REGION D DAC
MEETING with CIGNA Medicare
~
Tuesday, January 20, 2004
CIGNA Medicare Administration
2 Vantage Way
DAC Representatives:
Troy Paz, Chair Deanne Birch Sandy Carden
Yvonne Cordoza Velma Goertzen Rick Graver
Mike Hayden Wade Hendrickson David Hosman
Connie Lind-Fraher Joe McKnight Gloria Peterson
Rich Pozesky Carlos Reyes Pat Spanel
Barb Stockert Mary Turner
CIGNA Representatives:
Robert Hoover, M.D., Medical Director
Kathy Brock Barbara Douglas Ellen Edenfield
Doug Frazier Scott Hudson John Kelly
Melissa Lamb Kim Largeant Trisha Luna
Mary Rheinecker
CMS Representatives (via teleconference):
Becky Chapman Lori O’Neil
I. GENERAL BUSINESS
The meeting was called to order at 1:00pm. After introductions, the minutes from the previous
meeting were approved as submitted.
The 2004 proposed calendar was also approved as submitted.
II. MEDICAL DIRECTOR UPDATE
Dr. Hoover reported on the following:
•
Website Update - CIGNA added a section to its website containing educational
information to assist providers with medical review. CIGNA is in the process of
developing Net Courses to be added to the medical review section of the website,
including Progressive Corrective Action and Support Surfaces. Dr. Hoover requested the
DAC and that of State Associations to assist with informing providers about this new
tool.
•
Claims Error Rate Testing (CERT) – The 2002 analysis results identified problem areas
with glucose monitors, Ostomy supplies, and nebulizer drugs. Wade asked what results
CIGNA has received from training providers in these three categories. Mary Rheinecker
indicated that many of the claims for items in these groups are billed by mail order
companies.
•
Wheelchair LMRP – Clarified that the recent information released by the DMERCs was
not a new wheelchair LMRP, but rather guidance to providers outlining documentation
requirements. He reported that the Center for Medicare and Medicaid Services (CMS) is
working on a formal response to industry concerns.
Dr. Hoover indicated that he has always maintained a strict interpretation of national
policy that a beneficiary must be bed/chair confined. He informed the DAC that he had
appeared before a Congressional hearing on this issue and they concurred with his
interpretation. Region D has always allowed just a few steps for patient transfer.
However, two of the four regions did not maintain the same interpretation. Therefore, the
four DMERC medical directors needed to reach a consensus and clarify their
interpretation of policy to providers.
He also reported that CMS will be developing a physician/beneficiary educational
material on power wheelchairs, but he is not sure how that will be distributed.
•
Physician Education Packet – CIGNA is in its final stages of developing a pocket size
tool for physicians on DMEPOS. Currently 7,000 packets will be printed and distributed
within the next few months. CIGNA plans to also make the packet available via its
website.
•
BIPAA 2000 Requirements – CIGNA is in the process of converting policies to the Local
Coverage Determinations (LCDs) public information article format required by BIPAA.
The DMERCs have two years to convert current policy to this mandated format. Dr.
Hoover reported that some benefit information would not translate into the new format,
which will create the need for multiple documents. However, CIGNA’s website will
contain hyper links to the additional information.
The cervical traction policy will be the first reformatted to LCD.
Troy Paz asked for clarification on the Ostomy letters. Dr. Hoover responded that the letters have
been distributed quarterly to major providers. Any changes to the edit parameters will be posted
on the CIGNA website and possibly distributed through the list serve.
Dr. Hoover also indicated that power wheelchair frequently asked questions (FAQs) will be
included on the website under the medical review section.
Rick Graver asked Dr. Hoover to clarify functional ambulation. Dr. Hoover reported that patients
who can bear weight to transfer directly bed to chair would qualify. Not someone who parks their
wheelchair in the hallway and walks several steps to his or her bed/chair. Dr. Hoover was asked
how he would treat a beneficiary who can take four steps and then is going to fall down in terms
of ambulation; he stated that we should use an ABN in those circumstances.
In addition, Rick Graver asked about respiratory diagnosis being curtailed as an indicator for
power wheelchairs. Dr. Hoover indicated that the issue of respiratory diagnoses as an indicator is
tough and that they will need to find a way to deal with the issue.
Dr. Hoover also clarified that even though in some instances it may be medically indicated that a
patient have both a walker and a wheelchair, Medicare does not pay for both. Therefore, he would
recommend the provider obtain an ABN. He also informed the DAC that providers could request
that consideration be given to the wheelchair policy.
III. PET UPDATE
Kathy Brock provided the PET update. She reported that PET is approaching its 2 year
anniversary for Webinars. Net courses are in the final stages of development. She invited the
DAC to participate and present at CIGNA’s Spring Seminars.
Ms. Brock provided a copy of the CIGNA Medicare Fax Back Survey and asked for provider’s
participation on the survey. She indicated that this is available on the CIGNA website.
IV. A-TEAM LEADERS Q&A REVIEW
ORTHOTICS AND PROSTHETICS A-TEAM
Phil Danz, O&P A-Team Chair prepared a statement that was read by Wade Hendrickson on each
of the following questions:
Question #1 –Stance Control Knee Orthotic HCPCS Coding
Thank you for your input to this very important question. The O/P A-Team has already made
contact with AOPA and various manufactures groups and will work with them to help provide
further information to the SADMERC and the DMERC'S.
Dr. Hoover indicated that CIGNA is happy to hear we were continuing to move forward on this
and will assist where when possible.
Question #2 – LMRP for Lower Extremity Prostheses
What is the process by which DMEPOS products other than specific manual wheelchairs and
power wheel chairs can be added to the Advance Determination of Medical Coverage (ADMC)
process?
Dr. Hoover indicated that CIGNA is looking into to the possibility and are working on it to see if
the ADMC can be expanded to include Lower Extremity Prosthesis within the scope of current
regulations. CIGNA will get back to the DAC or help think of another avenue.
#3 – Prefabricated Appliances Coding
The O&P A-Team would like to confirm that the CMS/SADMERC update stating that the article
titled "Orthoses – Coding Clarification" that was published in the Winter DMERC Dialogue
(January 2004) relating to "Addition" codes used in conjunction with some prefabricated orthosis
base codes has been rescinded.
The O&P A-Team would request that CIGNA’s response to question #3 be changed to reflect that
the "addition to" policy has been rescinded.
Dr. Hoover indicated that the DAC’s observation is correct.
#4 – Therapeutic Shoes Fee Schedule
The O&P A-Team thanked CIGNA for its clarification relating to Therapeutic Shoes, and has no
follow up questions at this time.
Previously Submitted Question
Does CIGNA have any idea when guidelines for the implementation of Inherent Reasonableness
will be provided by CMS to the DMERCS?
Dr. Hoover indicated that it is not known at this time, but will let us know as soon as they do.
EDI / EMC A-TEAM
Sandy Carden asked for clarification to the following responses received from CIGNA:
#6 – Electronic Claims Forwarding to Other Carriers
Would Region D require electronic claims testing if a provider has already been tested by 1 to 2
of the other DMERCs?
Scott Hudson indicated that CIGNA believes that it would require testing; however, they will
need to research the issue and get back to the DAC.
Post Meeting Follow-up – Provided by Doug Frazier: If CIGNA has no record of testing then yes,
they will be required to test. But, there is no reason to have separate submitter numbers for each
region when one submitter can be used for all regions.
EDUCATION / COMMUNICATION
Question # 8 – Capped Rental / SNF
Connie Lind-Fraher thanked CIGNA for the answers provided to our question. She asked if it
would be possible to include this question and answer in the FAQs area of the CIGNA website
since the answer is different from the answer given at the "Dining with Medicare" fall seminar
program.
Doug Frazier responded that it would not be possible to put in on the FAQs since those are
generated from supplier questions submitted via the website. He will look into other options that
may be available to distribute the information. He will notify DAC Central of the result.
Post Meeting Follow-up provided by Doug Frazier: The clarification will be added to the
combined list of FAQs under capped rental and CMNs.
Question # 9 – Website as Official Provider Notification
Connie read back CIGNA’s answer "…web site serves as the supplier’s "official notice
date"…and DMERC Dialogues and the DMERC Region D supplier manual and updates
distributed via CD-Rom or hardcopy are considered the "official records." She asked if this
wasn’t a step back from what we had been told previously, that the web site was the "official
record"?
Doug Frazier said research was done and CMS has only stated that the website was for official
notification. Barbara Douglas pointed out a mistake that occurred on the CD-roms that were sent
out and the corrections were put on the website (the CD-roms were not corrected and re-sent) thus
making the website the corrected official record. CIGNA will do further research on this and
contact DAC Central with final clarifications.
RESPIRATORY A-TEAM
Question #10 – Oxygen CMN Re-certification
Joe McKnight asked for further clarification to Question # 10 regarding the re-certification of an
oxygen patient inherited from another provider. He specifically asked which method the carrier
would prefer providers use, a re-certification from the date that the provider began servicing the
patient or a new initial CMN.
CIGNA responded that providers should use a re-certification from the date that we start service
for that patient, even if that is in month 15 following the need for the recert.
Question #12 – Oxygen LMRP Re: Sleep Oximetry Studies
Joe McKnight asked that CIGNA further clarify whether a homecare company can own an sealed
tamper proof oximeter used to assess a patients O2 saturation levels if the results are downloaded
by an independent diagnostic testing facility (IDTF).
Dr. Hoover indicated that he felt that since the test was a result of the oximeter, if the oximeter
was owned by the HME company, the test could not be used for qualification regardless of who
downloaded the results. However, Dr. Hoover and Mary Rheinecker both noted that new
information was forthcoming from CMS on this issue; therefore, CIGNA could provide more
clarity on the issue at a later date.
INFUSION THERAPY
Deanne Birch thanked CIGNA for its response to their questions. She also asked whether the
physician education packet her referred to earlier would include in formation on PEN. Dr.
Hoover responded that it would include PEN information.
REHAB
Question #14 – Wheelchair CMN Transmittal
Rick Graver asked whether there is a technical way for providers to transmit CMN information
with the claim when a CMN is not necessarily required in order to qualify the patient for the
equipment. CIGNA said that there is no way to transmit a CMN as we would with a claim that
requires it. They suggested providers indicate in the HAO record that we have a CMN on file to
qualify the patient and include the necessary information in a narrative format. CIGNA can create
a "dummy" CMN for the patient in their common working file.
Rick Graver indicated that the DAC would track a claim using this method and communicate the
results to CIGNA.
Question #15 – Replacement Tire / Tubes Coding
Rick Graver noted that providers have received feedback from the SADMERCs on the proper
coding for replacement tires and tubes. He asked if CIGNA could clarify the description for
K0090 and K0091. Dr. Hoover indicated that clarification is provided in policy.
Question #16 – Coverage of Replacement Tires
Rick Graver sought further clarification on the frequency of tire replacements covered by
Medicare. Mary Rheinecker reported that she is not aware of any policy indicating how
frequently tires can/should be replaced.
Question #17 – ADMC Documentation
Rick Graver thanked CIGNA for is feedback to providers concerns that faxed documentation to
support ADMC is being lost. However, the Rehab A-Team has reported that 30% of its faxed
documentation is not accounted for. He requested that providers be able to call and verify receipt
of faxed information.
Mary Rhienecker indicated that she would check with the supervisor of the ADMC Department
and provide the DAC with a name and phone number.
Post Meeting Follow-up provided by Doug Frazier: Suppliers who wish to confirm receipt of
faxed ADMC requests should, no sooner than one week after transmitting the request, contact a
DMERC customer service representative (CSR) in the usual manner. Additional contact
information was provided to the Rehab A-Team for instances when a CSR is unable to confirm
receipt.
Question #20 – Re: CMN Timeliness for ADMCs
Rick Graver asked whether the CMN timeliness change has been proposed to the other DMERCs.
Dr. Hoover indicated that it has not been communicated and that it will be when other more
urgent matters have been addressed.
HOME MEDICAL EQUIPMENT (HME)
Barb Stockert thanked CIGNA for its answers and indicated that her team has no additional
comments or questions at this time. In closing she indicated that the HME A-Team would like
the opportunity to revisit the issues brought forth in question #18 regarding patients with capped
rental in a SNF. CIGNA indicated that this would not be a problem.
MEDICAL SUPPLIES
Pat Spanel thanked CIGNA for its response to its questions and indicated that they do not have
any further questions at this time.
IV. NEW BUSINESS
CIGNA provided information on where providers can write to report potential fraud and abuse.
The following address was provided for contacting the Benefits Integrity Unit:
CIGNA Healthcare Medicare Administration
B.I.U.
P.O. Box 950
Nashville, TN 37202
Wade Hendrickson asked whether providers would receive a response on their submissions. Doug
Frazier indicated that providers would not receive a response, as it is a privacy matter.
Troy Paz indicated that the DAC would compile the results from the Vendor Fair surveys and
share them with CIGNA. Doug Frazier indicated that those results should be sent to his attention.
With no further new business, the meeting adjourned.
Region D DMERC Advisory Committee
CIGNA Meeting
June 28, 2004
Via Conference Call
CIGNA Staff:
Boise: Kathy Brock Doug Frazier David Smith
Miranda Kiles
Nashville: Dr. Robert Hoover Ryan Burkholder Nancy Orman
Mary Rheinecker
DAC: Troy Paz, Chair Violeta Arnobit Deanne Birch
Yvonne Cordoza Phillip Danz Sha Eppley
Ed Erickson Rick Graver Mike Hayden
Wade Hendrickson David Hosman Mary Jackson
Janna Jurovich John Kenney Connie Lind-Fraher
Joe McKnight Gemma Perry English Gloria Peterson
Rich Pozesky Carlos Reyes Kimberly Rogers-Bowers
Pat Spanel Barb Stockert Val Taylor
Judy Thompson Mary Turner
I. GENERAL BUSINESS
At 12:31 Troy Paz called the meeting to order. Roll call and introductions were conducted and Troy Paz reviewed the meeting protocol.
II. MEDICAL DIRECTOR UPDATE
CIGNA Medical Director Dr. Hoover provided an update on the following:
· Wheelchairs – Medical Directors continue to work with CMS on wheelchair coding. A CMS open door forum in early September is the anticipate time for a coding proposal to be presented for comment. He will try to get feedback from the Rehab A-Team prior to September.
·
The medical directors have been looking at the definition of bed or chair confined. However the definition is primarily being addressed at the CMS level.
·
A Knee Orthosis policy is currently in development and will likely be available for public comment in the next month. Dr. Hoover requested feedback from the DAC.
a. Medicare Beneficiary Information Provider Access
Troy Paz reviewed guidance by CMS that the DAC prioritize issues relating to provider access to Medicare beneficiary information. John Kenney then summarized the background and a detailed outline of providers access needs included with the meeting agenda. He then requested feedback on how to proceed.
Dr. Hoover responded by summarizing his experience through a research project that would require him to give an academic researcher access to beneficiary information. He indicated that with his experience patient privacy concerns is a difficult hurtle and will likely prevent the DAC from succeeding at obtaining access to beneficiary information. He did recommend that the DAC start with the Office of Civil Rights with in DHHS. Once permission is granted then the DAC should work with CMS.
III. PET UPDATE
Doug Frazier provided an update on the following:
· CIGNA’s Boise staff is currently in Phoenix, AZ at a CMS sponsored customer service and PECOM conference this week.
·
The Spring 2004 Seminars were successful with over 2,000 attendees with only 15 sites.
·
The Fall Seminar will start August 26 and cover 25 locations. He invited the DAC to participate in the Fall seminars. Fall topics will cover a documentation review, LMRPs/LCDs, and KX modifier requirements
·
Webinars – Two new Webinars have been added that cover Oxygen policy revision and ABNs.
·
NetCourses – He reviewed the various topics available.
·
Vendor Exposition – CIGNA staff is looking at possible holding the next CIGNA staff vendor exposition training day next summer rather than January. However, this is still being discussed internally. CIGNA will provide an update as soon as a date is determined.
IV. A-TEAM LEADERS REVIEW Q&A
a. EDI/EMC
Rich Pozesky thanked CIGNA for the answers provided.
b. EDUCATION
Connie Lind-Fraher thanked CIGNA for the answers provided.
c. HME
Barb Stockert indicated that the HME A-Team had no comments.
d. INFUSION THERAPY (I.V.)
Mike Hayden thanked CIGNA and commented on the new TPN decision tree available on the CIGNA website. Dr. Hoover commented that the CIGNA website will continue to be updated with more educational tools to the medical review section of the website. He invited the DAC participants to recommend topics. He also suggested that DAC members have their staff take both the pre and post test on the NetCourses. This will not only help CIGNA assess and improve their education tools, but can be a valuable training and proficiency measuring tool for HME providers.
e. MEDICAL SUPPLIES
Pat Spanel indicated that the Medical Supplies A-Team had no comments.
f. ORTHOTICS AND PROSTHETICS
Phil Danz commented on the following questions and answers:
#12 - Thanked CIGNA for the verbal dispensing order information. He questioned whether specific information provided at the time of the verbal order, which is taken over the phone would qualify as a verbal order. Dr. Hoover requested that the DAC provide a detailed list of information that would be documented over the phone. Once he has a chance to review the information he can comment further
#13 – For code L3215-L3253 is it safe to assume that "shoes" used in these code descriptors defines a pair of shoes? Dr. Hoover indicated that is correct.
#14 – What timeframe can the response be received from the medical directors. Dr. Hoover can not give a timeframe at this time. It is a low priority.
#15 – Phil Danz requested that DMERCs publish additional clarification on coverage of L8035. He indicated that providers have received conflicting information from the SADMERC and billing erroneously.
Dr. Hoover responded that the SADMERC does not handle coverage issues just coding and pricing. He also clarified that a code and price does not mean that an item will be covered.
#17 – The narrative field is limited in space. Therefore, providers must use paper claims which will be held for an additional 13 days for processing due to lack of HIPAA compliance. Can the DMERC provide guidance on how to avoid these circumstances?
Dr. Hoover responded that further guidance is not available at this time on how to submit the information electronically.
Kathy Brock clarified that the paper claims are not being held an additional 14 days. It applies to non HIPAA compliant electronic claims. Therefore, the payment floor for paper claims has not changed.
g. REHAB
A-Team Leader Rick Graver requested clarification on the following questions and answers:
#18 – A paper claim was submitted for processing for a K0011. Question number 1 on the attached CMN is answered "N", and a GA modifier is used. The claim processed and paid when the provider was expecting a PR denial due to the valid ABN. Was this a claims processing error, or is it possible that additional documentation attached to the claim was considered and the claim was properly adjudicated? If the claim were properly adjudicated, would this infer that the power wheelchairs are considered for people who don’t need a wheelchair to move around in their residence? If the claim was processed in error, could this be a systemic problem? A recent conference call inquiry to check the common working file for past payment of durable medical equipment resulted in two different customer service agents declaring that Medicare had not paid for a certain piece of equipment that the beneficiary claimed was paid for by Medicare. Later research from a vendor in another state produced a copy of a Medicare EOB for the same beneficiary showing Medicare payment. These kinds of errors make it difficult to create an accurate patient file and may cause the provider to issue an ABN when in fact one is not needed.
Mary Rheinecker responded that the claim might have processed correctly, which means that if question number 1 is answered "N", the additional information included might override the answer to the question. A provider should still use an ABN if the answer to question number 1 is "N."
Ms. Rheinecker suggested that the DAC provide an example. CIGNA can then research this to see if it was a claims processing error or if the additional information justified the payment. CIGNA is not aware of any other system issues, and is interested in looking deeper into problems that providers may be having when providers get wrong information from customer service. We can follow up with them on these and they will determine if it is a training issue or some other system issue.
#19 – Assuming that the beneficiary had never had a capped rental wheelchair from Medicare before, in this same scenario, please clarify that the capped rental period would begin with Medicare considering the chair as a first month’s rental.
CIGNA responded that providers should start a new capped rental period, and the claim should be paid as the first month.
PREVIOUSLY DISCUSSED DAC/CIGNA MEETING - March 2004
Regarding wheelchair cushion testing questions: Thanks for the suggestion that we work with the SADMERC. We have assigned Evan Call, our wheelchair cushion expert to this project. Evan will correspond with the proper individuals at SADMERC and copy Dr. Hoover.
PREVIOUSLY SUBMITTED QUESTION No. 14 – January 2004
Are we being advised to submit these claims paper? Would this be considered a HIPAA compliance issue if an electronic solution is not found?
CIGNA responded that it does not have a solution at this time. It does manually enter CMN’s into the system when they are received paper, but they are not willing to accept the CMN’s in any other way than with a claim at this time. They are still exploring a technical solution to this issue, but do not have any other ideas on how to accept these CMN’s electronically unless they are accompanied by a claim.
PREVIOUSLY SUBMITTED QUESTION NO. 20 – OCTOBER 2003
When can the DAC expect an update?
Dr. Hoover indicated that an update is not available at this time and will likely not be available anytime soon.
V. NEW BUSINESS
Dr. Hoover will likely be attending Medtrade Fall.
Troy Paz inquired as to whether electronic attachments is a foreseeable solution to the HAO limitations. Dr. Hoover indicated that it is in its infancy and that CMS Administrator Dr. McClellan is interested in electronic Medical Records. Dr. McClellan hired an IP expert last Fall to explore the possibility with the contractors. One contractor sends to providers an Additional Documentation Request electronically and has the capability to accept a response electronically. It has been recently readdressed again, because CMS needs to talk to the contractors about how DME providers can use this feature.
Dr. Hoover added that one of the challenges is that CMS electronic security standards prevent this information from being transmitted via the Internet. Therefore, it would have to be submitted via dial-up connections, which offers limitations that have not been resolved. He estimated being two years away from being able to accept electronic attachments.
The meeting adjourned at 1:31 PM.
Region D DMERC Advisory Committee
Meeting with CIGNA Medicare
October 27, 2004 § 9:00a.m. (EST)
Orlando, FL
MINUTES
DAC Representatives:
Deanne Birch Sandy Carden Sheila Showalter
Cindy Coy Velma Goertzen Kay Johnson
Rick Graver Mike Hayden Wade Hendrickson
John Kenny Janna Jurovich Judy Thompson
Laura McIlvaine Joe McKnight Leslie Rigg
Sharon Nichelson Troy Paz Rich Pozesky
Carlos Reyes Pat Spanel Zena Jacobi
Barb Stockert Carl Greene Mary Turner
Kimberlie Rogers-Bowers Kevin Call Brady Vestal
Karen Atkins Chuck Gunther Joe Riley
William Popomaronis Duane Ridenour
CIGNA Representatives:
Robert Hoover, M.D., Medical Director
Barbara Douglas Doug Frazier Kathy Brock
Miranda Kyles Cathy Grako Mary Rheinecker
Steve Wisenan
The meeting was called to order at 9:00 am EST.
I. GENERAL BUSINESS
Chairman Troy Paz opened the meeting with a roll call of DAC Representatives and CIGNA Representatives. There was a request for approval of previous meeting minutes. The minutes were approved.
II. MEDICAL DIRECTOR’S UPDATE
Dr. Robert Hoover, CIGNA Medical Director, thanked everyone for the questions and answers. Dr. Hoover provided the following updates:
· Orthosis Policy: Comment period ended Monday. The DMERC will still accept comments. Dr. Hoover verified that he received comments from the DAC.
o
CIGNA was disappointed with the attendance at the public meeting. Kansas City meeting had only three representatives with nine on the telephone. CIGNA received approval to hold public meetings in Nashville. Will still have teleconference lines available. More information will be forthcoming.
·
Qualified provider for Prosthetics and Certain Custom-Fabricated Orthotics: Change Request (CR) 3373, on who is qualified provider for O&P, will be released. In the future, claims will be rejected if providers are not signed up as specialty type for O&P. Provider who have specialties identified as involving orthotics and prosthetics with the following specialty codes: 51, 52, 53, 55, 56, 57. The implementation date of this CR is 07-01-05 and most likely will incorporate the Knee Orthosis Policy to be the same date.
o
Dr. Hoover was not sure if Diabetic Shoes and External custom breast prosthesis were included in the list of HCPCs codes.
·
Continue to convert from LCDs to LMRP Policy Article. Medical Directors still having conversations with CMS about a search by key article. Distinguish by policy article and are associated with the LCD.
·
Medicare Coverage Data Base (MCDB): CIGNA website has mirrored the MCD. In the future will have links to MCDB. Awaiting CMS to approve this.
·
HCPC’s Codes Update: Meeting today at CMS on new HCPC’s process. The website address for CMS is:
www.cms.hhs.gov
. There will be new timelines and public comments process. This information will be forthcoming. Reminder to everyone there is no grace period once codes go into effect. It is Important to go to website and sign up for list serve. Deadline for bulletin articles is this Friday and lists of HCPC’s won’t be in it.
·
Wheelchair seating codes - Adjustable Cushions: There is a request to create new code for adjustable cushion, the code is now K0108 until a new code is established and definitions are ready. Bulletin article will be done by the end of this week. Look at product classification list for verification. Wheelchair codes will be permanent E-codes from K-codes.
III. Common Working File Update
Lauri Oneil was not available. CMS questions are being worked on. The DAC thanked Ms. Oneil for her effort.
IV. PET UPDATE
·
Doug Frazier reported that Cathy Grako is the new Ombudsman.
·
Thirteen seminars have been completed with another twelve scheduled. Mr. Frazier thanked the DAC for their participation in the meetings. Continue with the trend. March through May 2005 PET will be going to fifteen sites.
·
Webinars will be starting up in January 2005. Net courses that have been added are ABN, Trach and Suction with more being developed. Watch the CIGNA website. Over 200 attendees have participated thus far.
·
As of 1-1-05 there will be a change in how calls are handled. Change Request (CR) 3376 on the Implementation of the Medicare Modernization Act (MMA) Provider Customer Service program provides how customer calls are handled. They will use a triage approach to answer questions. There will be a 3 tier level when handling questions of varying complexity: level one – new, level two – more experiences, and level three being made up of experts. The Interactive Voice Response (IVR) will be expanded. The Customer Service Representative (CSR) could direct providers back to the IVR. PET will be changed to POE – Provider Outreach and Education. There is also a plan to enhance education on the internet. Conduct "Ask the Carrier" teleconferences quarterly. Look in the list serve for details on how they will change.
·
CR 3278 – Indian Health Services (IHS): Effective 1-1-05 claims will be filed to Medicare. DMERC claims going to CIGNA. It is up to them to educate the clinics on how to submit to Medicare. Doug will be working with them.
·
Dr. Hoover provided input that Medical Review has documentation check list. Send feedback on this checklist to Dr. Hoover. He also spoke about the net courses on the website, documentation errors from Cert program and offer fixes.
o
Wade Hendrickson asked Cert Program question: Through the National Supplier Clearinghouse Advisory Committee (NSCAC) a question was asked when a company is acquired and cert reviews go out, they are going out to current owner. Dr Hoover’s answer: Whatever information is on the current NSC list is who it goes to. It is based on supplier number on the claim. When a cert contractor has no response, may go to current owner.
o
Another question was posed regarding providers billing to get denials. In this scenario, is this showing up for a cert review? Answer: Cert reviews done statistically on random claims process, not denials, it is all claims. Based on the claims in the system. Errors are tracked correct or incorrect.
V. NEW BUSINESS
Troy Paz reported on the DAC elections that were held. The new DAC Executive Committee is as follows: Chair: Rich Pozesky; Vice Chair: Val Taylor; Secretary: Rick Graver; Treasurer: John Kenney; and Past Chair: Troy Paz.
VI. A-TEAM RESPONSE TO Q&A
EDI/EMC: Zena Jacobi, A-Team Leader, had no follow up questions.
Education/Communication/PCOM: Cindy Coy, A-Team Leader, asked for clarification on the following:
Q#4
1. It was requested to clarify the "period of use" referenced in the answer.
Response: If a patient had an item, returned it, and rented it again, the DMERC would need another Assignment of Benefits (AOB).
Q#5
1. Are all questions document and if not, which ones?
Response: The questions that would benefit everyone and questions that are place on the parking lot (easel) are questions that get put on the website Q & A.
HOME MEDICAL EQUIPMENT (HME)
Barb Stockert, A-Team Leader, asked for the clarification on the following:
Q#6
1. Why is the date printed on the example used not adequate?
Response: It has to be clear that the doctor signed the order. As long as they can be clear as to when the prescription was signed. Date needs to be by the signature. The DMERC needs to clearly associate the signature with the date it was signed.
2. The statement was made that electronic CMN’s are more prevalent. This response may need to be looked at.
Response: The DMERC requested to bring the issue back.
Q#7
1. If the question had stated as not appealed but reviewed, would the answer be the same?
Response: The response in the answer would be the same. In addition, CIGNA staff does recall doing "Favorable Decisions".
Note: Dr. Hoover indicated to the DAC on an update in the Appeals Process that recently eight Contractor Awards have gone out, and to keep an eye out for further information.
INFUSION THERAPY
Mike Hayden, A-Team Leader, added additional information on the following:
Q#9
1. Since the patient clearly does not qualify for questions on 6-11 on the DIF 080.02 would not be relevant in the situation stated in the questions. Claims should be denied as not covered and not CO-16 (not enough information).
Response: The DAC will send examples to Doug Frazier. Problem will be resolved. Dr. Hoover said DIF will be eliminated but not sure when it will happen. CWF changes will be made hopefully first part of the year.
Follow up response from CIGNA 12-16-04: Instructions were placed into the system to prevent this type of denial from happening again.
MEDICAL SUPPLIES
Pat Spanel, A-Team Leader, asked for clarification on the following:
Q#11
1. Two parts to the question. Part A has been answered. Part B not answered.
Response: The answer still applies to Part B because the article was wrong. A new prescription will be needed once a year. If there is increased utilization, then need a new prescription every six months.
Orthotics & Prosthetics
Sharon Nichelson, A-Team member, asked for clarification on the following:
Q#12
1. The A-Team commented they hope the DMERC will look to the A-Team as a favorable resource.
Response: They will.
Q#13
1. The A-Team will support a revision of the policy and asked when this would occur?
Response: Dr. Hoover responded yes. Dr. Hughes is the keeper of this policy and Dr. Hoover sent this question to him. There is not in upcoming revisions, but maybe in March 2005.
REHAB
Rick Graver, A-Team Leader, asked for clarification on the following:
Q#15
1. It is not expected that the beneficiary will receive both one set of swingaway lateral brackets and the fixed brackets that are listed in the descriptor on code E1028.
Response: Providers need to bill swingaway hardware with certain codes.
Q#16
1. We are confused on response. The question relates to claims going in specifically to be denied where providers used GA modifier. Claim being processed and paid even with GA modifier. Provider knows the patient can walk two steps, and the CMN was answered correctly.
Response: If all questions on CMN, a GA modifier doesn’t trigger that it should be denied, only that an ABN is on file. The documentation speaks for itself. Supplier can submit a voluntary refund.
2. Is this response the same with GY modifier?
Response: Not necessarily. There is a specific situation when using a GY modifier that may trigger a denial. Would reprocess claim as a medical necessity denial.
3. What about a post pay audit?
Response: If in an audit, and it shows that ABN supports, the patient would be responsible. If the documentation shows they meet medical necessity, but no further documentation was available on walking, and you know they can, then the CMN should be corrected.
4. Rick Graver stated that the providers are in the middle of this problem. Whose responsibility is it to verify the extent of bed or chair confined?
Response: Dr. Hoover indicated that if the CMN says bed or chair confined is answered "yes" and the beneficiary can walk, providers clearly know that. Provider needs to go back to the doctor to get updated CMN. Providers should be the watch dogs.
RESPIRATORY
Joe McKnight, A-Team Leader, asked for clarification on the following:
Q#20
1. If we attach the GY modifier, will that allow the supplier to obtain the PR response on the EOB or should they bill as E1399 so that we can bill the beneficiary in Medicaid situations.
Response: The DMERC can not give a denial needed for a secondary payer. Dr. Hoover reminded that there is DMERC Dialog article about this issue with in the past two years.
Q#23
1. The DMERC has indicated that we should use the HAO record for this purpose, but not sure being read or recognized. Multiple providers have examples.
Response: The DMERC cannot respond until they see examples. Rich Pozesky has the examples.
Follow-up response from CIGNA on 12-16-04: CIGNA reviewed the examples of claims being denied for the oxygen test. The first example (xxx-xx-xxxx) did not have HMO coverage so the
denial is correct. CIGNA also researched the provider number for similar denials and have adjusted those denied in error. CIGNA does have instructions to by pass the 30 day edit for HMO beneficiaries. It was found that several different approvers are making this error. CIGNA will
send a reminder to the claim approvers.
VII. Adjournment
Dr. Hoover recognized Chair Troy Paz for a great job and indicated the DMERC looks forward to working with new Chair Rich Pozesky.
Meeting concluded at 10:40 am EST.
Region D DMERC Advisory Committee / CIGNA Meeting
March 17, 2004 3:00 PM
Las Vegas Convention Center Las Vegas, NV
MINUTES
DAC REPRESENTATIVES:
Troy Paz, Chair Diane Abbott Doreen Alderete Violeta Arnobit
Reid Bellis Deanne Birch Harry Brandt Jeff Buchbinder
Kim Burnett Cindy Coy Asela Cuervo Phillip Danz
Sha Eppley Laraine Forr Velma Goertzen Rick Graver, ATS
Chuck Gunther Diana Guth Maureen Hanna Mike Hayden
Wade Hendrickson Mary Henningsen Cynthia Jackson Zena Jacobi
Tami Joplin Janna Jurovich John Kenney Herb Langsam
Miriam Lieber Connie Lind-Fraher Laura McIlvaine Joe McKnight
Sharon Nelson Sharon Nichelson Gemma Perry English Gloria Peterson
Marshall Pollock Leslie Rigg Kimberly Rogers-Bowers
Sheila Showalter Pat Spanel Barb Stockert Val Taylor
Steve Treinen Rosalie Webber
CIGNA STAFF:
Kathy Brock Doug Frazier John Kelly Miranda Kyles
Melissa Lamb Mary Rheinecker Amanda Zumwalt
CMS REPRESENTATIVE:
Lori O’Neil
I. GENERAL BUSINESS
Val Taylor conducted the roll call of the DAC State Representatives and A-Team Leaders. Troy Paz reviewed the meeting protocol.
II. MEDICAL DIRECTOR UPDATE
Dr. Robert Hoover, Medical Director was not able to attend so Mary Rheinecker provided the medical director update. Ms. Rheinecker reported on the following:
·
Explained the Claims Error Rate Testing (CERT) and reported that CIGNA continues to work on CERT problems as they are identified;
ACTION ITEM Mary Rheinecker indicated that she would check if an Advance Med contact could be given to the DAC.
ACTION ITEM Mary Rheinecker will check with CMS if providers can comment on CMN effectiveness during its review.
Wade Hendrickson inquired about how the DAC can provide additional comments on the wheelchair seating policy since its release. Mr. Hendrickson and Rick Graver indicated the DAC’s concern over how the cushions were tested and how basing coding off this testing could lead to potential utilization issues for Medicare.
ACTION ITEM Mary Rheinecker will ask Dr. Hoover how the DAC can comment on its concerns with the coding of wheelchair cushions.
a. Common Working File (CWF)
John Kenney summarized that the primary denial problems providers face are a result of same or similar equipment. If providers could have access to the CWF these denials would be reduced. Mr. Kenney indicated that with HIPAA fully implemented, the DAC would like CIGNA and CMS to revisit this issue. He prioritized the DAC’s request to: #1 – allow providers access to the CWF or #2 – allow providers limit access to the CWF to obtain only Same or similar information.
After discussing the issue Lori O’Neil suggested that the DAC should change the standing agenda item to be more specific to its concerns. She recommended not referencing it to the CWF, but can be addressed as information that is accessible by CIGNA.
There was discussion on how providers can reference patients’ equipment pick-up (p/u) information. Mary Rheineker clarified that CIGNA can reference the other DMERCs system to see that the item had been billed to another DMERC, but cannot reference p/u information because it is not kept in the CWF. If CIGNA received billing for that patient they may have p/u information. However, the p/u history in
CIGNA’s system is purged, so it is only accessible for a certain timeframe. She also indicated that the p/u information is not accessible if the provider has no claim history with the patient.John Kenney indicated that the DAC would readdress the issue with more specifics.
Wade Hendrickson indicated that the DAC would like to strengthen its relationship with CMS to resolve outstanding issues. Lori O’Neil reiterated CMS’ commitment to work with the DAC.
III. PET UPATE
Doug Frazier summarized the January equipment fair training for CIGNA staff and the benefits of this event. He also reported that the compilation of the Frequently Asked Questions (FAQs) on CIGNA’s website has been developed in a way that involves the DAC. The new format in the Supplier Resources for Claims Submission section of the website includes the past FAQs and selected Q&As from the DAC.
He reported that the medical review section of the website has a lot of information for providers to access. Power mobility issues have been addressed very rapidly. Support surface (Group II), enteral, and power mobility netcourses are available in medical review.
Mr. Frazier encouraged the DAC to communicate topics ideas for the CIGNA Fall seminars by way of Cindy Coy and Wade Hendrickson who are the DAC PCOM representative.
IV. A-TEAM LEADERS REVIEW OF Q&AS
a. EDI
Zena Jacobi, A-Team Leader requested clarification to question No. 1 relating to EDI/ERN agreements. CIGNA indicated in its response that the EDI enrollment form does not have the supplier number on the form; therefore, it requires the additional letter from the provider. Zena Jacobi indicated that the customer profile contains the supplier number; therefore, it is still not clear why the letter is required in addition to the form.
CIGNA responded that because there is no signature on the customer profile, a signed letter is a safe guard for providers.
Zena Jacobi asked whether the form could be revised to incorporate the signature.
ACTION ITEM CIGNA will check to see if the EDI/ERN agreement can be changed to incorporate the provider signature and report back to the DAC.
b. Education Communication
Cindy Coy, A-Team Leader thanked CIGNA for the answers provided.
c. HME
Barb Stockert, A-Team Leader asked for clarification on the following:
Question 5
a. Will providers be permitted to submit a paper claim when the number of characters entered in the HAO record exceeds the 80-character limit when providing the necessary information on same or similar?
Mary Rheinecker - CMS and the contractors are actively working on the issue of expanding the HAO; however, is not easily resolvable. In the meantime, CIGNA advised the DAC to use the second field, which gives an additional 80 characters expanding the HAO up to 160 characters.
e. Medical Supplies
Pat Spanel thanked CIGNA for answers and asked for additional feedback as follows:
·
Question 15Previously Submitted Question
Pat Spanel thanked CIGNA for its response and asked how the clarification can be presented to everyone? Doug Frazier responded that in the short term it will be in the Suppliers Recourse on the website and recommended that the DAC suggest it for provider training through the PCOM.
f. Orthotics & Prosthetics
Previously Submitted Question No. 3 – January 2004.
Phil Danz thanked CIGNA for its response and asked for additional clarification on how specific the initial date of purchase needs to be on a spinal orthosis.
ACTION ITEM Mary Rheinecker will get clarification on what specific date information is needed for the previously purchased item and report back to the DAC.
Previously Submitted Question No. 2 – January 2004
Phil Danz asked what the DAC could do to get lower extremity orthosis included as an item approved through the ADMC process. Mary Rheinecker responded that CIGNA is not currently doing anything to expand the listed items included in the ADMC, because the regulation limits what types of services contractors can approve through the ADMC process.
ACTION ITEM Mary Rheinecker will follow-up with Dr. Hoover to see how the DAC can work to expand the ADMC to include lower extremity orthosis.
g. Respiratory
Joe McKnight, A-Team Leader thanked CIGNA for its answer had indicated that the Respiratory A-Team has no further follow-up at this time.
h. Rehab
Rick Graver, A-Team Leader address the following:
Question 10 and 11
Rick Graver requested information about the proper procedure to verify accurate coding. Mary Rheinecker indicated that the DAC needs to look at the crosswalk codes that come out in early December and make the changes as applicable for the January 1 implementation date and that there is no grace period in 2005 for new codes.
Question 12
Rick Graver expressed the DAC’s belief that ADMC for K0011 would save money to the Medicare program, enough to outweigh any increased workload at the contractor level. He also stated the DAC’s concerns about making the beneficiary responsible for payment when the beneficiary feels that the documentation is adequate and the provider has a valid reason to use an ABN.
Question 13
He indicated the A-Teams appreciation of the definition of "considered" and verified that the definition given in the answer should be considered the definition of the word "considered" when used in other DMERC information. He also demonstrated different definitions of the word to demonstrate the ambiguity of such words and phrases, which adds to the confusion surrounding many definitions of words that the providers are asked to interpret.
Question 14
Rick Graver asked if there was any way providers could bill Medicare when seeking a denial for a patient residing in a skilled nursing facility (SNF) using HCPCS code A9270. Mary Rheinecker indicated that providers couldn’t bill Medicare covered items for patient in a SNF using HCPCS code A9270. There is no way to use an edit to make these codes deny as "non covered" when billed using place of service 31, and providers must obtain a CMN when necessary for items requiring a CMN, even if the place of service does not qualify for the item being provided, in order to obtain the proper denial to bill secondary insurance, Medicare requires all of the appropriate information to be submitted with the claim.
Previously Submitted Question 14 from January 2004
The Rehab A-Team requested if an anticipated time that clarification will be received from CMS. CIGNA indicated that there was no anticipated time. Rick Graver indicated, therefore, that this will continue to be a question from the Rehab A-Team.
Question 20
Rick Graver stated that the Rehab A-Team is anxious for resolution
V. NEW BUSINESS
General announcements were made about updates made to the DAC website, the date and time of the DMERC update at Medtrade Spring, and that Kathy Brock will represent CIGNA at the DMERC update.
CIGNA also announced that effective July 1, 2004, all providers not submitting claims in the 4010 A-1 (ANSI) format will experience increase processing time from 14 days to 29 day processing.
Adjourned at 5:10pm.