Region D DMERC Advisory Committee
Questions to CIGNA Medicare
Submitted 1/10/03
For 2/10/03 Conference Call
CIGNA Returned to DAC on 01/28/03
1.
For patients requiring liter flows greater than 4lpm, question 7 of the oxygen CMN states that testing
must taken at 4lpm to qualify. Can the testing be taken at greater than 4lpm as long the patients ABG
or Oxygen saturation level meets qualification (>88%) at the higher liter flow.
Answer: Only results of tests performed while the patient was on 4LPM may be entered as a
response to CMN Question 7. If testing was performed while the patient was on a flow rate greater
than 4LPM, Question 7 must be left blank. These test results may be submitted as additional
documentation with the claim and will be considered on an individual consideration basis.
2. In reviewing the Winter 2003 DMERC Dialogue & the Supplier Manual Update, the CPAP
accessories not only have Replacement (crosswalk) codes but some new codes have been created
for Full Face Mask (A7030), Face Mask Interface (A7031), Replacement Cushion for nasal
application device (A7032) and Oral interface used with positive airway pressure device (A7044).
a. As we know, the creation of new codes with fee schedules does not mean that they are
covered. Will they be covered starting 1/1/03?
Answer: Yes.
b. If they are covered, what is their rate of replacement? It is not reflected in the Supplier
Manual Update.
Answer: This has not yet been determined. If there is to be an established guideline for
utilization of these items, it will be published in a future revision of the CPAP LMRP.
3. The DAC would like the status of coverage determination on the following:
a. There is a serious need for the Cough stimulating device (E0482) by ALS patients. A
Medicare medical coverage policy was published for public comment. When can we
anticipate coverage for this vital medical device?
Answer: Probably early spring.
b. A similar question could be asked about High frequency chest wall oscillation air-pulse
generator system (E0483) along with the replacement part associated with the replacement
parts (A7025, A7026).
Answer: Probably early spring.
c. A new code for a pulse oximeter has been created (E0445). Will it be covered?
Answer: No. It does not meet the criteria for DME, so it is denied as non-covered because
there is no benefit category
.
What is the determined allowable?
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Answer: NA
4. From Winter 2003 DEMERC dialogue. Oxygen Qualification with Exercise Testing. Three oxygen
measurements of oxygen saturation are required to qualify for use during exercise; 1) testing at rest
without oxygen; 2) testing with exercise, but without oxygen, to demonstrate hypoxemia; 3) testing
with exercise, with oxygen applied, to demonstrate improvement of hypoxemia.
Since test number 3 is not a qualifying test and can in no way benefit the supplier, or impact
coverage, would it be acceptable for the supplier to administer this test?
Answer: All three test results are criteria for coverage (per CIM 60-4). As stated in the bulletin article
referenced above, "Failure to obtain and document test results under all 3 conditions for patients
attempting to qualify for oxygen therapy under the exercise category may result in the denial of the
claim and any subsequent claims that relied upon this testing result." Suppliers are prohibited from
performing any of these tests.
5. Many suppliers offer overnight oximetry as a no charge service to beneficiaries to assist physicians in
diagnosis of hypoxemia. Does the carrier feel that performance of oxygen oximetry on Medicare
beneficiaries who are not on oxygen or under the care of an HME provider represents an inducement
(as defined under anti-kickback statute, 42 U.S.C. §§1320a-7b[b]) to physicians or patients to secure
service with that provider?
Answer: CIGNA Medicare is not the appropriate entity to answer this question. We suggest you
contact the Office of Inspector General (OIG) for an advisory opinion (www.oig.gov) or consult with a
healthcare attorney knowledgeable in the area of anti-kickback statutes.
Previously Submitted Question – October 2002
Respiratory A team, question 15, page 9.
In regards to Bi-pap coverage for obesity hypoventilation syndrome.
a. Obesity hypoventilation syndrome is a restrictive thoracic disorder causing the exact
clinical symptoms as ALS.
b. Patient’s meeting coverage guidelines with ALS meet the guidelines because they are
hypoventilating.
c. Patient’s with obesity hypoventilation syndrome do not necessarily have obstructive
apnea or central apnea measured by a facility-based polysomnogram. copd is not
present.
d. Patient’s with ALS or obesity hypoventilation syndrome must have one of the following to
qualify under restrictive thoracic disorder:
��
PaCO2 of >45 mm hg while awake OR
��
SpO2 < 88% for at least 5 continuous minutes OR
��
FVC is < 50% predicted
QUESTION: Patient’s with ALS and obesity hypoventilation syndrome need a RAD due to
hypoventilation. Why is ALS covered and obesity hypoventilation syndrome not covered? Dr. Hoover
clinically agreed that this should be covered and indicated that he would confer with the other Medical
Directors and make a determination.
Answer: The DMERC medical directors made a collaborative decision on this issue. The person or
group seeking coverage for obesity hypoventilation syndrome may submit a request, in writing, for a
reconsideration of this coverage decision. The request should include pertinent medical literature from
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peer-reviewed sources to support their position. Please send copies of the information to all 4 DMERC
medical directors.
Previously Submitted Question
Per Dr. Hoover’s request we are resubmitting the following questions: Can an oxygen supplier obtain a
pulse oximeter in a sealed case from an IDTF, deliver it to a patient and then pick-up and return the pulse
oximeter to the IDTF for downloading and use for qualification purposes? Many patients are not able to
go into the IDTF (especially for overnight testing) and reimbursement is so poor (about $14.00) that IDTFs
cannot incur the expense associated with delivery. How does this issue differ from the letter provided to
Peterson Oximetry Services by Dr. Hoover?
Answer: See answer to #5 above.
Medical Supplies A-Team
No new questions at this time.
Rehab A-Team
6. Rehab seating and positioning products can be quite expensive and time consuming to provide,
particularly the custom products. Will CIGNA consider allowing ADMC for these products, either for use
on a covered wheelchair, or on a patient-owned wheelchair?
Answer: No. CIGNA does not have the authority to do this.
If not, is there a procedure to petition for these products to be included under ADMC?
Answer: As for any issue that must be addressed by CMS, the supplier/DAC may submit their
request in writing to CMS.
Items for consideration to the ADMC process, yet not all-inclusive.
a. Sunrise medical product Jay 2 solid back cushion model 2518K MSRP $425.00 designed to
address pelvis and trunk positioning while seated in a wheelchair. Can provide up to 15
degrees of seat to back angle.
b. Whitmeyer Biomechanix product Soft Pro Adult head support model PRO-1D, MSRP $504.00
for use in wheelchair positioning for individuals needing posterior support as well as lateral
cervical support.
c. Power tilt in space option, added to a previously funded power base.
7. An E0192 wheelchair cushion that needs to be specially sized has a retail price well above the
Medicare allowable. Is it appropriate to submit the cushion as K0108 with the specifications, etc, or
submit it on two lines with the second line being the upcharge for special sizing? This question was
asked of CIGNA customer service with both answers given, clarity would be appreciated.
Answer: Suppliers should request that the product be reviewed by the SADMERC for a coding
determination. They will determine if either of the coding solutions you mentioned are appropriate.
8. If gap fill methodology is being applied uniformly, what is the explanation for the discrepancies in the
percent of adjustment to the MSRP in each of the following examples? These claims are for custom
Contour U seating systems, and a power tilt system, in each case, documentation was submitted to
substantiate the billed charge. Should the attaching hardware or mounting pans be billed separately
if listed as a separate charge on the manufactures price list?
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Examples provided separately
Answer: Per the DMERC Region D Supplier Manual, Chapter 9, Wheelchair
Options/Accessories (WCC), page 5, "If multiple miscellaneous accessories are provided, each
should be billed on a separate claim line using code K0108. When billing more than one line item
with code K0108, ensure that the additional information can be matched to the appropriate line
item on the claim. It is also helpful to reference the line item to the submitted charge."
Gap fill methodology is being applied uniformly in Region D. When using gap fill methodology,
there is not one set percentage rate applied across the board to the suggested retail pricing, but
multiple variables that must be considered. The gap filling section in Chapter 12 of the DMERC
Region D Supplier Manual lists different ways that a price can be gap filled. On the claims
checked, the third option of "supplier price lists" was used. When using this option we must
consider several pieces of information (the date of the retail pricing information, the date of
service and the category of the equipment/item) and apply the deflation factors and covered item
updates from CMS that correspond to each of these pieces of information.
Below is the gap fill methodology for all DMPOS items……….
To establish a base fee from state fee year data greater than the base year, deflate the median amount by
multiplying the median amount by the appropriate CMS supplied year and category deflation factor as listed
below. NOTE: Deflation factors are applied only when reducing a price to base year. Most items have a
base year as 1986/1987, however, there are exceptions such as surgical dressings and parenteral/enteral
nutrition.
DEFLATION FACTORS
CATEGORY
SOURCE YEAR
JUNE 2002
JUNE 2001
JUNE 2000
JUNE 1999
JUNE 1998
JUNE 1997
JUNE 1996
JUNE 1995
JUNE 1994
JUNE 1993
JUNE 1992
JUNE 1991
JUNE 1990
JUNE 1989
JUNE 1988
JUNE 1987
OXYGEN
.609
.615
.635
.659
.672
.683
.699
.718
.740
.758
.781
.805
.843
.882
.928
.965
CAPPED
RENTAL
.613
.619
.639
.663
.676
.687
.703
.723
.745
.763
.786
.810
.848
.888
.934
.971
SURGICAL
DRESSING
.779
.788
.813
.844
.860
.875
.895
.919
.947
.971
--
--
--
--
--
--
PARENTERAL/ENTERAL
NUTRITION
.848
.857
.885
.918
.936
.951
.973
--
--
--
--
--
--
--
--
--
ALL OTHERS
.614
.621
.641
.665
.678
.689
.705
.725
.747
.765
.788
.813
.851
.890
.936
.974
To establish a current year fee from state fee year data less than the current year, index the median amount
to the current year level by multiplying the median amount by each year and category covered item update
factor, as listed below, from the source year through to the current year. NOTE: Covered item update factors
may be applied when indexing a price to any year level, regardless if it is the base year or the current year.
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COVERED ITEM UPDATE
Year DME Oxygen P & O Ostomy,
Tracheostomy,
Urological
Surgical
Dressings
Parenteral/
Enteral
Nutrition
1989 1.7% 1.7% 1.7% 1.7%
1990 FROZEN FROZEN FROZEN FROZEN
1991 3.7% 3.7% FROZEN 3.7%
1992 3.7% 3.7% 4.7% 3.7%
1993 3.1% 3.1% 3.1% 3.1% 3.1%
1994 3.0% 3.0% FROZEN 3.0% 3.0%
1995 2.5% 2.5% FROZEN 2.5% 2.5%
1996 3.0% 3.0% 3.0% 3.0% 3.0% FROZEN
1997 2.8% 2.8% 2.8% 2.8% 2.8% FROZEN
1998 FROZEN FROZEN 1.0% FROZEN FROZEN FROZEN
1999 FROZEN FROZEN 1.0% FROZEN FROZEN FROZEN
2000 FROZEN FROZEN 1.0% FROZEN FROZEN FROZEN
2001 (1st half) 0.3%* 0.3%* 1%* FROZEN FROZEN FROZEN
2001 (2nd half) 3.7 + 3.28%* .3%* (**) 3.7 + 2.6%* 3.7 + 3.28%* 3.7 + 3.28%* FROZEN
2002 0.6%* 0.6%* 1.0% FROZEN FROZEN FROZEN
2003 1.1% FROZEN 1.1% 1.1% 1.1% 1.1%
*Temporary increase not to be carried over into future periods.
**Oxygen equipment received the .3% temporary increase for all of 2001. No additional increase
received in 2
nd
half of year.
Research on claims indicated:
Example one submitted code K0108 for $825.00 was for a Contour U Cushion being billed with
date of service 1/23/01, example two submitted code K0108 for $1085.00 was for a Contour U
Cushion ($825.00), mounting pan ($175.00), plaster ($25.00) and labor ($60.00) with date of
service 5/13/00 and example three submitted code K0108 for $1245.00 was for a Contour U
Cushion ($865.00), mounting pan ($175.00)and mounting hardware ($205.00) with date of
service 07/15/02.
These claims represent different years of service and also contain different suggested retail
information, therefore the payment amounts will not be the same. In addition, the charges were
incorrectly bundled together and in the case of example three, the claim line only indicated one
reference for the item, therefore the allowable was only based on that item.
The different payment amounts can best be explained by walking through the gap filling for the
same specific items, such as the Contour U Cushion.
Date of Service 5/13/00:
Allowable based on gap fill methodology using attached suggested retail price with date of
service as date of retail pricing (due to lack of date on attachment).
$825.00 (Contour U Cushion) x .838 (At this time, we were using a cumulative conversion factor
combining deflation and covered item updates .665 x 1.017 x 1.037 x 1.037 x 1.031 x 1.03 x
1.025 x 1.03 x 1.028 = .838) = $691.35
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Date of Service 1/23/01:
Allowable based on gap fill methodology using attached suggested retail price with date of
service as date of retail pricing (due to lack of date on attachment).
$825.00 x .641 = $528.83 x 1.017 = $537.82 x 1.037 = $557.72 x 1.037 = $578.36 x 1.031 =
$596.29 x 1.03 = $614.18 x 1.025 = $629.53 x 1.03 = $648.42 x 1.028 = $666.58 x 1.003 =
$668.58
Date of Service 7/15/02:
Allowable based on gap fill methodology using attached suggested retail price with date of
service as date of retail pricing (due to lack of date on attachment).
$865.00 x .614 = $531.11 x 1.017 = $540.14 x 1.037 = $560.13 x 1.037 = $580.85 x 1.031 =
$598.86 x 1.03 = $616.83 x 1.025 = $632.25 x 1.03 = $651.22 x 1.028 = $669.45 x 1.037 =
$694.22 x 1.006 = $698.39
With the
three examples listed above, you can see that the deflation factor is different on all
three. The covered item update amounts are different for each date of service. For the last
example, the suggested retail amount was different; therefore, the allowables are not the same.
Fourth example provided separately. This claim is for a power-tilt system, the allowed charge had a 31%
discount applied off of MSRP, again we question if this has been calculated correctly?
Answer: For the
fourth example, a different product was supplied. This was for a K0108 for
$5012.00 for a power tilt only on an Invacare Storm Series chair (Part # PTO-STM) for date of
service 7/7/02. The allowable was based on gap fill methodology using suggested retail price
from manufacturer dated 4/15/02
and is correct.
$4195.00 x .621 = $2605.10 x 1.017 = $2649.39 x 1.037 = $2747.2 x 1.037 = $2849.07 x 1.031 =
$2937.39 x 1.03 = $3025.51 x 1.025 = $3101.15 x 1.03 = $3194.18 x 1.028 = $3283.62 x 1.037 =
$3405.11 x 1.006 =
$3425.54
9. A state-funding agency will pay for a custom wheelchair with seating system when the provider
follows the charges as listed by the manufacturer. Using a motorized wheelchair K0011 as an
example, if the provider supplies a K0011 and the manufacturer charges the footrests separately, the
state will pay for the wheelchair base and the footrest separately. If this same wheelchair is billed to
Medicare first, the footrests will be denied as included in the purchase price of the wheelchair (insert
denial code). The state will not pay for the footrests because the denial code used by Medicare is not
acceptable to the state. The provider has been unsuccessful in having the denial code changed. It
was suggested that the provider obtain an ABN from the beneficiary stating that Medicare does not
pay for footrests separately from the wheelchair base, the claim then is billed using the GA modifier.
Problem: if this is done, the provider runs the risk of "routinely providing ABN’s" for their dual
eligibility clients as there is no medical justification for the denial and it is likely that Medicare will say
that the equipment is not being denied as it is included in the allowable for the wheelchair base.
Given the circumstances for the dual eligible client, can CIGNA:
a. Change the denial code when appealed by the provider to an acceptable denial such as
patient responsibility or not a covered benefit?
Answer: Reference article in DMERC Dialogue Winter 2000, page 2. Medicare cannot
change the denial code.
b. Give the provider a mechanism of obtaining a denial code that will be acceptable to the
secondary payer.
Answer: See answer above.
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c. Provide a letter to the state agency that given the circumstances of dual eligibility, that this
should be considered a denial for patient responsibility?
Answer: See answer above.
Furthermore, ABNs are not applicable for unbundling denials, which would be the case in this
scenario. It is a reimbursement issue. If Medicare's reimbursement wheelchair base includes
payment for the accessory in question, it would not be appropriate for a supplier to seek
reimbursement from another insurance company that would pay for that accessory again.
10. At the Medtrade DAC meeting, one of CIGNA’s topics included how the carrier is attempting to
educate the provider in cases where the provider has an inordinate number of denials. One member
reported that their rehab company provides only custom wheelchairs and seating systems and had
received a notice from CIGNA that over 90% of their K0108 claims had been denied. This member
spoke to a CIGNA representative about this, indicating that when the provider bills for a capped rental
wheelchair as a purchase, the rehab technology company expects the wheelchair (and all of the
K0108 components) to be denied. (The purchase of the capped rental wheelchair is denied, as it
does not meet rent/purchase guidelines).
The CIGNA representative told this provider that the provider is REQUIRED to rent this equipment, or
the company may be in violation of Medicare guidelines. Problem: the provider only provides
services to clients who have dual eligibility with Medi-Cal (Medicaid). The state agency will not rent
this equipment as the client has a permanent disability and it is not cost effective to rent this
equipment. The state agency will not issue an authorization for long-term rentals. Question: Is the
provider in violation of Medicare guidelines if the provider does not rent capped rental items?
Answer: Per clarification from CMS, there is no Medicare requirement that suppliers must rent capped
rental items. As long as the supplier informs the patient that Medicare will only pay for rentals, then there
is nothing wrong with submitting a claim for purchase of a capped rental item. Medicare will simply deny
the claim. The rule is that Medicare will not pay for purchased capped rental DME, not that the supplier
must always rent it.
Previously Submitted Questions
1. We would like to know the result of the medical director’s review of policy in regards to short-term
rental of power wheelchairs. (Length of need less than or equal to 6 months).
Answer: This is Still being reviewed for policy consideration
.
2. CIGNA was to attempt to revise their process for entering ADMC CMN information into their system
to avoid denial of items that had previously been deemed medically necessary through ADMC. Has
this revision been completed? If not, when may we expect this to be completed?
Answer: Yes, at about the same time the information was presented at the last DAC meeting
.
3. Rehab providers are concerned about the new ANSI format, and the reduced amount of space in the
HAO field. Can we be of assistance to CIGNA in the development of abbreviations that are to be
used in the HAO field? May we have a list of the proposed abbreviations so that we may comment on
them prior to them becoming policy?
Answer: Thank you for offering your assistance, but we have no plan to develop a list of
abbreviations for use in the narrative field. Although we make every effort to read all abbreviations
that suppliers send to us, we prefer suppliers use standard medical abbreviations, for which accepted
definitions are widely available (e.g., there are Web sites that provide free access to medical
abbreviation lists as well as books). Nurses who review claims are generally familiar with these
abbreviations and also have access to lists of standard medical abbreviations.
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The Provider Education and Training department is currently working with ombudsmen in the other
regions to form a work group to establish some abbreviations for manufacturers, products, etc. not
related to any medical abbreviations. Region D has published some abbreviations in the EDI Edge
1999-3 edition on page 1. This new work group was developed to expand this list to provide better
assistance to the supplier community. Lisa Fix is the ombudsman working on this endeavor. We
would welcome assistance from the DAC on our project.
4. Now that salvage value will be considered by CIGNA for a patient who expires prior to receiving
custom DME what is the recommended date of service, and how is the reimbursement,
determined?
Answer: Section 2005.3 of the MCM
2005.3 Artificial limbs, Braces, and Other Custom Made items Ordered But Not Furnished.
A. Date of Incurred Expertise.--If a custom-made item was ordered but not furnished to a beneficiary
because the individual died or because the order was canceled by the beneficiary or because his/her
condition changed and the item was no longer medically necessary or appropriate, payment can be
made based on the supplier's expenses. (See subsection B for determination of the amount of
reasonable charge.) In such cases, the expense is considered incurred on the date the beneficiary
died or the date the supplier learned of the cancellation or that the item was no longer medically
necessary or appropriate for his/her condition. If the beneficiary died or his/her condition changed and
the item was no longer medically necessary or appropriate, payment can be made on either as
assigned or unassigned claim. If the order was canceled by the beneficiary for any other reason,
payment can be made to the supplier only.
B. Determination of Amount of Reasonable Charge.--The reasonable charge is based on the services
furnished and materials used, up to the date the supplier learned of the beneficiary's death or of the
cancellation of the order or that the item was no longer medically necessary or appropriate in the
particular situation. Take into account any salvage value of the device to the supplier.
To bill Region D, you will need to provide the medical necessity for the item. In addition, in order for
the carrier to determine the allowable the provider will need to submit a detailed itemization of the non
salvageable materials. This list should include the labor encountered up to the date as specified
above and a breakdown of the materials, which cannot be reused, including their manufacturer
names, product names, product numbers and suggested retail prices.
EDI/EMC A-Team
11. The DAC has the following questions with respect to HIPAA implementation:
a. Will Medicare continue processing eligibility inquires over the phone after the October 2003
HIPAA implementation?
Answer: Yes
b. We’ve been told that we can’t send our HIPAA EDI claims in as a Zipped file. We are
sending our current NSF claims in Zipped. Why isn’t DMERC D supporting file compression
under HIPAA, when they are supporting it now? Is there any plan to change this policy in the
future? By the way, our 837 test files are ¼ of the size compressed as compared to their
non-compressed size.
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Answer: PM 1534 states, DMERCs are not required to support ANSI zipped files. Due to
various technical reasons it was determined that we would not support this function.
12. The DAC has the following questions about 837 and 835 transmissions:
a. Does DMERC D support any 837 or 835 transmission methods other than dial-up? Are there
any plans to add additional transmission protocols in the future?
Answer: At this time the only method that we accept is dial-up. There are currently no plans
to add additional transmission protocols.
b. Please provide the scheduled dates that DMERC D will be ready to begin the 837 and 835
addenda version testing.
Answer: As of this date the Final Rule for the 837 addenda has not been published on the
web. Until the final rule is published on http://hipaa.wpc-edi.com/HIPAAAddenda_40.asp we
are unable to provide final dates.
c. Please provide the scheduled dates that DMERC D will be ready to begin processing
production 837 and 835 addenda version transactions.
Answer: See answer "b" above
d. Due to the DMERC 9,999-loop limit within an 837 transaction, we’re anticipating sending
multiple daily transmissions to DMERC D. Will the acknowledgement reports be compiled
into a single report per submitter or will we receive individual acknowledgement reports for
each 837 file that we send? Likewise, will we receive an individual 997 interchange for each
837 interchange we send or will we receive an interchange that includes multiple 997
functional groups?
Answer: If you send multiple daily transmissions, you will receive individual 997
acknowledgements for each transmission. If you send multiple interchanges per transaction,
then you will receive one 997 acknowledgement displaying the count for the number of
interchanges sent.
e. Currently the DMERCs send both the NSF/ERN and paper EOBs. Are there any plans to stop
producing the printed EOBs? If so, when would that happen and does it have any relationship
to the HIPAA 835 transaction?
Answer: There are currently no plans to stop printing paper Remittance Notices unless
requested by the user, or you are set up for Electronic Funds Transfer.
13. With the current ERN transaction, the DMERCs generate a check for each provider #. The ERN
format clearly supports that processing because the Check Number is on the same record as the
provider #.
In the 835 transactions, there’s only 1 payee per 835-transaction set (loop 1000B). The Payee
Identification segment, N1, will always contain the Federal Taxpayer's ID # (at least until the National
Provider ID is implemented). That segment and field are required. We're trying to determine if the
REF segment in loop 1000B, Payee Additional ID, will be populated on the DMERC 835 transaction.
That's a Situational segment that would be used to populate the Medicare Provider #.
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Answer: Yes, the REF segment will need to be populated with your 10-digit supplier number. The N1
segment will require the Tax ID.
If the 835 is implemented consistently with the ERN format, then the 835 Payee Additional ID will
always be populated and there will be an individual 835 transaction for each provider # in the
Functional Group. In other words, there will continue to be an individual check for each provider #, not
for each Tax ID.
Can you confirm whether that is how the DMERC 835s will be generated?
Answer: That is correct. A separate transaction set will be generated for each provider number
because it is check driven. There will also be a separate transaction set for each provider for denied
claims. The provider will see two transaction sets if they have paid and denied claims on the 835.
14. ASCA requirement clarification:
Answer: We have not received final instructions from CMS regarding the following three questions.
Once final instruction has been published, we will be glad to answer your questions.
a. Will custom rehab wheelchairs, lymphedema pumps and TENS unit claims be exempted from
the ASCA requirement that all Medicare claims be billed electronically starting October 16,
2003?
b. Will Medicare secondary claims be exempted from the ASCA requirement that all Medicare
claims be billed electronically starting October 16, 2003?
c. Will non-assigned or non-qualified claims be exempted from the ASCA requirement that all
Medicare claims be billed electronically starting October 16, 2003?
Education/Communication A-Team
15. On the new ABN CMS-R-131 form is the "estimated cost" amount the beneficiary out-of-pocket
amount (e.g. deductible, coinsurance and disallowed amount) or the full retail amount?
Answer: CMS standards for ABNs published in Program Memorandum AB-02-168 state: Section
I.3.E.1.vi. - "Estimated Cost" Line--The physician or supplier may provide the patient with an
estimated cost of the items and/or services. The patient may ask about the cost and jot down an
amount in this space. The physician or supplier should respond to such inquiries to the best of their
ability. The lack of an amount on this line, or an amount which is different from the final actual cost,
does not invalidate the ABN; an ABN should not be considered to be defective on that basis. In the
case of an ABN which includes multiple items and/or services, it is permissible for the physician or
supplier to give estimated amounts for the individual items and/or services rather than an aggregate
estimate of costs. Amounts may be provided either with the description of items and services or on
the "Estimated Cost" line."
What elements are required to be noted if someone other that the beneficiary signs the ABN?
Answer: CMS standards for ABNs published in Program Memorandum AB-02-168 state: Section
I.3.E.2.a. - "The beneficiary himself or herself may sign an ABN. In the case of a beneficiary who is
incapable or incompetent, his or her "authorized representative," as defined for ABN purposes in
Section I.1.F may sign an ABN. The policy enunciation in Section I.1.F of who may be an "authorized
representative" supersedes the previous policy that "generally applicable rules of the Medicare
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program with respect to who may sign for a beneficiary apply to signing notices, including ABNs." The
regulations on signature requirements for claims purposes at 42 CFR 424.36(b) do not apply to ABNs
except that, with respect solely to ABNs for unassigned claims for physicians’ services, someone
eligible to sign for the beneficiary under 42 CFR §424.36(b), who is an "authorized representative" as
defined for ABN purposes in Sections I.1.F and I.1.F.3 notwithstanding, may sign an ABN."
Information regarding the Advance Beneficiary Notice is available at:
http://www.cms.gov/medlearn/refabn.asp
.
16. Can you provide to us, the information that will be contained in the CWF for a free upgrade item? At
the Phoenix Medicare Safari the presenter stated that if the free upgraded item were repaired at a
later date, then Medicare would only pay for repairs to the item ordered. Does this mean that
Medicare will never pay for repairs to a free upgraded item? If they do pay for repairs, how would it
be billed?
Answer: Medicare will pay repairs on the upgrade equipment, but not on the upgraded feature. If a
K1 was ordered and a K11 was received as a free upgrade, repairs would be allowed on the standard
equipment, but not on the motorized features. Repairs should continue to be billed under current
processing. This includes giving make and model, date of purchase, medical necessity (CMN or
letter from physician) for the prescribed equipment, detailed explanation of the nature of repairs,
parts used (include manufacturer name, product number, and suggested retail price), and labor.
17. During the Phoenix Medicare Safari discussion on ABN’s it was stated that for upgraded items the
Medicare Remittance Notice (MRN) for the beneficiary would show only the item ordered by the MD
while providers MRN would show both the ordered and upgraded items. Since beneficiaries are
asked to report to the Fraud Unit any items billed that they did not receive…couldn’t the fact that they
only see one item on their MRN provoke them to unnecessarily report violations when there is none.
Answer: The beneficiary's Medicare Summary Notice (MSN) has a combination of the two lines. It
includes a description and the HCPCS code for the item provided, the total charge for the item
provided, the approved amount for the item approved. For example:
Ln 1 K0011RRKHGA submitted $1000.00 allowed 000.00
Ln 2 K0001RRKHGK 400.00 350.00
MSN will have:
Service provided K0011RRKHG - Motorized Wheelchair, amount charged $1000.00, Medicare
approved $350.00, amount paid provider $280.00, Beneficiary may be billed $670.00 (difference in
submitted amounts plus 20% of the approved)
18. We have received denied claims with a code of OA-109. This denial code can mean the claim was
submitted to the wrong DMERC, or that the beneficiary was under a Part A covered benefit. We must
then call the DMERC for each of OA-109 denials to determine what the actual reason is. Is there a
solution to this problem?
Answer: If the denial is due to a Part A covered benefit, an additional message would be on the
remit. N73 - A SNF is responsible for payment of outside providers who furnish these
services/supplies under arrangement to its residents. If 109 was the only message received, it would
mean the wrong Medicare carrier was billed.
19. We would like clarification on replacement supplies. We know the RP modifier must be used, but is a
new dispensing order also needed?
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Answer: The RP modifier would be used on any DMEPOS for equipment and accessories unless
the code definition was a replacement item. Replacement supplies do not require modifier RP. A
new dispensing order is required for these items unless replacement is required because of loss or
irreparable damage and in the judgment of the carrier the equipment as originally ordered,
considering the age of the order, still fills the patient's medical needs.
References: (MCM §2100.4(C)) and Region D DMERC Supplier Manual, Chapter 3, page 4.
HME A-Team
20. The Winter January 2003 DMERC Dialogue General Release 03-1, page 19, addresses a
"New Modifier For No Order on File," and states, "For items requiring an order by statute, failure to
obtain an order will result in the claim line(s) being denied as noncovered (no benefit)."
But it goes further and states:
"Items specified as requiring a written order prior to delivery (WORD):
•
Power Operated Vehicles (POV)
•
Seat Lift Mechanisms
•
Tens Units
•
Support Surfaces
•
Negative Pressure Wound Therapy
The DMERC Region D Supplier Manual, Chapter 3 page 3, under "Written Order Prior to
Delivery," states: "Certain items require a written order prior to delivery." After the list it
continues on page 4 and states, "For these items, the supplier must have received a written
order, which has been both signed and dated by the treating physician, before dispensing the
item."
We have asked the following question several times, but still do not have an answer. Namely that
both the DMERC Supplier Manual and the DMERC Dialogue are vague in clarity to this point:
a.
Can a supplier legally sell to a Medicare Beneficiary an item on the "Written Order Prior to
Delivery," list without a written order prior to delivery? If the answer is yes, what are the
requirements?
Answer: Yes. However, if it is a Medicare-covered item, mandatory claim submission
requirements apply. In addition, the provider should append the EY modifier to the claim line
for the HCPCS code being billed.
b.
Both the Manual and the Dialogue state you must have "a written order prior to delivery."
So how can you sell and deliver an item without a written order, to only then bill Medicare
with the new modifier? (It has been assumed by Medicare staff in interpretation, that within
the verbiage, one can extrapolate it to mean that this is required in order for the item to be a
covered. But that is not what is written.)
Answer: The regulation governing the written order prior to delivery is a payment regulation,
not a coverage regulation. The claim is just not reimbursable without the WOPD.
c.
We can never assume with Medicare. What is written is law! We need written clarification
that clearly defines and spells out our rights to sell an item in this instance. If within the
wording printed, "Certain items require a written order prior to delivery," clearer verbiage was
added, then it would not leave everyone guessing. An example could be to read as follows:
Certain items require a written order prior to delivery for it to be considered for payment by
Medicare, by not obtaining the written order prior to delivery, the item is not covered and the
13
beneficiary is responsible for full payment. Then it would be clear and would give the
supplier the right to sell the item without a prior written order to the beneficiary with an ABN.
A supplier could then bill Medicare with the new modifier after all the paperwork is obtained.
As it stands, the letter of the law states, "Certain items require a written order prior to
delivery," thus meaning no written order, then a supplier cannot deliver.
Answer: None required. The above is just a statement
.
Answers to all the above: These issues have been sent to CMS for guidance.
21. A question was posed about free upgrades. Could a free upgrade be considered an enticement for
the patient and physician? (See attachment)
Answer: CIGNA Medicare is not the appropriate entity to answer this question. We suggest you
contact the Office of Inspector General (OIG) for an advisory opinion (www.oig.gov), or consult with a
healthcare attorney knowledgeable in the area of anti-kickback statutes.
Previously Submitted Question –October 2002
Question and answer number five, in regards to the repair policy, from the CIGNA Q&A dated 10/24/02.
We need an update on the status of the new policy and a possible effective date.
Answer: Medical Directors are working on this policy. There is no effective date at this time.
Orthotics & Prosthetics A-Team
No new questions at this time. However, 3 follow-up items are provided below:
Previously Submitted Question
Again there is talk threw out the industry especially communications out of Region A that "other health
care provider" is going to be interrupted in a way that would exclude many health care providers.
Referring to our previously submitted question; is Region D thinking of changing its direction also or will it
continue to follow the stated reply below?
In the past the DAC O/P A-team has asked the status of credentialing/certification for the area of
Diabetic shoes fitters. Has there been any more information, thoughts or open lines for us to
communicate our position on this issue. In regards to this same matter, there has been some
speculation through out our industry that if the current phrase "other healthcare provider" were to
be interpreted no to include the current mix of providers, there may be a potential to retroactively
asking for revenue already paid, back from the provider. Though at this point only speculation,
any comments to help educate us, and what could we provide to the DMERC to preclude this
possibility.
Answer: The DAC O & P A-Team is welcome to send comments or thoughts through Dr. Hoover
on the issue of credentialing diabetic shoe fitters. From the perspective of Region D medical
review, the speculation that any changes in the interpretation of "other healthcare provider" would
be applied retroactively is unfounded. Unless Region D medical review is instructed by CMS to
the contrary, any changes to the current mix of providers would be applied prospectively with
adequate notice.
Number one follow-up answer: Follow the stated reply
.
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Previously Submitted Question – October 2002
Two procedure codes for an ocular prosthesis appear to be out of step with the current usual and
customary fees as defined by Medicare and what the actual cost is to a Medicare patient.
Physicians in region D commonly prescribe the two codes V2623 and V2627. Ocularists rarely
can take (Biddle & Associates attachment pp1-13) assignment of benefits, as the fees charged
for these prostheses are usually 50% higher than what Medicare deems to be fair and reasonable
charge. The ocularists in region D commissioned a cost and benefits survey to be handled by an
outside and neutral survey company. The results of this survey were outstanding in that the
number of ocularists that can take assignment of benefits from a patient hovered around 14%.
The majority of ocularists had to charge a rate that was 50% higher than the amount allowed by
Medicare. This has the appearance of a situation where Medicare is out of step with the market in
setting up the Medicare allowable fee. It is apparent that steps need to be taken to close this gap
in the allowed amount and the usual and customary charge by the majority of ocularists in region
D to not place an undue burden on the Medicare recipient who is in need of the services by
ocularists to fabricate, fit and deliver an ocular prosthesis. What information can we provide to the
DMERC to get Medicare to readjust the fee schedule to better the reimbursement rate to relieve
this burden on the Medicare recipient. The results of this survey are non participating this is
evidenced by the small amount of respondents who indicated that they were participating
providers (Region D participating and non participating providers).
Question: What is your usual and customary fee for procedure #V2623 (fitting and fabrication of
a custom ocular prosthesis) versus a Medicare allowable fee?
See attachment No. 1
Answer: CIGNA is aware that the fees for ocular prosthetics codes are, in some cases,
significantly lower than the "usual and customary" fees charged by ocularists. Until inherent
reasonableness authority is restored to the DMERCs, there is no mechanism for adjustment of
the fee schedule for these procedure codes.
Follow-up question: Now that inherent reasonableness authority has been re-instated to the DMERCs,
how, when and at what percentage of increase can we expect to see for #V2623 and #V2627?
Number two follow-up answer: Inherent reasonableness has only been reinstated to the extent that the
Interim Final Rule has been published in the Federal Register. It has an effective date of February 11,
2003. Contractors have no authority to act upon this rule until written instructions are received from CMS.
Our assistance is always available to you at your request, for data etc.
Thank you.
Previously Submitted Question
The Question of the deletion of code 61 was something that CIGNA wished to check into and Mary
Rheinecker is the CIGNA contact for this issue. The DAC appreciates the following answer that was
provided by CIGNA; however could you please reference to us where we can find the documentation on
this answer, so we can have material to support this when asked by our referrals?
15
POS 61 - Comprehensive Inpatient Rehabilitation Facility: We have received confirmation from
CMS Central Office that these have a PPS rate that includes DME, like acute care hospitals.
DME provided to CIRF inpatients should not be billed to DMERCs.
Number three follow up answer:
-
CIGNA has sent an e-mail to CMS requesting the regulation
.
Infusion Therapy A-Team
No new questions at this time. However, one follow-up question is provided below.
Previously Submitted Question – Spring 2002
At the Spring 2002 MedTrade DAC Conference the IV A team presented the following Q (below) to Cigna
and was referred to Barbara Douglas. We had additional correspondence with Barbara Douglas at the
Fall 2002 MedTrade DAC meeting, but have no final resolution or direction with this issue.
Q: With the onset of HIPPA regulations requiring payers and providers of home infusion services to
adopt standard medical code sets for all electronic claims submissions - Would Region D DMERC
consider implementation of the S codes that were released in the 2002 HCPCS coding book for infusion
therapy.
This would benefit both home infusion payers and providers through:
��
S code sets include professional pharmacy services, compounding, and all needed supplies for
administration. Drug and nursing are billing separately.
��
Electronic claims processing that dramatically reduces claims administration costs
��
Simplified contract development based on a standard industry coding set.
��
Simplification with billing for "denial" for non-covered infusion services with crossovers to the
secondary payer sources.
��
S codes are very specific and well defined for Infusion services, making it easier to determine
which Home Infusion services are "non covered" under Medicare, and therefore easier for
adjudication of claims.
To aid in compliance with the HIPAA requirement, CMS has approved and included over 80 new medical
codes in the 2002 HCPCS release to fill many of the gaps that have historically posed a challenge for
billing home infusion services.
Follow-up answer: SADMERC suggested that the concerned party send the request to CMS to have
the "S" codes be permanent HCPCS codes. The rationale would be for billing purposes, so all carriers
would recognize the same codes. To make the 2004 tape, you need to send the request to CMS by April
1, 2003.