positive airway pressure (CPAP) device?
A4. When Medicare pays the full 13-month rentals, medical necessity is considered to have been established at the time of initial payment. Payment may be made for supplies that are necessary for the effective use of durable medical equipment. While nebulizer coverage requirements are different than CPAP, establishment of medical necessity with the full 13-month rental payments are the same. See Chapter 5 of the Supplier Manual for more information on capped rental items.
Q5. If a physician does not electronically sign a beneficiary medical record, can he/she then validate his/her notes by signing an attestation statement?
A5. Providers should not add late signatures to the medical record, (beyond the short delay that occurs during the transcription process) but instead should make use of the signature authentication process. See CMS Regulations and Guidelines and the Noridian website for more information: Noridian Medicare Website > Browse by Topic > Documentation > Medical Documentation Signature Requirements.
Q6. Can a beneficiary switch from CPAP to a Bilevel positive airway pressure (Bi- PAP) device? It states in the Local Coverage Determination (LCD) that ineffective is defined as documented failure to meet therapeutic goals using a single-level CPAP device during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and pressure settings). Progress notes document why the CPAP has failed in the home setting but does not mention multiple masks and pressures have been tried. Do the progress notes have to specifically notate what exactly has been tried to switch to bi-pap or is what the physician documented acceptable?
A6. Documentation should include notes from the physician that the CPAP was tried and ruled ineffective, or that therapy was tried and failed (based on the LCD definition above) for a BI-PAP device to be ordered. See the PAP LCD for more information.
Q7. For OR02 orthotics that are issued as off-the-shelf, must they be billed as a miscellaneous HCPCS?
A7. An OR02 (orthoses prefabricated (custom fitted)) provided as off-the-shelf (OTS) must be billed with the corresponding OTS equivalent HCPCS code. If there is not an equivalent OTS HCPCS code, then it must be billed with the miscellaneous HCPCS code. On March 11, 2021, the medical directors posted two articles which can be found on the Noridian website to assist suppliers in determining which HCPCS code to use when providing OTS and custom fit items.
Policies > Medical Director Articles > 2021 > Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised
Policies > Medical Director Articles > 2021 > Custom Fitted Orthotic HCPCS Codes Without a Corresponding Off-the-Shelf Code - Correct Coding
Q8. With the October 14, 2021, updates to the Claims Processing Manual, Chapter 30 regarding Advance Beneficiary Notices of Noncoverage (ABNs), does the new language allow ABNs to be valid for longer than a year?
A8. Effective October 14, 2021, there is a change that removes the requirement for ABN renewal every year. Due to this change, an ABN will need to be renewed when there has been a change in the care the beneficiary is receiving that was described on the ABN, a change in the beneficiary's health that requires a change in their treatment for the condition that was non-covered, or there has been a change or update in the policy. See MLN Matter 12242 for more information.
Written Questions Asked During ACT
Q1. Where is the fee schedule for HCPCS code K0739 for the state of Hawaii located and who determines these rates?
A1. The Centers for Medicare and Medicaid Services (CMS) determines the rates for these items. This information can be found at Fee Schedule webpage.
Q2. Did the LCD change for braces? Do braces still have to be dispensed on the same day they are ordered?
A2. Braces that are part of the Competitive Bid program and are being provided by practitioners, occupational therapists, and physical therapists must be provided on the same day as the professional office visit to qualify under Competitive Bid.
Q3. When will the Targeted Probe and Educate (TPE) program resume and will there be post pay audits along with TPE? Also, will TPE include dates of service during the Public Health Emergency (PHE)?
A3. Post-payment reviews will be closing and TPE will be resuming. If you are selected for a TPE review, you will receive a Notification Letter indicating when the review will start. TPE will be pre-payment reviews and may include dates of service within the public health emergency. See the CME TPE webpage for more information on TPE resumption.
Q4. The new ABN effective October 14, 2021, has language to strike through sentences for dual eligible (Medicare/Medicaid) beneficiaries. Why is this needed?
A4. Dually eligible beneficiaries must be directed to check Option Box 1 on the ABN for a claim to be submitted for adjudication. This is an exception to the usual ABN guidelines prohibiting the notifier from selecting one of the options for the beneficiary. These edits are required because the dual eligible beneficiary cannot be billed by the supplier when the ABN is furnished pending adjudication by both Medicare and Medicaid per federal law. The strike through information can be found on the Noridian website at Jurisdiction D ABN Instructions.
Q5. What are the key differences between the new nutrition LCDs versus the old nutrition LCDs?
A5. We have a new webinar specially created to outline the differences. Because of the complexity, we suggest attending one of our nutrition webinars. The next enteral nutrition webinar will be held on October 20 and the next parenteral nutrition webinar will be held October 21. Please see the Schedule of Events to register. We also have DME on Demands, which are self-paced education tutorials, on our website for enteral and parenteral nutrition.
Q6. With TPE resuming, will post payment reviews continue as well?
A6. CMS has directed that all post-payment reviews close when TPE starts. Final Edit Effectiveness results will be posted as they are available.
Q7. Is there an end date published for the Public Health Emergency (PHE)?
A7. The current end date is October 20, 2021; however, we do expect this to be extended. Please refer to this COVID-19 webpage for the most current information from CMS.
Q8. Is Medicare paying for a replacement machine due to the Respironics recall?
A8. At this time, we are continuing to work with CMS to clarify the many issues created by this unprecedented recall. Please monitor the CMS, DME MAC and the Philips Healthcare websites for updated information regarding the Philips Healthcare recall.
Suppliers of impacted devices should work with their Philips Respironics sales representative to obtain replacement Positive Airway Pressure (PAP), Respiratory Assist Device (RAD), or ventilator products for their Medicare beneficiaries. Philips Respironics encourages all beneficiaries in possession of a recalled device to register that device. Additional information is available on the Philips Respironics website.
Q9. Can the licensed/certified medical professional (LCMP) who is also a certified Assistive Technology Professional (ATP) perform the evaluation and help select a K0005 wheelchair for the patient?
A9. In order for the LCMP's records to be considered part of the face-to-face encounter by the treating practitioner, the LCMP cannot have a financial relationship with the supplier. Suppliers must employ a RESNA certified ATP for direct in-person involvement in wheelchair selection. If this individual is the same person, the LCMP evaluation would only be considered as additional information and not part of the practitioner face-to-face requirement.
Q10. Is the receptionist able to sign on behalf of the beneficiary on a proof of delivery (POD)?
A10. The proof of delivery must be signed by the beneficiary or a designee. Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary.
Q11. My question is regarding RAD setup for beneficiaries with a neuromuscular disease. Is the beneficiary able to qualify with a sleep oximetry that demonstrates oxygen saturation less than or equal to 88% for greater than or equal to five minutes of nocturnal recording time (minimum recording time of two hours), done while breathing the beneficiary's prescribed recommended FIO2, or does the patient have to qualify under the neuromuscular disease (only) criteria with either i or ii, i. Maximal inspiratory pressure is less than 60 cm H20, or ii. Forced vital capacity is less than 50% predicted?
A11. If the beneficiary has a neuromuscular disease, they must qualify with either i or ii.
i. Maximal inspiratory pressure is less than 60 cm H20, or
ii. Forced vital capacity is less than 50% predicted
Please see the RAD LCD [PDF] for more information on coverage criteria.
Q12. Will the changes with the ABNs cover those that are filed before October 14t, 2021?
A12. ABNs that are set to expire after October 14, 2021, will be included in the update. If an ABN expires prior to October 14, 2021, then a new ABN will be needed. See our ABN webpage for all ABN updates.
Q13. We received a TPE notification letter, however, it does not indicate a start date of when to expect TPE additional documentation request (ADR) letters. Is there a set number of days or weeks before we start receiving ADR letters?
A13. The review starts effective the date of the letter. ADR letters will begin arriving shortly after the notification letter. If you have any specific questions on your review, please reach out to your nurse case manager.
Q14. Can you share the error rate for PAP device billing and reimbursements?
A14. The 2020 CERT error rate for PAP was 32.8% for a total of $280M. See the CMS CERT webpage for more information.
Q15. When a beneficiary has a home health episode, is the episode diagnosis dependent or is home health responsible for all costs associated with that episode?
A15. Home health episodes are included in consolidated billing. Please refer to our consolidated billing tool on our website after checking eligibility for items included in the Home Health episodes. Home Health payment is not diagnosis driven. See the Consolidated Billing Tool for more information.
Last Updated Fri, 08 Oct 2021 12:43:56 +0000