ACT Questions and Answers - November 8, 2018

Questions Received Prior to ACT Meeting

Q1. If you use a DWO as both your dispensing order and your DWO and that DWO has a LON of less than 99 does the dispensing order expire when your DWO expires (i.e.; DWO is for CPAP and CPAP supplies and the LON is for 13 months will a new dispensing order be required for any resupply orders places after month 13?)
A1. Yes, because after 13 months the order is no longer valid for billing to Medicare.

Q2. This question is regarding the recent guidance issued by Noridian prohibiting the first delivery of immunosuppressant's to the patient while they are still in the hospital immediately after transplant. Patients may not have friends or family that could bring this first delivery to the patient in the hospital so that the patient can receive education prior to discharge. What does Noridian suggest for this situation? Many hospitals can't dispense that 7-day supply that the guidance suggests because of state laws preventing dispensing. Other patients have unreliable family members who do not bring the medication to the hospital and hold up discharge for several days costing more money and putting the patient at greater risk of hospital acquired infections. The bottom line is that we don't see the logic of prohibiting that initial delivery being made to the patient in the hospital 1-2 days prior to discharge, it's putting a burden on the patient's family and frequently delaying discharge.
A2. As medication reimbursed under Medicare Part B cannot be used in a setting other than the beneficiary's home, delivery to the hospital cannot occur. Exception: SNF stay were Part A benefits are exhausted. Suppliers do have the option to mail the immunosuppressive drugs to the beneficiary's home up to two days prior to anticipated discharge from an inpatient stay to assure that they are available upon discharge. The discharge date is then the date of service.

Q3. We'd like clarification on Q8b from the May 8, 2018 ACT question and answer session.

Q8b. Why should a supplier (pharmacy) be punished by taking back the Medicare payment when the supplier did their due diligence?
A8b. It is the responsibility of the supplier to ensure that the beneficiary is at home or in a Part A facility before dispensing. The discharge paperwork from the hospital should list to where the beneficiary is being discharged.
The answer seems to assume that the rehab stay is immediately after transplant. It frequently is not.
Situation:

  • Patient is transplanted 01/01/2018
  • Patient is discharged to their home 01/04/2018
  • Patient is admitted to rehab 01/25/2018
  • Patient brings their medication to the rehab because they won't admit the patient otherwise
  • Patient calls the pharmacy for refills 01/27/2018 and states untruthfully that they are still home
  • Medicare and the IVR have no record at this time of this Part A stay
  • Pharmacy delivers medication 02/01/2018 to the patient's home, at which point a loved one brings it to the rehab for them to continue to use
  • The money is subsequently recouped from the pharmacy that following year
  • What recourse does the pharmacy have and what does Noridian suggest we do in these situations?

A3. It remains the responsibility of the supplier to determine the location of the Medicare beneficiary prior to dispensing. Noridian would hope that this would be a rare case where a beneficiary would be dishonest regarding their location.

Q4. A patient receives a non-covered IV medication (i.e. Vancomycin) in the home via gravity administration (no pump or DME is involved) via a PICC line. Because the Vancomycin in the home is non-covered by both Medicare Part B and Medicare DME (since it is not on a pump, and not a covered drug), we bill the Vancomycin to the patient's part D; however, we also need a denial from Medicare for the associated infusion supplies. Since there is no DME equipment involved, should the supplies be billed to Medicare Part B or Medicare DME for denial?
A4. Because there is no pump, any supplies billed will be denied by DME as not reasonable and necessary.

Q5. To bill Medicare Part B refractive lenses specifically. is it required to add the ordering/referring physician to each CPT line item for the claim to be paid? If so, is there documentation stating this specific step is necessary?
A5. Refractive lenses are billed to the DME MAC using HCPCS coding. The ordering referring physician is listed one time on the claim with their associated National Provider Identifier (NPI).

Q6. Is there any guidance on whether Medicare will allow a provider to only bill for HCPCS Q0512 dispensing fee ($16.00) instead of worrying about attaching the HCPCS Q0511 ($24.00) to one claim per month? We seem to be spending more time trying to submit redeterminations for incorrect dispensing fee codes than it is worth.
A6. Adjusted response from the call: Technically, it is incorrect coding not to use HCPCS Q0511 for the first dispensing fee in the month; however, if a supplier chooses not to use HCPCS Q0511 dispensing fee code for the extra allowable on the first prescription for each 30-day period there will not be a denial. Another alternative may be that the supplier could develop edits with their software vendor to identify the first drug per month as HCPCS Q0511 is allowed for multiple pharmacies.

Q7. Why doesn't Medicare recognize Hypersomnia as Excessive Daytime Sleepiness. In Tabers Medical Dictionary, it is notated as such.
A7. Depending on the full medical record, hypersomnia may be recognized.

Q8. Can Noridian confirm that HCPCS E2402 is still considered a capped rental (CR) item and if the provider has received 13 payments, the title of the pump transfers to the patient?
A8. HCPCS E2402, negative pressure wound therapy electrical pump, stationary or portable is categorized as capped rental. As such, 13 months will be paid by Medicare for qualifying beneficiaries. At the end of 13 months, title will transfer to the beneficiary.

Q9. Full face masks bill under HCPCS A7030, nasal masks bill under HCPCS A7034. If a patient switches type of mask is a new order required from the physician? If the patient then switches back to original type of mask later would another order by required from the physician?
A9. There must be a detailed written order (DWO) for the specific type of mask being used by the beneficiary. If there is a change in the mask used, a new DWO will be required. To return to the previous mask, a new order will be required as that constitutes a change as well.

Questions Received During the ACT meeting

Q1. When an external infusion pump internal battery clock is replaced at three years as a preventive measure per manufacturer recommendation, can it be covered as a repair?
A1. Medicare does not cover preventive repair. In this case, if the clock is not under warranty, an ABN could be completed for the replacement prior to the 5-year RUL.

Q2. What documentation is required as evidence of parts cost in the completion of a repair? Is a detailed repair invoice required?
A2. It will be necessary to have something, though Medicare doesn't specify a format, to show the parts and their cost that were a part of the repair.

Q3. Does labor have to be broken down in minutes for each part? The manufacturer is issuing a flat fee that includes parts and labor.
A3. Labor must be billed in 15-minute increments. The supplier must know the minutes involved. Only the entity completing the repair will be able to provide this information.

Q4. A beneficiary is in a skilled nursing facility but outside the Part A covered stay. Will speech generating device be reimbursed by Medicare?
A4. Neither HCPCS E2510 nor HCPCS E2512 are payable by the DME MAC under any circumstance when a beneficiary is in a skilled nursing facility.

Q5. Can medication be delivered to a nursing home and billed to Medicare Part B?
A5. This will depend on the medication and whether the beneficiary is in a covered Part A stay. (Example: Immunosuppressant medication may be delivered to the skilled nursing facility. During the Part A covered stay, the supplier will look to the nursing home for reimbursement. Once the Part A stay is exhausted, immunosuppressant drugs may be billed to the DME MAC under Part B.) Additionally, Noridian maintains a Consolidated Billing/SNF/Home Health/Hospice Lookup where suppliers may enter the HCPCS code being provided and receive notification of whether Medicare will reimburse.

Q6. If a beneficiary is going on vacation outside the United States, can additional medication be provided beyond the LCD allowed amounts?
A6. If your pharmacy laws allow the additional quantity to be dispensed, anything over the LCD allowed amounts require an ABN that makes the beneficiary liable for the additional units.

Q7. Is there a requirement to obtain a new beneficiary authorization annually?
A7. No, there is not a requirement to obtain a beneficiary authorization annually. Suppliers need a new beneficiary authorization if a new item were provided. In addition, if a rental item is billed non-assigned, a new beneficiary authorization is required for each month.

Q8. Who can deliver diabetic supplies when the competitive bidding contracts expire on December 31, 2018?
A8. During the gap period of 18-24 months, any willing supplier can provide services previously covered under the competitive bid program. This will allow shipment of diabetic supplies by any supplier.

Q9. If a supplier provides medication today and the beneficiary becomes incarcerated on the same day, can the supplier bill the beneficiary?
A9. No. There was no reason to obtain an ABN at the time of service since the incarceration was after the provision of the medication. In this case, Noridian recommends suppliers appeal a denial and indicate that the medication was provided prior to incarceration.

Q10. When Medicare is secondary and the primary insurance allows a 90-day supply, will Medicare make an exception to the 30-day supply restriction?
A10. No. Medicare rules are the same regardless of whether Medicare is primary or secondary.

Q11.When there has been a change in medical condition, whould the RA modifier be used for a change in equipment within the 5-year RUL?
A11. No. The RA modifier is only appended when there is replacement due to lost, stolen, or irreparably damaged equipment and when oxygen is replaced after 5 years. Noridian recommends a narrative on the change in condition. If there is same/similar equipment on file, the claim will most likely deny and the supplier will need to appeal with the medical documentation to justify the change. It is encouraged to indicate a change in condition on the Redetermination Request Form when appealing the same/similar denial.

Q12. Can Noridian confirm that PAP and power wheelchairs are the only items that require suppliers to have documentation on file of the face-to-face (FTF) encounter prior to delivery?
A12. PAP and Power Wheelchairs require FTF per their policies. Additionally, all items found on the Affordable Care Act (ACA) list require a 5 Element Order and FTF encounter prior to delivery. The FTF encounter for ACA items is not currently being enforced by the MACs, but is currently being enforced by CERT. If CERT denies for a missing or invalid FTF, the Redeterminations department has been instructed to stand on that denial unless additional documentation is submitted to supporting a valid FTF.

Q13. For initial coverage of CPAP, will Medicare allow a sleep study that includes an REI (respiratory event index)?  The AASM is advocating this index for use with some home sleep studies.
A13. The current National Coverage Determination (NCD) 240.4 and Local Coverage Determination (LCD) do not allow for the REI measurement regardless of the AASM guidelines. Until the NCD is updated by CMS, Noridian and the other contractor cannot accept an REI measurement to meet coverage criteria.

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  • February 13, 2019, 1 p.m. CT

Last Updated Thu, 13 Dec 2018 08:21:42 +0000