DAC Representatives:
Wade Hendrickson, Chair Violeta Arnobit Cindy Coy Ed Erickson
Velma Goertzen Adea Goselin Rick Graver Mike Hayden
David Hosman Zena Jacobi Kay Johnson Janna Jurovich
Connie Lind-Fraher Joe McKnight Sharon Nelson Traci Oswalt
Troy Paz Gloria Peterson Rich Pozesky Carlos Reyes
Leslie Riggs Kimberly Rogers-Bowers Pat Spanel
Barb Stockert Val Taylor Paul Webber
CIGNA Represenatives:
Robert Hoover, M.D. Kathy Brock Doug Frazier Mary Rheinecker
Tricia Luna Barbara Douglas
I. GENERAL BUSINESS
The meeting was called to order at 12:30pm (PST). Gloria Peterson conducted roll call of the DAC representatives, and the CIGNA representatives announced their participation on the call. Wade Henrickson reviewed the meeting protocol.
II. MEDICAL DIRECTOR UPDATE
Medical Director Dr. Hoover provided an update. He informed the DAC that five Local Medical Review Policy (LMRP) revisions are nearing completion. Three of these policies will be published in the fall newsletter – Motorized Power wheelchair Base, Surgical Dressings, and Home Dialysis Supplies and Equipment. He also reported that several policy revisions will be published in the winter and spring publications to address HCPCS code changes, many of which are a result of HIPAA coding requirements.
Two LMRPs have been finalized that have a January 1, 2004 effective date. They are Automatic External Defibrillators (AED) and Oxygen and Oxygen Equipment (He reported later in the meeting the date these medical policies would be available on-line, see Respiratory A-Team). Dr. Hoover indicated that the medical directors did not keep the requirement in the draft revision for retesting all Group I patients in the third month of oxygen therapy however, the issue of retesting may be revisited at a later date. The rationale for not including the retesting requirement was not clinical, but practicality issues of implementing the requirement.

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Dr. Hoover indicated that the DMERCs would be publishing a CMN grid and repair/replacement grid in their fall newsletters. He will provide the CMN grid to Doug Frazier who will forward it to the DAC.
Dr. Hoover thanked providers who responded to his recent requests for the names of their corporate compliance officers. He plans to use these names as contacts for education regarding Comprehensive Error Rate Testing (CERT) errors for failure of their branch officers/sites to provide documentation requested by Advance Med, the CERT contractor. Record request are made to comply with CERT requirements. He cautioned that Advance Med is tracking non-responses providers.
He also announced that CIGNA’s Medical Review department will have its own website. The website will include modules on CERT, education, and the results of wide-spread probe reviews that are conducted as part of the Progressive Correction Action process. The web site will likely be available in November or December of this year.
Dr. Hoover did not have an update on provider access to the Common Working File.
III. PROVIDER RELATIONS UPDATE
A. PET ISSUES

Doug Frazier provided an update on CIGNA’s Provider Education and Training. He indicated that the first face-to-face seminar this year is scheduled for August 19. Registration for these seminars are available on-line under the "Medicare Learning on Demand" section of the CIGNA website and include a credit card payment option. (payment by credit card is not an option at this time)
B. HIPAA PERPAREDNESS

Doug Frazier reported that 500 suppliers have received HIPAA education in the past two months. He reminded DAC representatives that providers’ software programs must be ANSI compliant by October 16, 2003.
Mr. Frazier reported that the Center for Medicare and Medicaid Services (CMS) would be hosting a HIPAA training teleconference on August 20 from 1:00pm – 12:30pm (CT). Providers will receive additional information via the CMS list-serve.
IV. A-TEAM LEADERS REIVEW OF QUESTIONS & ANSWERS

A. EDI/EMC
A-Team Leader Zena Jacobi expressed concern with regard to the time frame that CMS will take to respond to questions 1 and 5 of the Q&A. Doug Frazier responded that CMS has acknowledged that these are important and time sensitive issues. CIGNA will provide clarification to the DAC as soon as it is received from CMS. He also indicated that he would check with the CIGNA EDI manager to

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see if Ms. Jacobi can maintain an open line of communication with CIGNA on these issues.
(Question 1 Addendum: In a conference call with CMS on Thursday, August 28, 2003, Janice Nero-Phillips, with the CMS Office of Information Services (OIS), told the DMERC medical directors that CMS will issue an instruction to contractors to implement the PWK (paperwork) segment, which allows electronic billers to tell the recipient that additional hard copy documentation has been sent to accompany the electronically billed claim and how that documentation was sent (e.g., by mail). CMS does not expect this instruction to be implemented before April 2004. Contractors are not required to have a mechanism in place to accept and match up hard copy documentation for electronically submitted claims until the implementation date of this instruction. In the interim, it is acceptable for Medicare billers to submit paper claims when they need to submit additional documentation with the claim. CMS expects to have this exception to the electronic billing requirement published in writing in the mid-September to early-October timeframe.)
C. EDUCATION / COMMUNICATION

Connie Lind-Fraher asked questions about the following items:
Question #6 – Who within CIGNA is working with CMS on this issue and whether a timeframe has been established for resolving this issue? Barbara Douglas indicated that this issue would not likely be addressed in 2004; however, CIGNA will inquire with CMS on the timeframe. Ms. Lind-Fraher indicated that the DAC would leave this item as a standing item in the Q&A.
#8 – Are claims payments mailed to the address indicated on the claim or to the address contained in the Common Working File (CWF). Doug Frazier asked that the A-Team provide examples of the issue.
D. REHAB

A-Team Leader Rick Graver inquired about the following items:
#9 - Providers of powered mobility want to be able to gather ALL of the necessary information to document the medical necessity for the products they provide. We have been given a "not all-inclusive" list of the type of information, which will assist the DMERC in making a determination, and we appreciate the guidance. He request that CIGNA consider providing the DAC with any kind of template, flow chart, or guideline that can be used to better document the medical need.
Dr. Hoover responded that CIGNA would not expand upon the list provided. CIGNA does not deem any list of suggested medical documentation all-inclusive,

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as it would take away providers’ flexibility. He suggested that the DAC look through back issues of the DMERC Dialogue for additional items.
#10 - Rick asked for CIGNA’s definition of seating system and whether the DAC can have access to the information used to determine the pricing. He indicated providers’ concern that the HCPCS codes and fee schedules will become global (i.e. other insurance companies adopting them), leading to the provision of the most basic economy seating systems that can be provided under this fee schedule. Providers are concerned that a seating system (seat and back only) will be confused with a seating system that might include lateral trunk supports with hardware, headrest, lateral hip guides, medial thigh support, seat and back modifications, etc when being coded for reimbursement.
Barbara Douglas responded that the code includes a basic back and seat. Any additional or special features would be considered add-ons to this base code.
#11 – Mr. Graver asked whether CIGNA has the authority to implement a modifier that could be appended to a claim, which would indicate that medical necessity guidelines have been met and are on file. If so, this will assist electronic claims under HIPAA by keeping the HAO record within limits, and with clear coverage guidelines being met, the provider will have accepted responsibility for proper documentation when the modifier is used.
Dr. Hoover responded that it is feasible for the medical directors to implement a modifier for this purpose. He also mentioned that there are many new HCPCS codes for wheelchair accessories that are to be implemented January 1, 2004, which will hopefully reduce some of the additional documentation that is being submitted now. He will bring up the issue of a new modifier during the medical directors’ review of the policies.
E. HOME MEDICAL EQUIPMENT

Janna Jurovich, A-Team Leader indicated that the DAC is in the process of gathering examples for question #11. She also requested clarification to the following:
CIGNA's response: The supporting documentation required for POVs is addressed in a bulletin article published in the Summer 2002 DMERC Dialogue entitled "Documentation Requirements for Power Operated Vehicles (POVs) - Region D Change and Power Operated Vehicle local medical review policy in the DMERC Region D Supplier Manual. Additional information about medical records as documentation is found in the DMERC Region D Supplier Manual Chapter 3 & in the CMS Program Integrity Manual (PIM) Chapter 5, both in sections entitled "Documentation in the Patient's Medical Record." PIM Chapter 5, section 1.1.4.2 addresses DMERCs "authority to request to verify the information on a CMN at any time." The National Coverage Determination for POVs (Coverage Issues Manual 60-5) states "A specialist in physical medicine,

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orthopedic surgery, neurology, or rheumatology must provide an evaluation of the patient's medical and physical condition…"
Beginning in July 2003 we began using a "new and improved" letter for development of POV claims which we believe more clearly describes the type of information we are looking for. The letter states "We need additional documentation to determine if a power-operated vehicle (POV) is reasonable and necessary for this beneficiary. Please provide a dated and signed copy of the ordering physician's required evaluation of this patient's medical and physical condition relating to the need for a POV. For more information refer to the Power Operated Vehicles local medical review policy and/or the national coverage determination for POVs in the DMERC Region D Supplier Manual or on the Internet at: www.cignamedicare.com"
#13 – Ms. Jurovich asked if it is the correct interpretation to assume that providers that contact a patient and document continued use over a span of time (i.e., 6months to a year) would meet documentation requirements.
Dr. Hoover responded that this is an individual business decision. He cautioned that any time elapsed between the provider’s contact with the patient in an overpayment is determined would leave the provider with no recourse to bill the patient.
Mary Rheinecker expanded on this issue emphasizing that if a provider were to frequently document contact with the patient’s then the provider could show he did not know and could not be expected to know that the item would not be covered by Medicare (Limitation of Liability) and would have recourse to bill the patient if an overpayment should be determined.
Troy Paz also inquired as to whether an EOB sent to the patient serves as notification to the patient that the item continues to be billed to Medicare. He asked whether this would automatically place responsibility on the patient to notify the provider if it was no longer in use. Wade Hendrickson indicated that CMS confirmed on an open-door conference call that providers could bill the patient whenever equipment is deemed to be no longer in use.
F. ORTHOTICS & PROSTHETICS

Paul Webber, A-Team Leader indicated that the DAC is in the process of gathering examples for question #14.
Mr. Webber asked Dr. Hoover if Rehab question #9 relating to the distance a patient can walk with a cane, crutch, or walker in the determination of need for a wheelchair and how that rationale applies to patients with a lower extremity orthotic devices who also use a power wheelchair. Dr. Hoover responded that the interpretation of the wheelchair policy stipulates that the patient must be bed or

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chair confined. Patients’ with lower extremity orthotics should be ambulatory and their need for a wheelchair not necessary.
In addition, Mr. Webber thanked CIGNA for keeping the policy discussion for graduated compression stockings open.
G. INFUSION THERAPY

Mike Hayden, A-team Leader indicated that the DAC will work with CMS to further address question #17, but would like to keep Dr. Hoover in the loop on this issue. Dr. Hoover indicated that CMS would be in contact regarding the span date information.
H. RESPIRATORY

A-Team Leader Joe McKnight indicated that the A-Team would have questions for the next meeting. Dr. Hoover reported that the Oxygen and AED policies would be posted after 9/1/2003.
V. NEW BUSINESS

Gloria Peterson reported that the next DAC meeting with CIGNA is scheduled for October 10, 9:00am – 11:00am in Atlanta, GA. More information will be released when the meeting room assignment is received.
The meeting adjourned at 1:23 pm.

DAC Representatives:
Violeta Arnobit Deanne Birch Sandy Carden
Cindy Coy Sha Eppley Velma Goertzen
Rick Graver Mike Hayden Wade Hendrickson
David Hosman John Kenny Janna Jurovich
Connie Lind-Fraher Laura McIlvaine Joe McKnight
Sharon Nichelson Troy Paz Rich Pozesky
Carlos Reyes Duane Ridenour Pat Spanel
Barb Stockert
CIGNA Representatives:
Robert Hoover, M.D., Medical Director – absent
Barbara Douglas Doug Frazier John Kelly
Miranda Kyles Mary Rheinecker
CMS Representative:
Lori O’Neil
I. GENERAL BUSINESS

The meeting was called to order at 9:00 am EST.
a. Introductions
Val Taylor of DAC representatives conducted role call, and CIGNA Medicare representatives introduced themselves and their respective roles.
b. Approval of Minutes

Minutes were reviewed and approved by Rich Pozesky and seconded by Laura McIlvaine.
II. MEDICAL REVIEW UPDATE

Mary Rheinecker spoke briefly of Dr. Hoover’s absence due to a previous continuing educational commitment. She went on to state the oxygen and AED policies are being published and to expect them in the Fall DMERC Dialog ue. She indicated that the wheelchair seating policy is still being worked on and to expect it to be released in 2004 and the code request has been submitted to the Alpha-Numeric Workgroup.
Ms. Rheinecker also spoke about Operation Wheeler-Dealer and that the four DMERC Medical directors are currently reviewing the "bed or chair confined" requirement and appropriate

documentation required for power drive wheelchairs. They are also working on medical review policies and progressive correction actions. One focus will be to educate physicians, providers and beneficiaries, as to who in fact qualifies for these services.
The DAC inquired as to whether CIGNA would be auditing all suppliers for wheelchair claims. CIGNA answered no, but that it would continue to conduct supplier specific audits for wheelchairs based on data analysis findings and according to the PCA process.
Ms. Rheinecker cited continued efforts to educate physicians and suppliers about the CERT program and its importance to CMS and the contractors.
Ms. Rheinecker gave a HCPC code update for A, E & L codes, deleted codes, and new or revised descriptions. The release is scheduled for the Winter DMERC Dialogue. Approximately ninety new codes are anticipated across the board.
Ms. Rheinecker also mentioned the new redesigned CIGNA website. The site is easier to navigate, new policy releases will be listed on the site, and a link has been added for provider suggestions on how to further improve the Web site.
Medical review will be hosting Webinars. The focus will be support surfaces & power drive wheelchairs and parenteral nutrition. Many will be limited to invitation only for the providers who may be involved in PCA. Net Courses will be available for all providers with focus on policies and documentation requirements.
III. PET ISSUES

Doug Frazier addressed the group with PET Issues. Doug mentioned that the Fall Seminar season is at capacity or near capacity and to register soon if you had not. He further stated the PET staff is down to 3 individuals to represent 40,000 providers. The focus of the seminars is to educate suppliers on resources available to those that are new to working with Medicare. The PET staff will also be doing Congressional Briefs identifying problems with Part A&B Carriers and CMS. Mr. Frazier stated 15 seminar sites would be available in the spring compared to 25 in the fall.
IV. A-TEAM RESPONSE TO Q&A

Education / Communication A-Team
CIGNA was thanked for the answers provided to the team’s questions.
Previously Submitted Question – July 2003. Re: Claims submissions to the wrong DMERC.
Clarification was asked for (which we submitted examples) on the previously asked question concerning the claims being "forwarded" to the "correct DMERC’s" when submitted to the "incorrect" DMERC by the provider. Does a provider need to be enrolled to bill electronically with each individual region for this to occur?
The answer was yes, i.e., for a claim sent to Region D by mistake to automatically forward to Region A, B, C the provider must be enrolled with both Regions D and the other applicable region (Region A, B, or C). The provider needs to have an EDI profile filled out at each DMERC this is only for electronic claims as mentioned, paper claims would not follow the same process

Standing Agenda Question #6 – HCPCS Coding
CIGNA was asked about two new S codes that are thought to be listed on Region C’s website, when we might see them on Region D’s site.
CIGNA indicated that they were not aware of any codes at this time and that they would be posted on the CMS website as opposed the CIGNA website.
Orthotics & Prosthetics
#17. Re: Denials for AFO’s because a patient has a powered mobility device.
The supplier should submit a hard copy appeal of the AFO denial. The basis of the appeal should be medical necessity. Documentation should be provided in the appeal information submitted to the DMERC that provides proof of the patient’s ability to ambulate.
CIGNA Medicare would like to review specific claim denials of AFO’s or similar O & P products where the Region D DMERC denial was based upon the beneficiary’s prior receipt of non-ambulatory DME. The DAC O & P Team will provide this information to the DMERC.
HOME MEDICAL EQUIPMENT (HME)
Question #10. Re: Capped rental CO57 denials.
Barb Stockert asked CIGNA to clarify the bullets in the answer to question this question. She specifically asked:
Q: Can we say that the condition of the patient has "changed" or must we be more explicit?
Mary Rheinecker replied "No. We need to know what the patient’s condition was, and what it is now. It must be clear to us that such a change would necessitate a change in equipment. Saying that the patient’s condition has "changed" or "improved" does not provide enough detail.
Q: We would also like to clarify whether it is necessary to provide a pick up ticket in such an example (Question 10). If the patient had equipment 7 years ago from a supplier who is unknown to us and/or a defunct company now, this is extraordinary work and research. Customer Service routinely tells us we need the pick up ticket, regardless of the situation.
Mary Rheinecker replied that she would have to look into this.
Previously Submitted Question #1
Barb Stockert asked CIGNA if the DAC could defer this question to a previous time. The DAC would like additional time to gather examples of the problem. CIGNA gave the Okay to defer the question.
RESPIRATORY
Question #21. Re: Sleep study requirements for CPAP.

The Respiratory A-Team wanted additional clarification to CIGNA’s answer and offered: If the RDI was an acceptable calculation methodology for provision of CPAP before the language was changed, why can we not use the data that was acceptable at that time. Many sleep labs do not have all the raw data available now more than a year later. RDI was calculated using a number of data points other than Apnea/Hypopnea indexing. Obtaining this data is difficult at best, and in some cases impossible. Again we ask, why can’t we use the original Data.
CIGNA indicated that they would have to respond to the DAC’s additional comments at a later date.
The DAC also noted: "Region C is doing a probe review in advance of payment on RAD (K0532/K0533). Is CIGNA looking to do a similar review and if so, what are they looking for?"
CIGNA indicated that they were not doing a probe review and did not normally do such reviews in advance of payments. The do reviews from benefit integrity side, but they are on specific vendors, not large scale probes like Region C.
EDI / EMC A-TEAM
Question 1. Re: Additional documentation requests on electronic claims.
Our answer was, on Denial or Development, Medical review would normally be the ones to ask for this information. Paper claims will still be accepted even after October 16, 2003 if we feel that the additional information needs to be submitted with the initial claim. This will cut down on double work for both the supplier and CIGNA Medicare.
Question 2B. Re: Drug claims with NDC coding.
Medicare is aware of crosswalk errors and are working with SADMERC to update and add new, SADMERC is in charge of the cross walking, if we submit a claim with the invalid NDC# the supplier will receive a denial and we will have to go to SADMERC for the correction.
Question 3A. Re: Duo-Neb Coding.
The supplier will submit duo-neb under the NDC# and Medicare will split out since the allowable on albuterol portion is .14, and the Ipratroprium portion is $3.34, they will do the calculations.
Question 4. Re: Dispensing fee coding.
Medicare will again split out the dispensing fee is the supplier is billing the allowable or above.
REHAB A-TEAM
Previously Submitted Question Re: Special sized E0192 cushions
The DAC representative indicated that the answer CIGNA provided was sufficient. CIGNA reported that the wheelchair cushion policy would be coming out next year with the new codes in January 2004.
Question #19. Re: Pediatric wheelchair coding