QA 2004

Region D DMERC Advisory Committee
March 2004 Questions

EDI / EMC
Zena Jacobi, Leader, Sandy Carden, Asst. Leader

1. A supplier bills directly to CIGNA electronically under their own submitter ID# from 2001-2002. In January 2003, the supplier signs a contract with a billing service. New EDI/ERN agreement forms are completed and signed indicating they wish to bill under a different submitter ID#. Why does CIGNA DMERC Region D EDI require a written letter in addition to the new EDI/ERN agreements to switch billing under a different submitter ID#??

Answer: CIGNA Medicare requires this information as the current EDI Enrollment Form does not have a place to indicate which Submitter ID needs to be associated with the supplier number. The letter from the supplier provides authorization to switch from one Submitter ID to another.

Follow-up question: Can you add a signature to the Customer Profile form so that we don’t have to send a switchover letter?

Follow-up answer: At this time, CIGNA Medicare still requires a letter from the supplier providing authorization to switch from one Submitter ID to another. We will take the suggestion under advisement as we are currently reviewing this requirement.

2. When a take back is done it just appears on the remittance advice (MRN) as a provider adjustment (AJ) with code WO and a FCN #, there are no beneficiary names or HICN# or a way to identify the claim being taken back. This FCN# does not translate back to anything that has been requested via overpayments letters. We must call customer service to get the beneficiary info. The Region D Supplier Manual Chapter 12 page 4 Overpayments & Offsets states two letters will be sent and an AJ or OF (offset) will appear on the remittance advice after 40 days from the initial letter with the FCN # matching. We only received one letter and the code on our remittance advice (MRN) was a WO & the FCN# matched nothing.

QUESTION:
Why are take backs not identified by beneficiary, date of service, type pf service, amount, interest amount and the proper codes on the MRN? (ex FCN# 03291200105000)

Answer: The FCN does tie back to a demand letter previously sent giving the particulars such as beneficiary name, HICN and claim number creating the overpayment. CIGNA Medicare sends two overpayment letters (2nd request letters for overpayments of $50.00 or more) if the receivable is not satisfied in 30 days. We send an offset letter the week after the offset has been taken.

EDUCATION/COMMUNICATION
Cindy Coy, Leader

3. Because Medicare covers medications administered through DME when medical guidelines are met, and some Medicare patients also have a prescription card that covers most medications, we were not sure who the primary payer should be when a patient presents both their Medicare card and their prescription card.

Answer: Medicare Secondary Payer rules are very specific. There are two factors that determine if Medicare is primary or the secondary payer. They are the reason for Medicare eligibility (Disability, working age, ESRD) and if the beneficiary is covered under an employer group health plan that meets the criteria for primary payment. See Chapter 11 of the DMERC Region D Supplier Manual for Medicare Secondary Payer rules.

Example 1: If a patient has Medicare primary, with a Medigap co-insurance that also has prescription coverage, and the Medigap denies the secondary as not covered. When we attempt to then bill the prescription payer offered thru the Medigap policy, they tell us they are unable to process secondary claims.
· What is our obligation for determining the resolution of the secondary balance?
· Can we write it off since we have billed the secondary and received a denial?
· Or are we still obligated to bill the patient?
· Or, is the prescription plan considered the primary and we cannot bill Medicare?
Answer: Since Medicare is the primary payer any Medicare covered drug should be billed to Medicare first. The determination of secondary benefits would be between the supplier, the beneficiary and the medigap company.

Example 2: Patient has Medicare primary, with a Medigap co-insurance that also has a prescription plan, however the Medigap pays the co-insurance.

· Are we obligated to bill the prescription plan as opposed to Medicare and the Medigap plan?

Historically the Date of Birth rule has applied. Is this rule still in effect and how does that apply to the above questions?

Answer: Since Medicare is the primary payer any Medicare covered drug should be billed to Medicare first. The determination of secondary benefits would be between the supplier, the beneficiary and the medigap company.

4. CMS states that on all Physician orders starting 1/1/04 that stamped signatures and dates are now acceptable but not on CMNs. According to the new DMERC Region D Supplier Manual, Chapter 3, Page 2, under Written Orders, the last bullet states:

"Both the signature and date must be personally entered by the physician and may not be a stamp or other substitute."

We are seeking clarification on this and feel that it ties back to our Question #9 from the January 20, 2004, meeting relating to the "official record."

Answer: On February 12, 2004 CIGNA Medicare sent out a listserv message entitled "DMERC Region D Publications, Local Medical Review Policies, and Local Coverage Determinations – Official Notification Medium and Official Record Formats" which stated that the CIGNA Medicare Web site is the official notification medium for all notices developed and distributed by CIGNA Medicare. On December 9, 2003, a listserv message was sent indicating that as of 1/1/04 stamped signatures would be allowed on written orders.
The reason that signature and date stamps are not accepted on CMNs is that this is an OMB-approved form and the instructions to disallow signature and date stamps is printed on the form. Making a change, even as minor as eliminating these instructions, requires submitting the form for OMB re-approval. This process is currently underway, however, we do not expect the change to occur for 12 – 18 months.

The April 2004 update to the DMERC Region D Supplier Manual will reflect the revision to Written Orders and the use of stamped signatures.

HOME MEDICAL EQUIPMENT
Barb Stockert, Leader, Sha Epley, Asst. Leader

5. We send paper documentation about same and similar with the claim because it’s safer to let the DMERC know what our situation is before receiving a same/similar denial. This example does not appear to be a covered circumstance in which it’s acceptable to send a paper claim, based on the DMERC’s January 19, 2004 Mandatory Electronic Medicare Claims posting. Will any consideration be given to this?

Answer: On the same or similar denials CIGNA Medicare will need three pieces of information for capped rental: date the equipment was picked up and why, the medical necessity reason(s) for a new piece of equipment. Since this is not addressed as an exception, please enter the information into the narrative field.

6. Region D is the only region we know of that does not accept a CMN electronically with a liter flow in Q.6 when it contains a decimal. We have to send these to paper. If the physician represents 2.5 LPM for the liter flow, how should we enter this on the CMN to ensure it matches paper? The only reference to this question is from the January 2002 Q and A, discussing a range of LPM from 2-4. The answer given was that it should always be the highest. Can we make assumptions that rounding up from 2.5 to 3LPM is appropriate?

Answer: You are correct. CIGNA Medicare has always required a whole number. In the June/July 1994 Region D DMERC Dialogue it instructs the supplier to round the number to the nearest whole number. For example, 2.5 would be entered as "3" and 2.4 would be entered as "2". In addition, the ANSI 837X12 Implementation Guide lists valid values as 1-999 liters per minute and X for less than 1 liter per minute for the REF02 segment.

7. You have a patient with a capped rental piece of equipment that was denied in the first month for medical necessity. Can I get an ABN for the remainder of the period? Region B said no, Region D has always said yes.

Answer: CIGNA Medicare has always instructed that it is appropriate for the supplier to obtain an ABN on a capped rental piece of equipment which has been denied for medical necessity. The ABN would only be valid for one year.

8. If the beneficiary is using a capped rental item from one supplier, i.e. hospital bed, CPAP, etc. and then decides to switch provider due to one of many reasons, i.e. bad service, can a new provider then switch that patient to its service using an ABN stating exactly why the new supplier won’t be paid by Medicare (because all months have been paid and met previously to other supplier) and collect private pay payments from that customer?
Answer: An ABN may only be given for medical necessity denials, lack of a valid supplier number, for unsolicited telephone contacts and for ADMC. In the example provided, an ABN would not apply because a beneficiary switching suppliers is not one of the reasons a supplier would be able to get an ABN. If the supplier suspects that Medicare will deny due to same or similar equipment, an ABN would be appropriate for that reason.

INFUSION THERAPY
Mike Hayden, Leader, Deanne Birch, Asst. Leader

9. When receiving a physician order for Special Enteral formulas (category 3 – 6, HCPCS B4153 – B4156) for a patient that has not failed a trial of a category I-B4150, or category II- B4152, or does not meet other criteria. The provider will normally consult with the physician regarding a possible change to a different category of formula. On occasion, the physician is adamant that the patient stays with a particular formula and is not willing to change to a different category due to the patient’s specific disease state.

When coverage criteria have not been met for the higher category, the DMERC will down code to category I or II and payment is made based on the lower category. Is it appropriate use of an ABN to inform the patient that they will be billed for the difference in category provided and category paid?

When down coding occurs, the allowable of the lower category usually will not cover the cost of the higher category formula.

Answer: Yes, providers should obtain an ABN advising the beneficiary that it is likely Medicare will not pay the higher level formula at the billed amount and that they will be responsible for the difference in cost. The ABN should specifically state why the supplier believes Medicare will reduce payment for the claim.

REHAB
Rick Graver, Leader, Leslie Rigg, Asst. Leader

10. What is the proper code to use for a manual wheelchair with a manual reclining back? The code was K0028, and is now E1226, but the descriptor for E1226 says that it is a manual reclining back for a custom wheelchair. This is not a custom wheelchair, but a manual wheelchair K0001.

Would it be appropriate to bill this chair under a capped rental with code E1060?

Answer: The official description for E1226 says nothing about a custom wheelchair. E1226 is for a fully reclining back for a manual wheelchair. E1225 is for a semi-reclining back for a manual wheelchair. E1060 is not a valid code – except for maintenance and service claims for wheelchairs provided pre-DMERC

11. Certain HCPCS codes listed in published format for reference are also listed in the current fee schedule. How can a provider verify if Medicare covers codes listed in these reference books if the codes are not referenced in the LMRP, or supplier manual?

Answer: SADMERC should not be queried about Medicare coverage for codes. That is not their role. The problem here is that there is usually some lag between the implementation of new HCPCS codes and the revision of an LMRP. DMERCs have 120 days from the date of notification of HCPCS and ICD-9 code changes to review and approve and/or appropriately revise affected LMRP (CMS Manual System, Pub. 100-08, Program Integrity Manual, Chapter 12, Section 5). In many cases new permanent codes (A – V) replace deleted temporary codes (K). Suppliers can use information published in the Region D DMERC Supplier Manual, Chapter 16, crosswalk information to determine if a new code replaces a temporary code. If so, and the temporary code is in an LMRP, a supplier should anticipate that the replacement code will also be in the LMRP when it is revised. The supplier can call DMERC customer service to confirm. A supplier can also call DMERC customer service to inquire as to whether a LMRP applies to a new code that does not replace a deleted one. The same Supplier Manual chapter can be reviewed to determine if a CMN is required for a new HCPCS code.

12. Who determines which codes can be considered under ADMC? If the DMERC has the authority, will the DMERC be willing to consider other codes, K0011, E1230, bariatric products and other items under ADMC? This would ease the burden placed on providers to determine if a patient is going to qualify for these items. Providers are concerned because they feel a beneficiary will qualify based on the documentation received, but that a review might find otherwise.

Answer: CMS has the authority to give ADMC consideration to other products; however, ADMC is also associated with an increased workload at the contractor. At the present time, CIGNA Medicare is unaware of CMS considering the addition of items to the ADMC list.

Follow-up question: DAC raised the issue of that K0011 and E1230 do not meet the requirement for customized item. The DASC wants CIGNA Medicare to acknowledge the problem/risk they are having with K0011 and E1230 claims and help them obtain ADMC for them in light of what has happened (Operation Wheeler Dealer).

Follow-up answer: CIGNA Medicare cannot change the statutory requirements for what is and is not considered customized. We acknowledge that review of K0011 wheelchair claims has increased; however, we are unable to accommodate the request for any changes to the ADMC process for these products.

13. How is a patient "considered" bed or chair confined? Could the DMERC please define the word "considered" as it was used on previous CMN forms, and in the phrase "Would the patient be considered bed or chair confined without the use of a wheelchair?"

Answer: Webster’s defines "considered" as "to regard as." A patient would be "considered" bed or chair confined if they’re not able to walk. "Consider" this classification of states of patient being – 1) Confined (Webster’s again: "To restrict" or "to keep shut up, as in a prison or sickbed, etc.") to a bed, 2) Confined to a chair, or 3) Able to get up and move about (i.e., ambulatory). Everyone can be classified in one of these three states. If you are in state #1 or #2, you qualify for a wheelchair. If #3 you likely do not.

Follow-up question: The DAC read numerous other definitions of considered. The DAC feels both the word and statement are ambiguous. The DAC wants more formal and direct language e.g., Is bed or chair confined. Is current language in the NCD?

Follow-up answer: The NCD for wheelchairs reads, "Covered if the patient’s condition is such that without the use of a wheelchair he/she would otherwise be bed or chair confined." Dr. Hoover apologizes for the insertion of the somewhat ambiguous word considered. The use of the word considered is not in the NCD. Thank you for pointing this out and CIGNA Medicare will make this point to CMS with respect to future instructions on how to adjudicate these claims.

14. RE: How to bill Medicare for denial when a patient is in a SNF

Section 4432(b) of the Balanced Budget Act (BBA) requires Consolidated Billing for SNFs. The CB requirement essentially confers on the SNF itself the Medicare billing responsibility for the entire package of care that its residents receive. While as a supplier we are aware of this and do not provide and bill Medicare for these services, some secondary insurance companies do not have this same requirement. They do not recognize this Medicare standard, so it is necessary to bill Medicare for a denial so we can then submit it to the insurance company for payment consideration.

In these cases, we have been told by customer service that we must follow Medicare billing guidelines, i.e. we need a prescription; and if required a certificate of medical necessity; and any other documentation to show medical necessity for the items. Then we must bill Medicare using established HCPC codes, knowing that for patients in a skilled nursing facility Medicare would not cover these items billed for due to the place of service.

In reference to the guidelines required by Medicare above, the whole process demands a great deal of time and inconvenience just in order to receive a denial. (I.e. The time required to send the documentation to the physician, having the physician complete the documentation, receiving the documentation back in our supplier office, reviewing it for correctness, to finally being able to provide the equipment, just to send it all in with the claim for a denial!) To complete this process can be very time consuming for the supplier, the physician, for Medicare and ultimately draws out the time before a consumer can receive a piece of equipment. This seems mundane and redundant since the items are not even covered by Medicare anyways, due to the place of service.

Therefore, we are searching for the correct and most efficient way to bill for a non-covered denial or an invalid place of service for a piece of DME while the patient resides in a SNF? Is there a modifier to use that would flag the claim to deny a certain way?

Could A9270 "Non-covered item or service" be used with the correct place of service to get the denial? Customer service has stated that we cannot use A9270 and that we must bill using the correct HCPC codes associated with a particular item. Then all prescriptions, CMNs and documentation must be attached, even an ABN for cases where it is not medically necessary, just so we can get it denied for other insurance considerations. Since the item is going to be denied for invalid place of service, why must the beneficiary, suppliers and physicians all go through this? Aren't the paperwork burdens already enough? What is the rationale for having to supply all this documentation when Medicare is not going to pay and the other insurance companies do not require these documents? If A9270 is defined as "non-covered item or service", which DME is when the beneficiary is in a SNF, why can't we bill using this code with the 31 POS?

Answer: The appropriate DME HCPCS code should be billed and the place of service where the item was provided. The correct denial should be ANSI – "Payment adjusted because treatment was deemed by the payer to have been rendered in an inappropriate or invalid place of service".
Several edits have been identified where the incorrect denial was being given. These edits are currently being corrected.

Follow-up question: The DAC clarified suppliers want to use A9270 to bill for items that have specific codes but are being provided in non-covered circumstances, specifically DME provided to beneficiaries in a SNF. The CIGNA Medicare response does not address the requirements for some claims to be accompanied by CMNs- EMC claims are rejected on the front end if no CMN. CIGNA Medicare clarified in the meeting that suppliers should bill these claims to the DMERC unless they are requested to do so (e.g., denial for secondary insurer). How can suppliers bill these items without having to obtain and provide CMNs?

Follow-up answer: CIGNA Medicare does not know of any way this could be accomplished. CIGNA Medicare does not agree with the use of code A9270 since we autodeny A9270 with a non-specific coverage denial, which may or may not be the appropriate denial under the circumstances applicable to the claim. A9270 is only used for items that do not have a more specific HCPCS code.

PREVIOUSLY SUBMITTED QUESTION No. #14 – January 2004

The questions was raised regarding the ability to transmit an electronic CMN with claims that do not require a CMN; examples being where a wheelchair was purchased by Medicaid, and the beneficiary is now on Medicare and in need of repairs, providers want to notify Medicare that the patient meets Medicare coverage guidelines through the use of a CMN which will become part of the beneficiaries common working file. The DMERC suggested that a "dummy" CMN be created on the DMERC side based on information transmitted within the HAO record. Providers request a more technical solution, as we are concerned that these types of "dummy CMN" claims would still result in denial. Can the DMERC create a technical way for us to transmit this information without the use of the HAO record, and may we be of assistance?

Answer: CIGNA Medicare is awaiting further clarification from CMS.

Previously Submitted Question No. 20 – October 2003

Please provide an update on time extensions from initial/signature to the date of service?

Answer: CIGNA has no update at this time.

MEDICAL SUPPLIES
Pat Spanel, Leader, Mary Turner, Asst. Leader

15. In the One-Time Authorization the supplier agrees to…(third bullet)… "All claims include the statement: ‘Responsibility for overpayment accepted’." We have always been instructed to indicate "Signature on file" on CMS-1500 (12-90)’s as well as in our electronic format. Is "Signature on file" acceptable?
a. Could you please define "Responsibility for overpayment accepted?"
b. Does this statement apply to the patient or the supplier?

Answer: CIGNA Medicare is waiting for further clarification from CMS on this issue.

Previously Submitted Question – February 10^th , 2003 Conference Call with CIGNA :

According to the Winter DMERC Dialogue, it states that according to the Medicare Carriers Manuel 2332, Medicare will not pay for items billed by immediate relatives of beneficiaries or by immediate members of their household. We would like to know when this was enacted, and also isn’t this going against the patient’s right to choose providers under the Balanced Budget Act of 1997. Please explain.

The question was referred to Lori Borelli and to date we have not seen a response and would like this question presented again.

Answer: The updated reference for the MCM is CMS Manual System, Pub. 100-2, Chapter 16, Section 130
(Rev. 1, 10-01-03)
A3-3161, HO-260.12, B3-2332
A - General
These are expenses that constitute charges by immediate relatives of the beneficiary or by members of their household. The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.
B - Immediate Relative
The following degrees of relationship are included within the definition of immediate relative.
· Husband and wife;
· Natural or adoptive parent, child, and sibling;
· Stepparent, stepchild, stepbrother, and stepsister;
· Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
· Grandparent and grandchild; and
· Spouse of grandparent and grandchild.
NOTE 1: A brother-in-law or sister-in-law relationship does not exist between the physician, supplier or owner of a provider (or supplier) and the spouse of his wife’s or her husband’s brother or sister.
NOTE 2: A father-in-law or mother-in-law relationship does not exist between a physician or the owner of a provider and his or her spouse’s stepfather or stepmother.
A step-relationship and an in-law relationship continues to exist even if the marriage upon which the relationship is based is terminated through divorce or through the death of one of the parties. For example, if a provider treats the stepfather of the owner after the death of the owner’s natural mother or after the owner’s stepfather and natural mother are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the death of their spouse, the services are considered to have been furnished to an immediate relative, and therefore, are excluded from coverage.
C - Members of Patient’s Household
These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.
D - Charges for Provider Services
Payment is not made under Part A or Part B for items and services furnished by providers to immediate relatives of the owner(s) of the providers. This exclusion applies whether the provider is a sole proprietor who has an excluded relationship to the patient, or a partnership in which even one of the partners is related to the patient.
E - Charges for Physician and Physician-Related Services
This exclusion applies to physician services, including services of a physician who belongs to a professional corporation, and services furnished incident to those services (for example, by the physician’s nurse or technician) if the physician who furnished the services or who ordered or supervised services incident to their services has an excluded relationship to the beneficiary.
Professional corporation means a corporation that is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law. Any physician or group of physicians which is incorporated constitutes a professional corporation. (Generally, physicians who are incorporated identify themselves by adding letters such as P.C. or P.A. after their title.)
F - Charges for Items Furnished by Nonphysician Suppliers
This exclusion applies to charges imposed by a nonphysician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related. It does not apply to charges imposed by a corporation (other than a professional corporation), regardless of the patient’s relationship to any of the stockholders, officers, or directors of the corporation or to the person who furnished the service.

ORTHOTICS & PROSTHETICS
Phillip Danz, Leader, Gary Hill, Asst. Leader

16. The O&P Team would like to request CIGNA’s assistance in ensuring that electronically submitted claims for miscellaneous coded orthotic replacement liner / covers are accepted and reimbursed. On May 7, 2003, the DAC was advised to provide the date the orthotic was initially purchased, the reason for the replacement (i.e., 6 month replacement), and the suggested retail price or manufacturer’s invoice price in the HAO record on the claim submission. We continue to hear from the supplier community that miscellaneous coded claims submitted electronically are being automatically denied.

Answer: CIGNA needs some denied claim examples.

Previously Submitted Question No. 3 – January 2004

The O & P Team is requesting clarification on the correct procedure to bill repairs and/or "Addition to" items on:

1.) Orthoses/prostheses that have been previously paid for by either a Third Party Payer and the beneficiary has now converted over to Part B Medicare Benefits as their primary insurer.

2.) Orthoses/prostheses that were bundled or included on a Medicare Part A billing from a hospital or SNF, where the outside O&P provider received a Purchase Order for the devices.

It states in Chapter 9 of the Medicare Manual: "If the prior carrier approved purchase of a item, necessary repair of the item will be covered if the cost does not exceed the cost of the replacement cost of the item."

However, some providers, who have supplied that original appliance, have been denied payment on repairs or "Addition to" items, as CMS does not recognize (i.e., previously paid for in Part A) the existence of that original item. In order to provide the best service for the beneficiary it is common to provide a new appliance under the Medicare Plan with a new full warranty, instead of merely doing a less costly repair or "Addition to" to an existing appliance.

Our question is: How does an O&P supplier bill for providing a repair or "Addition to", to an existing orthosis/prosthesis which was provided by that supplier and was paid for by other means in order to receive reimbursement from Medicare?

Answer: There was an article in the January 2004 (Winter) DMERC Dialogue that addressed additions to prefabricated orthoses. This article is being rescinded and a clarification will be in the April 2004 (Spring) DMERC Dialogue that indicates additions can be added to some of the prefabricated orthoses.

Additions and Repairs to orthotics and prosthetics that were not submitted to Medicare require:
A complete description, including HCPCS codes and date of purchase, for the original orthotic or prosthetic
Medical necessity information as required by the Medicare guidelines for the original piece of equipment in the HAO/narrative field or as an attachment.
A complete description of each addition/repair, including retail price or a breakdown of the charges for custom made items, that is billed under a Not Otherwise Classified Code (i.e., L4210, L7510)
A complete description of the labor that was done, including a breakdown of the time, for charges billed under the labor codes.
Medical necessity information as required by the Medicare guidelines for each addition.

Follow-up question: Suppliers are sometimes unable to obtain the date of purchase. Would the year and/or year and month be adequate in lieu of the exact date?

Follow-up answer: Yes, CIGNA Medicare will accept the month and year of purchase.

O&P Previously Submitted Question – January 2004

Dr. Hoover indicated that CIGNA is looking into to the possibility and are working 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. Has there been any progress on this important issue?

Answer: Not at this time.

Follow-up question: Is CIGNA Medicare willing to initiate and pursue adding lower extremity prostheses as eligible for ADMC? If yes when?

Follow-up answer: The decision to add items to the list of DMEPOS eligible for ADMC is a CMS, not CIGNA Medicare, decision. ADMC presents a considerable workload for contractors with the present list of codes; therefore, CMS would need to consider the additional workload and expense this change would entail. CIGNA Medicare is not in favor of adding additional ADMC items at this time and will not lobby CMS to do so.

RESPIRATORY
Joe McKnight, Leader, Yvonne Cordoza, Asst. Leader

17. If a beneficiary is using a BIPAP unit and is required to visit the physician after 3 months to continue to have the unit paid for by Medicare but for some reason doesn’t or chooses not to--can the provider use an ABN stating the exact reason mentioned above, which would then allow us to bill the patient?

a. We have a patient where we’ve made several unsuccessful attempts to obtain the Medicare Beneficiary Statement for a RAD and lack an ABN. What recourse do we have when a patient will not complete this statement and the physician won’t D/C the equipment?

Answer: Yes, the supplier can obtain an ABN that specifically addresses the issue that the patient did not return to the doctor after 3 months.

18. When a claim is sent to the review dept we are not getting a response, it is simply being forwarded to the hearings dept without our knowledge. This does not give the provider a chance to add/obtain additional documentation for the hearing officer and if the hearing is lost the amount is to low for an ALJ.

QUESTION:
Why is there no response for reviews being written in letterform and sent to the provider before being forwarded to the hearing dept in accordance to the Region D Supplier Manual Chapter 13, pages 2-3? (ex hearing case# 03343500028)

Answer: Every effort is made to ensure that appeal requests are directed to the appropriate department. From time to time review requests are misrouted to the hearing department in error. While we strive to make sure that all mail is routed correctly, it is equally important that suppliers correctly identify the department on their correspondence.
The particular case referenced above was adjusted and paid on 2/16/04 by the review department.

Previously Submitted Question No. 8 - October 2003

The Respiratory A-Team wanted additional clarification to AHI vs. RDI question (#21) of that set: If the RDI was an acceptable calculation methodology for the provision of CPAP before the language was changed, why can’t we use the data that was acceptable at that time? Many sleep labs do not have all the raw data available now more than a year later. RDI was calculated using a number of data points other than Apnea/Hypopnea indexing. Obtaining this data is difficult at best and in some cases impossible. Again we ask why can’t we use the original data that was acceptable at the time of the original sleep study?

CIGNA indicated that they would have to respond to the DAC’s additional comments at a later date. Has there been any further information?

Answer: RDI was included in the acceptable documentation by mistake. There is much disagreement on what constitutes an RDI; therefore, it did not comport with the requirements of the national policy to use apneas and hypopneas in determining coverage. This fact is affirmed by noting that RDI was removed from the LMRP within one publication cycle.

DAC Discussion Items Requiring Follow-up:

1. Kimberly Rogers-Bower reported a problem of the CERT contractor sending 2^nd or 3^rd documentation requests after the supplier has already sent them the requested documentation. The frequency at which this is occurring is increasing and the occurrence of the problem was corroborated by other DAC members. When they call the AdvanceMed contact number they are told they must re-send the documentation. There are two concerns – the extra work for suppliers, and the work for contractors if the supplier is referred for non-response.

Follow-up response: Dr Hoover contacted AdvanceMed:

Dr Hoover:

Thank you for your question regarding medical records requests and sending duplicate records. I apologize for any inconvenience the CERT process may be causing. I spoke with our Medical Records Dept. Manager, Ms. Pat Smith about your concerns.

The CERT process generates 4 medical record requests. An initial letter followed by a letter at day 20, 35 and 45. The last letter sent is on OIG letter head. When any provider calls our customer service personnel in response to a medical record request, our personnel always look in our case tracking system to see if the record is received before directing a provider to send a record. Because the first letters are sent relatively close together, a medical record sent by a provider can cross mail with one of our request. This has happened. So it is possible for customer service personnel to state a record is not received, after a provider has mailed the record.

I can only advise the provider to wait a few days after their first call, and call one more time, if the provider is absolutely certain the record is sent to the correct CERT address. We have also had occurrences of the records being sent to CMS, AdvanceMed addresses at other locations other than the CERT Operations Center, and to the Medicare Contractor who processed the claim.

Beginning with the January 2004 sample month, the CERT medical record process will change. After the initial request, we will make 3 phone calls within the first 30 days and not send a second letter until day 30, followed by a 35 and 45 day letter. Hopefully, the upfront phone calls and the delay in between the first and second letter request will mitigate this problem of duplicate records and the confusion by providers and Medicare Contractors on CERT "non-responders."

Dave Perez, MD

2. Wheelchair seating policy – DAC members submitted comments about draft LMRP and thought they would have another chance to review it before it was released as final. They have new issues they consider major about the testing procedure requirements and their potential impact on cost and quality.

Follow-up response: This request is being forwarded to Dr. Doran Edwards at the SADMERC.

Region D DMERC Advisory Committee
Questions to CIGNA Medicare for
June 28, 2004
Conference Call

EDI / EMC
Zena Jacobi, Leader, Sandy Carden, Asst. Leader

1) Provider would like to transmit a claim for wheelchair repair electronically; this claim includes multiple lines that are NOC K0108. The HAO record does not allow enough space to list the necessary information needed to properly adjudicate the claim, as the information for each K0108 is different. An example might be multiple parts like a speed potentiometer, on/off switch, wire harness, electric brake, all for the same piece of equipment and all on the same date of service. Each item should be described with the information regarding part numbers, mfg name, MSRP, and medical necessity, along with the information regarding the equipment being repaired so that Medicare can identify that the item being repaired is the item that Medicare paid for. Can the DMERC advise us on how to properly transmit this claim electronically, given the space constraint in the HAO record? Please assume that we are using the abbreviations and that in the abbreviated form, there is still a space constraint.

Answer: CIGNA Medicare does not currently have a process in place to handle this situation. Once a process is in place, suppliers will be notified through the web site and Region D DMERC Dialogue.

2) We have received conflicting information regarding usage of 2300 & 2400 NTE segments. A suggestion was made to use the 2300 (claim level) NTE segment in addition to the 2400 (detail line level) NTE segment. That would have given us an extra 80 characters per claim for narrative information. At the DMERC Update held at Medtrade Spring in March 2004 with all four DMERCs present, it was suggested that if we sent in both the 2300 & 2400 NTE segments, the text in the 2400 level would overwrite whatever was in the 2300 level. Please clarify, for DMERC D, whether we can send in both claim level and line level NTE segments and if so, please verify that one level won’t overwrite the other level.

Answer If a claim is sent to Region D with a 2300 NTE and a 2400 NTE they with both come through and will be looked at for processing. The line NTE does not overwrite the claim level NTE segment. The claim level (2300 NTE) should have information that pertains to the whole claim. The line level (2400 NTE) should have information pertaining to the specific line it is attached to.

3) There was mention at the March 17, 2004, DAC/CIGNA meeting that testing on the 270/271 transactions was put on hold. We never saw an official document confirming the 270/271 testing status. Please provide an update on whether you are conducting 270/271 testing.

Answer: Currently 270/271 is still on hold and we are not testing with submitters at this time. As soon as there is a change we will make sure that you receive that information.

Also, please provide an update on whether you are conducting 276/277 testing.

Answer: Yes, we are accepting 276/277 tests and have been so for about a year. If you are interested in testing batch Claim Status Inquiry, please complete the DMERC Customer profile indicating this choice. As soon as the setup process is completed you can start testing at your convenience.

PREVIOUSLY SUBMITTED QUESTIONS No. 3 - August 2003 & January 2004:

After one of the last question sets, an EDI technical analyst said that CIGNA is looking into the possibility of sending and receiving compressed 837 and 835 files. Has there been any progress in this area? Also, is there any progress on using other communication protocols besides dial up for transmitting claims and receiving ERN’s?

January 2004 Response: We are in the process of receiving zipped ANSI files and should know very soon. CIGNA will make sure this information is sent to the DAC as soon as it is finalized. CIGNA is expecting this to be in production this month.

May 2004 Question: Was this moved into production as expected?

Answer: Yes, but it does require testing. The compression of 835 files is still being researched. At this time, we do not have an update.

EDUCATION/COMMUNICATION
Cindy Coy, Leader, Connie Lind-Fraher, Asst. Leader

4) Now that faxed Written Orders Prior to Delivery (WOPDs) are acceptable, we occasionally receive pad prescriptions whose watermarks are visible once going through the fax, noting "ILLEGAL" or "VOID" across the face of the pad prescription. This verbiage is not visible on a live pad prescription, and the watermark is intended to show up when the prescription is copied. Does this make the WOPD invalid for items like support surfaces, or for written orders?

Answer: No, it does not make it invalid. The watermark is there primarily for scheduled narcotics to prevent copying and reuse of prescription pads.

5) If a patient does not qualify for a piece of equipment and the doctor would still like them to have it but the patient doesn't want to pay, can you pick up your equipment? If so, should you have them sign an ABN and what would you have it state? Is there any difference if this occurs with oxygen or a wheelchair?

Answer: If the patient does not qualify for the equipment, you can pick it up. An ABN would be appropriate if it was given prior to providing the equipment and it specifically stated why it was the supplier’s belief that the beneficiary would not qualify per Medicare policy. This would apply to wheelchairs and oxygen as well.

6) The provider community has received information that in April 2005 CMS is asking for the right to charge providers who forward duplicate, unprocessable, and same/similar denial claims to the DMERCs $5.00 per claim. Our question is what recourse does the supplier have on this charge if the proper information was sent with the claim, however, the adjudicator does not look at the HA0 record or the attachments on paper claims and denies the claim in error?

Answer: Till CIGNA Medicare receives final instructions from CMS, we have no way of answering this question.

7) The list-serve from CIGNA/Medicare has become a valuable tool for providers to utilize in their business. We receive a massive amount of list-serve communication a week from CIGNA/Medicare and other government entities. In most cases, companies take immediate action for changes necessary to stay compliant to the list-serve information. What has happened several times is that a provider takes corrective action and then a correction is made to the original release, which causes us to have to go back and spend the time and resources to correct your correction. Also it would be very unfortunate if a provider received the 1st communication but, for some reason, missed the 2nd.

Our question is -what due diligence is performed prior to the release of a list-serve notification to insure the accuracy of the information being sent and insure that correct information is being distributed the 1st time? Also, what thought process is gone threw to consolidate the information to control the amount of e-mails providers receive from CIGNA?

Answer: Nearly all of the ListServ messages that are sent out by CIGNA Medicare are directions sent to us from CMS. CIGNA Medicare does not have any control over the content and are required by CMS to send out this information. The changes that may come back are again sent to us from CMS and we pass the information along. These changes and corrections affect us just as much as they do the provider/supplier community.

Also, CMS requires that we send out the ListServ messages individually by a particular date. CIGNA Medicare does not have the ability to consolidate messages. If ListServ subscribers want to limit the number of messages they receive, they can narrow down and update their preferences on their registration form, but we cannot control the number of ListServ messages that are sent due to CMS requirements.

HOME MEDICAL EQUIPMENT
Barb Stockert, Leader, Sha Epley, Asst. Leader

8) When a provider is billing for a K0001 manual wheelchair electronically a hard copy CMN is completed by the physician with only the required questions completed. If the patient is receiving only a K0001 manual wheelchair and no other options and/or accessories are ordered, only question 1 must be answered by the physician. However, if a physician answers question 8, then question 9 must also be answered. When transmitting electronically, it says it would be appropriate for the supplier to enter "D" for "does not apply" in question 9, if the physician answered question 8 and left question 9 blank. The Summer 2002 DMERC Dialogue states that we can submit electronically without requiring the physician to complete those questions on the CMN. Will the provider be held responsible because the hard copy in the file will not have this information completed/ filled out by the doctor? Would the same hold true for all the rest of the questions on the CMN if only question #1 is answered--or would the CMN have to go back to have all the rest of the questions completed?

Answer: In the case of the manual wheelchair CMN only, it is appropriate for the supplier to enter "D" for does not apply for a claim submitted electronically if the physician answered question 8 but failed to answer question 9. Otherwise all information transmitted must match the hard copy CMN. EDI EDGE Summer 2002, page 9.

INFUSION THERAPY
Mike Hayden, Leader, Deanne Birch, Asst. Leader

9) We would like clarification on when a failed trial of tube enteral nutrition and/or failed pharmacologic means are required in order to qualify a patient for coverage of parenteral nutrition.

1. If a patient meets criteria A - F, the supplier does not need documentation of a failed trial of tube enteral nutrition.

2. If a patient meets criteria A - F, the supplier does not need documentation that pharmacological means have been tried and failed.

3. The following situations do require a failed trial of tube enteral nutrition and pharmacologic means.

a) patients receiving intradialytic parenteral nutrition (IDPN)
b) patients with a moderate abnormality (does not meet criteria A-F)
c) patients who do not meet criteria A - F, but do meet criteria G and H.

Answer: Please refer to the educational tool available on the CIGNA Medicare web site that addresses this question – www.cignamedicare.com/dmerc/mr/pdfs/decisiontree.pdf

10) There is confusion in the industry on the coverage of IVIG in the home setting by Medicare. Is the following information correct with regards to Medicare coverage of IVIG and is there any additional information available?

1. IVIG is covered with or without a pump if the Diagnosis requirements are met.

2. If a pump is used, an External Infusion CMN is required.

3. Medicare will not pay for a pump or administration or supply kits even if the IVIG is paid or not paid.

4. An ABN can be written to cover the pump and kits, so that the patient or other insurance will be responsible for payment for these items.

5. If the IVIG is administered without a pump, the J drug code is the only item needed to bill and be paid if the Diagnosis meets requirements.

Answer: The information stated in 1 through 5 is correct. There are two situations where IVIG can be considered for coverage. The first is under the new legislation in the MMA covering IVIG for primary immunodeficiency. IVIG is covered but a pump is not. The second situation is for indications other than primary immunodeficiency. However, since there is no medical necessity for the use of a pump to administer IVIG, the IVIG, as well as the pump, is denied as not medically necessary.

11) In March an OIG study stated Medicare might be overpaying for Category I enteral nutrition formula. As a result of the findings, the OIG recommended CMS consider using its inherent reasonableness authority to reduce payment on the formulas. Is there any information available that this may be put into effect?

Answer: CIGNA Medicare is unaware of any discussions to use the IR authority for Category I enteral nutrition.

MEDICAL SUPPLIES
Pat Spanel, Leader, Mary Turner, Asst. Leader

No questions submitted.

ORTHOTICS & PROSTHETICS
Phillip Danz, Leader, Gary Hill, Asst. Leader

12) Can a verbal dispensing order from the treating physician be communicated to a provider via the physician’s nurse or other staff member?

Answer: It would be acceptable for the supplier to accept a verbal dispensing order from the nurse or staff member employed by the treating physician.

13) It has been brought to the attention of the O&P A-Team that in March of 2003, clarification from CMS was provided to a major O&P organization regarding the language used in the Orthopedic Footwear L-Codes L3215-L3253. Most specific, the codes L3215-L3253, language "shoes" or "shoe" is intended to be billed as the unit "each" and not as the unit "pair." By virtue of the language it has always been the understanding of the DAC that "shoes" means a pair and "shoe" means each. Since Medicare has no allowable for these codes (except for L3224 and L3225), this clarification apparently is needed for office billing protocols when the codes are used for documentation purposes. Would CIGNA clarify this, as there is no record of this clarification under the Local Medical Review Policy found in the Orthopedic Footwear Section of the AETNA / CIGNA Medicare Manuals?

Answer: The DMERCs have requested that the code verbiage be changed for 2005 to clarify the units of service for these codes.

14) Region D DAC O&P A-Team is requesting that the add-on code L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET and L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET be allowed as a legitimate add-on code to be used with Preparatory codes:

-L5540 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL

-L5590 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL

Per Medicare guidelines, codes L5629 Acrylic Resin (for Below Knee) and L5631Acrylic Resin (fore Above Knee) currently cannot be used as an add-on with a L5540 BK Preparatory socket or L5590 AK Preparatory socket. Since the introduction of epoxy-acrylic resin, polyester resin has fallen out of favor in the O&P industry and Epoxy-Acrylic resin has become the industry standard in socket fabrication over that of polyester resin.

An inquiry of Southern Prosthetic Supply, a major distributor of epoxy-acrylic resin and polyester resin states that for every 1 gallon of polyester resin sold, they in turn sell 8 gallons of epoxy-acrylic resin. This data is for California alone. Cost comparisons show that 1 gallon of Epoxy-Acryl with the catalyst paste included equal $59.75 whereas 1 gallon of polyester resin is $34.61 and the required catalyst paste $14.72 and promoter $13.30 total $62.63.

Per Medicare guidelines, the code L5629 Acrylic Resin is not able to be used in combination with a Preparatory socket L5540 or L5590. Since Epoxy-Acrylic resin has become the standard in socket fabrication over that of polyester resin is it possible to petition Medicare to allow acrylic resin to be used with the L5540 and L5590?

Answer: The DMERC medical directors will discuss this proposal and provide a response after discussions with CMS and the SADMERC.

15) The O & P A-Team is requesting clarification on the reason why Medicare does not cover Custom Breast Forms L8035. Per the Provider Manual, Custom Breast forms are "Not Medically Necessary" and will be down coded to L8030. Providers are under the impression that this is a payable item since there is a maximum allowable rate. In addition, many providers have been initially told that these devices were covered when they called into SADMERC, yet the claim was denied and worse yet the claim was originally paid and then Medicare has asked for the reimbursement back 2-3 months after original payment. Having the claim paid and then later rescinded also has given providers the false impression that this is a payable item and so they continue to provide L8035 unwittingly. What documentation is necessary in order to justify coverage of custom breast forms?

Answer: As noted with each local coverage determination, the assignment of a unique code does not necessarily indicate coverage. This could also be expanded to state that the assignment of a unique code AND fee schedule does not necessarily indicate coverage. With the implementation of HIPAA, there are frequently HCPCS codes created for use by other insurers (e.g., Medicaid and private insurers) but are not payable by Medicare.

Specifically with respect to custom breast prostheses, the local coverage determination states that they are not medically necessary and will be paid at the least costly medically appropriate alternative, a prefabricated prosthesis.

Addressing the overpayment issue, in November 2003 CIGNA Medicare identified a problem with an automated edit that allowed claims to pay in full in error. This resulted in a request for overpayment. We believe the edit problem is resolved.

16) A clear policy regarding orders for replacement of components for prosthetic devices has been produced on page 23 of the 4/12/04 update from CIGNA Medicare. Does this policy also apply to Orthotic devices requiring replacement components?

An example might be a KAFO, which needs to have the Knee joints replaced.

Answer: Yes

17) Why is a request for a replacement socket to existing prosthesis routinely either denied initially or rejected pending review of additional hard copy medical documentation?

Answer: CIGNA Medicare must follow the requirements for reasonable useful lifetime on prosthetics. Unless information is available in the narrative field of the claim, it may be developed for additional medical documentation justifying the medical necessity of the replacement socket.

REHAB
Rick Graver, Leader, Leslie Rigg, Asst. Leader

18) Providers are having problems with claims that are being submitted with GA modifiers. Providers are in some cases submitting claims to receive a denial based on secondary insurance, but either receiving a C0-16 denial (which is invalid for secondary billing), or a payment. Would it be appropriate to submit a claim for a power wheelchair when the CMN question #1 is answered "no" with the modifiers GA and GY?

Answer: If the wheelchair CMN is submitted with the claim and the response to question 1 is "N" and there is no information that justifies coverage under the NCD and LMRP, it is appropriate to execute a valid ABN. If a valid ABN has been executed, modifier GA must be used. If billing for denial and a valid ABN has not been executed, modifier GZ must be used. The use of either of these modifiers does not ensure denial; coverage determination is based on the information provided with the claim. Use of the modifiers does ensure correct application of liability of payment denied due to lack of medical necessity. It will be CO denial if there is no ABN, or a PR denial there is a valid ABN.

19) If a beneficiary is on a Medicare HMO and has been renting a wheelchair, will CIGNA be aware of this if the beneficiary drops the HMO and goes back to Medicare? Should the modifier be used to indicate which month they are in as if they were on Medicare the whole time? No Do we need a revised CMN? No Would we start with a new capped rental? Yes

Answer: DMERC Region D Supplier Manual Chapter 3:
Medicare HMO Beneficiaries Transferring to Fee-For-Service Medicare
[CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 20. § 10.3]

As explained in the "Documentation" chapter, a beneficiary who previously enrolled in a Medicare HMO/Managed Care program, returning to traditional Fee-For-Service (FFS) Medicare, is subject to the same benefits, rules, requirements, and coverage criteria as a beneficiary who has always been enrolled in FFS Medicare. When a beneficiary returns to FFS Medicare, it is as though he or she has become eligible for Medicare for the first time. Therefore, if a beneficiary received any items or services from their HMO or Managed Care plan, they may only continue to receive such items and services if they would be entitled to them under FFS Medicare coverage criteria and documentation requirements.

For example, a beneficiary who has obtained a manual wheelchair through an HMO/Managed Care plan must under traditional FFS Medicare obtain a CMN and meet FFS Medicare criteria for a wheelchair before a new capped rental period would begin.

20) Providers are having difficulty collecting co-payments from Medicare when Medicare is secondary to a private HMO. The denial being received is CO-22, the claims are being submitted with EOB’s and should be clean for co payment. Is the DMERC aware of claims processing problems with MSP claims?

Answer: Need examples…
Many times claims are filed for the copay only. In order to receive the proper secondary payment the claim should be submitted with the same charges as filed to the primary insurance company with an explanation of benefits attached. CIGNA Medicare will then compare the Medicare allowable and the primary allowable and consider payment for the difference between the higher allowable or the obligated to accept amount and amount paid by the primary.
When only the copay is billed it causes the incorrect allowable to be considered in the secondary payment calculation.

PREVIOUSLY DISCUSSED DAC/CIGNA MEETING - March 2004

Following is an excerpt from the minutes of the March 17, 2004, DAC/CIGNA meeting:

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.

As a follow-up to this dialogue, the Rehab A-Team would like CIGNA to answer the following questions regarding wheelchair cushion testing:

a. Can there be a barriatric specific test fixture or test modification for cushion lines that are only barriatric?

b. Can there be a preconditioning or a pre-shaping of zero memory cushions to better accept the test indenter?

c. Can SADMERC specify a minimum life test to put all cushions on a similar footing aging or use wise?

d. Is it appropriate to just add air to an air-containing product until it passes the test?

e. Do wear and tear failures in the product, i.e.; cracks in molded foam, compression set, etc., constitute a failure if the cushion passes the post use test?

The Rehab A-Team would like to acknowledge that answers to these questions might be too lengthy to provide as part of the Q&A. Therefore, it would be open to having separate dialogue with CIGNA on wheelchair cushion testing.

Answer: Dr. Hoover suggests that these questions be posed to the SADMERC since they are the primary source of the cushion testing standards and will be conducting the testing for new cushions.

PREVIOUSLY SUBMITTED QUESTION No. 12 - March 2004

Providers believe that ADMC is a valid solution to a majority of the problems surrounding the power wheelchair benefit. Has CIGNA Medicare become aware of CMS considering the addition of K0011, E1230, or certain bariatric products to ADMC?

Answer: CIGNA Medicare is not aware of CMS adding any new codes to ADMC.

PREVIOUSLY SUBMITTED QUESTION No. 14 – January 2004

The questions was raised regarding the ability to transmit an electronic CMN with claims that do not require a CMN; examples being where a wheelchair was purchased by Medicaid, and the beneficiary is now on Medicare and in need of repairs, providers want to notify Medicare that the patient meets Medicare coverage guidelines through the use of a CMN which will become part of the beneficiaries common working file. The DMERC suggested that a "dummy" CMN be created on the DMERC side based on information transmitted within the HAO record. Providers request a more technical solution, as we are concerned that these types of "dummy CMN" claims would still result in denial. Can the DMERC create a technical way for us to transmit this information without the use of the HAO record, and may we be of assistance?

Answer: At this time CIGNA Medicare cannot create a more technical way for the supplier to transmit these types of claims. If the situation should change the DAC would be informed.

Previously Submitted Question No. 20 – October 2003

Please provide an update on time extensions from initial/signature to the date of service?

Answer: CIGNA Medicare has no update at this time.

RESPIRATORY
Joe McKnight, Leader, Yvonne Cordoza, Asst. Leader

21) The new oxygen LMRP states a patient tested during sleep must have a minimum of 5 minutes at 88% or below (oxygen saturation) to qualify for Group I and 89% for group II. If a patient is tested and the results indicate the cumulative time at or below 88% is 2 minutes and the time at or below 89% is 7 minutes, is the patient considered group I or group II? Which test result should be recorded on the CMN?

Answer: In this example the patient would be considered Group II because they did not establish the 88% or below oxygen saturation for the full five minutes as indicated in the Oxygen and Equipment LMRP, DMERC Region D Supplier Manual, Chapter 9, Oxy, pages 1 & 2.

The results of the test indicating the oxygen saturation value for at least five minutes would be recorded on the CMN.

22) How would the following be handled during an audit or post payment review? On Question #4, testing facility, of the oxygen CMN, the physician enters the street address but does not enter the city, state and zip code. The billing software requires that the city, state and zip code be entered or the CMN will reject. If the provider enters transmits the CMN with the city, state and zip, how does that get handled during a postpay review or audit? If the testing facility is the physician listed in Section A, does that have any change the results?

Answer: From a claims processing viewpoint – Front end paper claims would only be accept this if the testing provider was the same as the ordering provider (In section A) or if it is a hospital. Otherwise a complete address is needed in question 4.

From the Benefit Integrity Unit standpoint – When Benefit Integrity reviews records in an audit we review according to the guidelines established. If a change was made to a CMN for any reason it should be documented in the supplier’s file.

Region D DMERC Advisory Committee
Questions to CIGNA Medicare for
October 27, 2004

EDI / EMC
Zena Jacobi, Leader, Sandy Carden, Asst. Leader

1) On occasion a providers EDI system will inadvertently resend a claim file. The other DMERCs will reject the entire file at the EDI front-end when they see the identical ISA Control Number for that Sender ID. Cigna accepts the file, but then each of the claims isare individually denied as a duplicate. This causes end-user problems because they see all of the denials and also because the denials come in before the payment due to the payment floor. Would Cigna consider enhancing their EDI system to recognize duplicate claim files and rejecting the entire file rather than allowing the claims to enter the adjudication system?

Answer: New edits that prevent duplicate batches of claims from being accepted by CIGNA Medicare will be implemented January 3, 2005. For ANSI files, the edit is 20268. This edit looks at the create date, the sender identification number and the interchange control number. If these are the same as a previous batch of claims accepted by CIGNA Medicare, the file will be rejected. For NCPDP claims, the edit is 65082. This edit looks at the create date, the sender identification number and the batch number. If these items are the same as a previous batch of claims accepted by CIGNA Medicare, the file will be rejected.

PREVIOUSLY SUBMITTED QUESTIONS No. 3 - August 2003, January 2004 & June 2004

After one of the last question sets, an EDI technical analyst said that CIGNA is looking into the possibility of sending and receiving compressed 837 and 835 files. Has there been any progress in this area? Also, is there any progress on using other communication protocols besides dial up for transmitting claims and receiving ERN’s?

January 2004 Response: We are in the process of receiving zipped ANSI files and should know very soon. CIGNA will make sure this information is sent to the DAC as soon as it is finalized. CIGNA is expecting this to be in production this month.

June 2004 Question: Was this moved into production as expected?

June 2004 Answer: Yes, but it does require testing. The compression of 835 files is still being researched. At this time, we do not have an update.

Answer: A user may send in zipped ANSI files but must test with us first to make sure we receive and are able to unzip them. If you would like to start the testing process please call the DMERC EDI department at 866.224.309 and let the support person know this is what you would like to do. We will be happy to assist you.

September 2004 Question: Is there any update regarding sending 835 files in a compressed format?

Answer: There is no update at this time.

EDUCATION/COMMUNICATION
Cindy Coy, Leader, Connie Lind-Fraher, Asst. Leader

2) The following questions relate to the decision by the U.S. District Court for the Eastern District of California on 06/30/04 relating to CMNs. In the decision it states the Secretary cannot require that the DME suppliers obtain Medicare beneficiaries’ medical records. Instead any and all information required from suppliers to make medical necessity determination must be contained on the CMN.

a) Does CIGNA interpret this to mean that in all other districts when prepayment, probe and post-payment reviews are done they will no longer require medical records?

b) To what extent are suppliers are liable for CMNs?

i) When the MD does not indicate the most currently test (e.g. oxygen).
ii) The MD does not reflect all information on the CMN (e.g. wheelchair). Most of the information is subjective and the CMN does not lend itself to indicate this information.

Answer: The decision in the Maximum Comfort case was issued by the United States district court for the Eastern District of California on June 28, 2004. The government has 60 days to appeal the ruling and is currently considering whether to do so. Therefore, the decision is not final. Moreover, even if it becomes final, the decision will have limited precedential effect, since it represents the view of only a single district judge. For these reasons CMS has no current plans to change its longstanding national policy regarding medical necessity documentation.

3) At the January 20^th DAC/Cigna meeting, Dr Hoover referenced a physician education packet being distributed this year to physicians. Has it been sent out yet? May we have a copy so we can reference them to their tools? Looking on the website, the most recent revision was 2002. Is there an update as to when we might be able to expect this?

Answer: Dr Hoover continues to work on the Physician Information Packet. We do not have a projected publication date.

4) Per our discussion on the Assignment of Benefits form: The DMERC Manual, pp44, (ref MCM 60 SS3047.3) states "suppliers may obtain and retain a one time authorization from a patient applicable to any current and future services. In the sample document they offer for suppliers to use, it again clearly states:

Name of beneficiary HICN
I request that payment of authorized Medicare benefits be made either to me or on my behalf to (supplier) for any services furnished me by that supplier. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and it agents any information needed to determine these benefits or the benefits payable for related services.
Signature Date
The manual goes further to state:

"Any supplier using the one-time authorization procedure agrees to the following:
· Authorization must be renewed if a new item is rented or purchased."

Since the manual states that "any current and futures services", why must a new AOB be obtained for each new piece of equipment? The patient signs for each new piece of equipment. The notice doesn't reference any particular piece of equipment rented or purchased.

IWe would like the HME team or someone to ask the carrier why the note that "authorization must be renewed if a new item is rented or purchased."
Answer: CMS’ response, This is CMS’ policy for DME suppliers that accept assignment. CMS is willing to rely on a one-time authorization/assignment for the period of use of one item, but is not willing to rely on a one-time authorization/assignment that extends beyond the use of a particular item. CMS’ concern is about paying indefinitely, because a patient may no longer need the item, may not use it, may be dead or institutionalized. Thus, CMS has been willing to take a risk on one item, but not on other items. This policy is to protect CMS from risks described above.

5) With a new round of educational workshops beginning, we would request that any questions that arise and are documented at any of the workshops be collected and then disseminated either through the DAC or the Cigna website for all providers to access.

Answer: The documented questions from the Fall 2004 seminars will be posted on the CIGNA Medicare web site in two locations, on the Medical Review web page and in the Resource web page under Supplier Resources for Claims Submission.

HOME MEDICAL EQUIPMENT
Barb Stockert, Leader, Sha Epley, Asst. Leader

6) Rec ently we have been receiving electronic prescriptions from physicians. These are prescriptions in which the physician types the information into the patient's electronic medical record during the office visit and the information is either faxed to us or brought to us by the customer.

The manual states that the physician must personally sign and date the prescription. These are signed by the physician but the date is often typed or electronically added onto the prescription. Is a date such as this permissablepermissible?

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