Region D DMERC Advisory Committee
Questions to CIGNA Medicare for
January 2005
Example:
DOS = 2/20/04
Paper claim assigned CCN #:
Claim #: 04211480958000
EOB # = 00001328442-082304
Answer: CIGNA Medicare Region D DMERC will be removing edit 40047 in April 2005.
PREVIOUSLY SUBMITTED QUESTIONS No. 12a – January/February 2003
Previous Q & 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?
Follow-up Question: Is there any update on either of these questions?
Answer: We still offer the dial up option but we now also have two other options. Please go to the following web sites to determine whether one of these options will meet your communication needs:
www.Visionshareinc.com
HOME MEDICAL EQUIPMENT
Barb Stockert, Leader, Sha Epley, Asst. Leader
5)
When a customer comes into a store and purchases a product (transport chair) for a customer and 2 weeks later returns with an Rx asking we bill the product. How would the supplier handle the following situations?
a)
If a family member buys a product for a beneficiary and does not let it be known to the supplier that the product is for a Medicare beneficiary, are we obligated to bill to Medicare.
Answer: At the time of purchase, if information was not provided that this product was for a Medicare beneficiary, you would not be obligated to bill Medicare. If two weeks later the beneficiary would return to the supplier and provide the Medicare information, but still does not have a physician’s order, the claim could be submitted with the modifier EY.
b) If the family members provides information that this is for a Medicare beneficiary, but still has no Rx, and the supplier told the customer it would not be covered due to no Rx, and after being told the product would be used outside the home (transport chair)it would not be covered.
Answer: When the supplier receives information that there is no order, or Medicare criteria is not met for an item that is being requested by a Medicare beneficiary, at this point, the supplier should get an ABN to receive a PR denial.
If a CO denial is received in this situation, the supplier should request a redetermination and provide documentation of why this should be a PR denial.
In instance B the product was billed at the customer’s request with an EY modifier, and the claim denied as CO. The Provider was told by Customer Service that this would never deny as PR even if an ABN had been acquired and the GA modifier had been used.
Answer: From the example provided, this claim denied because it was a purchased capped rental item (E1031NUEY). CIGNA Medicare has instructions from CMS that these types of claims should be denied with group code CO. The CSR was correct in that an ABN would not apply with this type of denial. If the claim had denied for no order an ABN would apply. This claim would still receive a group code CO if the denial is changed because there is no indication of an ABN with the claim.
Answer: Please refer to answers above.
Answer: There are certain situations in which an ABN should be obtained, regardless of the presence of an EY modifier.
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) (PR46). Those items include:
Three Policy groups with HCPCS or NDC codes:
• Oral Anticancer Drugs
• Oral Antiemetics (Full Replacement for Intravenous Antiemetics)
• Therapeutic Shoes for Diabetics
AND
Items specified as requiring a written order prior to delivery (WOPD):
• Power Operated Vehicles (POV)
• Seat Lift Mechanisms
• TENS Units
• Support Surfaces
• Negative Pressure Wound Therapy
Because these items are denied as non-covered (PR46), an ABN is not needed.
However, if the item does NOT require an order by statute, claim lines billed with the EY modifier will be denied as not reasonable and necessary (CO50). Therefore, if an ABN has not been obtained, the patient would NOT be held financially liable…EVEN IF THERE IS NO ORDER FOR THE ITEM. When you obtain the ABN, remember to append the GA modifier.
b) What is a supplier’s responsibility to maintain equipment on the M/S cycle (Medicare has paid a minimum of 15 months) if the beneficiary moves out of state or their service area? Customer Service (CS) has informed suppliers that it is OK for the current supplier to pick up MS equipment and the new Supplier in the other state/service area may start a new billing cycle for the NEW capped rental equipment. Is CS informing us correct?
Answer: According to the CMS Manual System, Pub. 100-4, Medicare Claims Processing Manual, Chapter 20, Section 30.5.4, "If the beneficiary changes suppliers during or after the 15-month rental period, this does not result in a new rental episode. For example, if the beneficiary changes suppliers after his 8
th
rental month, the new supplier is entitled to the monthly rental fee for seven additional months (15 – 8). The supplier that provides the item in the 15
th
month of the rental period is responsible for supplying the equipment and for maintenance and servicing after the 15-month period".
INFUSION THERAPY
Mike Hayden, Leader, Deanne Birch, Asst. Leader
7)
Under HIPAA requirements all drugs are to be billed separately, including the heparin and saline flush used for flushing the IV catheter before and after each dose of medication and/or for line maintenance when no drug is being administered via the IV line.
Answer: We are not aware of any HIPAA requirement to break down the components of a supply kit into separate line items for the drugs that are included as part of the kit. Per instructions for infusion therapy in the companion document, "Claims for home infusion products must be billed on the ASC X12N 837 using the HCPCS codes to identify the drug and related supply." This does not mean that the supplier is to break out drugs that are part of a supply kit under their individual drug code. They are to continue to bill these as the related supply code. Please refer to the Local Coverage Determination and Policy Article for External Infusion Pumps for the supply codes to be billed with durable infusion pumps.
For 2005 dates of service, a new HCPCS code was established for infusion supplies not used with external infusion pump. The code is A4223 and the description reads "Infusion supplies, not used with external infusion pump, per cassette or bag (list drugs separately)". The portion of this description that states "list drugs separately" is not referring to those drugs such as the flush, diluent, etc. that are deemed part of the supplies.
Under most circumstances the drugs we are billing for are statutorily non-covered under Medicare Part B DMERC, and we are billing for denial to cross the claim over to the beneficiaries’ secondary insurance for payment. We are using the modifier GY and the HCPCS code J2912 for the saline and J1642 for the heparin as these are drugs with NDC numbers and require a prescription to dispense.
What we are seeing is the J2912 (sodium Chloride) changed on the DMERC end to A9900 CC and denied with a C0-97 (contractual obligations) instead of the PR-96 indicating patient responsibility.
In calling to resolve this issue with the DMERC we are being told this is a claim adjustor misunderstanding of how to properly adjudicate the claim. We are wondering if further education or a publication in the DIALOGUE would help to educate or eliminate this problem as it is very time consuming to get the appropriate denial code for cross over.
Answer: The examples given were denied incorrectly because the drugs are not being administered through an infusion pump. If billed with an infusion pump these items would be included in the supply kits. The supplier did bill these claims correctly. Education has been provided to the claims processing area to avoid these types of denials in the future.
Answer: CIGNA Medicare agrees with the answer provided by Region B. Closed end and drainable pouches could be allowed in the same month and the daily allowances outlined in the policy would apply. As with Region B, CIGNA Medicare would find it inappropriate and not medically necessary to use both types of pouches on the same day.
The provider has presented these examples (Note: HIC Number used in example was taken off electronic file and was provided verbally):
(HIC Number) and (HIC Number) are both vent patients. When the claim originally billed with A4609, they denied saying it is included in the rental of the item (C097 Denial code) or that they need ownership of the rental item information (C096, M124 remark). Reviews were sent for both of these patients and Medicare then processed an adjustment claim for both of them. On (HIC Number), they then paid date of service 9-8-03 through review. On (HIC Number), they denied through review for dates of service 3-25-03 and 4-28-03.
CIGNA Medicare has evaluated this coverage position and in the future will pay separately for codes A4609 and A4610 (now code A4605). Code A4605 will be incorporated into the Suction Pump Local Coverage Determination (LCD).
21) For the purpose of qualifying a patient for a CPAP or RAD (with a diagnosis of OSA), is it permissible to allow rounding up of the AHI using normal mathematical standards (i.e., 4.5 or higher rounded up to the next whole number).
Example: A patient has an AHI of 14.6. The AHI would be rounded to 15. No documentation of an additional qualifying condition would be necessary. This patient would qualify.
Region C has said to providers that it is acceptable to round up. Would Region D agree?
Answer: Yes, it is permissible to round up using standard mathematical methods as described in the example above
.
Region D DMERC Advisory Committee
Questions to CIGNA Medicare for
April 2005
EDI / EMC
Zena Jacobi, Leader, Sandy Carden, Asst. Leader
1)
In this example, please presume that the coverage criteria for the wheelchair have been met, and a valid CMN has been obtained to verify the ownership and medical need by the beneficiary. Also, the patient has never had same or similar equipment with Medicare and the patient’s owned wheelchair currently is in need of repair. Medicare will pay for repairs to patient owned equipment when coverage criteria have been met. Medicare does not have a record of this equipment, so we have obtained the CMN to document that the patient meets the required criteria. The provider would like to submit the claim for the repair electronically, but an electronic CMN cannot be transmitted with the claim because the repair items being provided do not require a CMN; however, a CMN is needed so that the common working file shows that the patient has a wheelchair. We have a couple of questions related to the scenario.
a.
How can the provider transmit the claim in a HIPAA compliant manner that includes the CMN which is required to document the ownership and medical need for the equipment?
Answer: DMERC Region D recognizes that certain claim types, such as claims with attachments in some cases or certain types not supported by free billing software, must continue to be submitted on paper pending any contractor or shared modifications to enable those claims to be submitted electronically. Pending issuance of the future CMS instructions concerning submission of medical records for electronic claims, providers and Medicare contractors can continue current policies and practices regarding submission of attachments with claims. Suppliers billing DMERC Region D should continue with the current process of submitting claims with attachments on paper. The temporary exception does not apply to submission of paper EOBs or RAs for electronic claims when Medicare is secondary and there is only one primary payer.
Answer: We would like to see examples of this situation. However, for beneficiary owned equipment we would need to know when the equipment was purchased along with documentation to show the beneficiary has met Medicare coverage criteria. We would then set up the appropriate records to show the patient has purchased equipment and meets Medicare criteria.
At the redetermination level, if the initial claim is billed with a KX modifier only the purchase information is required. If the initial claim is billed without the KX modifier and the redetermination request is sent asking for the KX to be added, we would require the medical documentation to support adding the KX modifier in addition to the purchase information. If subsequent claims are submitted without the KX modifier, we would require the supporting documentation to justify adding the KX modifier. In the example above of the CPAP supplies, redeterminations would be looking for the statement of continuous use for those supplies if the subsequent claims were submitted without the KX modifier on the initial submission.
Example 1: A patient had a K0001 that was prescribed for 3 months due to a broken leg. One year later the patient was prescribed a second K0001 due to having a stroke. The redetermination request contained a Redetermination Request Form, a copy of the claim, and a copy of a signed delivery slip that also stated "I have never had same or similar equipment before". The redetermination decision would be favorable as the patient needed the wheelchair for two different reasons and the first one was only prescribed for 3 months.
Example 2: A patient had a K0001 that was prescribed for 15 months due to a stroke. One year later the patient receives a second K0001 for the same condition. The redetermination request contained a Redetermination Request Form, a copy of the claim, and a copy of the signed Assignment of Benefits form that contains the same or similar paragraph. The redetermination decision would be unfavorable as the patient needed the wheelchair for the same condition and no documentation was provided to show the first wheelchair was picked up.
Answer: Coverage is determined on the current medical need
.
Answer: This is not the correct format. J1563 would be billed with a GY modifier if no DME pump was used. Modifier GA would be used if a DME pump was used and an ABN had been obtained. Modifier GZ would be used if a DME pump was used and no ABN had been obtained. E0781, A4222 and A4221 would be billed with a GA modifier if an ABN had been obtained and with a GZ modifier if no ABN had been obtained.
"What’s New" 3/25/05
Answer: CIGNA Medicare will refer this question to CMS for further guidance.
Answer: The hardware is included in the reimbursement of E2618, if hardware is billed A9900 should be billed.
Answer: There is no reimbursement, it would deny as included in the base code (E2618).
Answer: Currently there is no fee schedule for this code. Payment will be gap-fill based on the manufacturers suggested retail price submitted on the claim
Answer: Dr. Hoover will bring this up for discussion with the other DMERC medical directors
SADMERC
Wade Hendrickson, Leader, Mary Turner, Asst. Leader
16)
A recent list-serve announcement indicated that the E1010 code is now a pair code. The allowable was not changed. As an each code, the allowable provided adequate compensation and allowed the supplier to supply only what was needed, left versus right or both. We are concerned that current compensation levels will limit access to certain products. We are also concerned that there was no prior notification of this change. Suppliers who had products in process will have to change products or be unable to provide the product. The consumer may be affected by being provided with 2 leg rests when potentially only one was needed. What is the process by which the E1010 allowable definition changed from "each" to "pair"? Why does the allowable not reflect an increase in reimbursement with the increase in product number?
Answer: In investigating the reimbursement of code E1010 we found that the original description of the code had "each" and majority of the products used to price this code were based on a "pair". The description of the code was changed in 2005 and the fee was adjusted to delete the "each" products from the pricing array.
17)
It is our understanding that if a cover is changed on a cushion (for example from a standard 2-level cover to a 4-way waterproof stretch cover), but the cushion itself is not altered in any way, the cushion may be
submitted using the HCPCS code initially assigned to the product. Please verify.
Answer: This statement is correct. Covers for cushions may be interchanged without a need to resubmit the cushion to testing or for code verification by the SADMERC. No alteration of the internal components or configuration can be made without retesting and resubmission for coding verification by the SADMERC.
18)
Effective January 1, the HCPCS system has two new codes for nutritional formulas designed for patients with inborn errors of metabolism, such as Phenylketonuria (PKU). One new code (B4162) is designed for pediatric use; the second code (B4157) is intended for adult use. Teenagers and many children use B4157 adult formulas. The SADMERC has recognized this fact and has assigned eighteen products to either code ("B4157 or B4162"). When should a provider use one code rather than another? At which age does a patient's product use shift from B4162 to B4157?
Answer: Nutritional formulae are provided based on the physiologic, not chronologic age of the patient. Therefore no absolute age limits have been set. In general, we relied upon the medical community use of "pediatric" and "adolescent" as a general guide for the age of transition between the two classifications of pediatric and adult.
19)
If a provider submits a claim for a pediatric code (e.g. B4158) for a Medicare Part B eligible beneficiary, how will you determine reimbursement since there is no fee schedule?
Answer: Any product submitted for reimbursement that meets medical necessity and does not have a fee schedule would be gap-filled based on the manufacturers suggested retail price submitted with the claim.
20)
The SADMERC has recently turned off the allowables for some of the pediatric mobility codes. They have left the code as a place holder but do not pay for the equipment. However, when the provider is processing
a Medicare/Medicaid claim, the denial given by Medicare does not provide adequate justification for Medicaid to proceed with processing the claim. Is this a Medicare problem or a Medicaid problem?
Answer: Please refer this question to the DMERC for further clarification.
21)
There is a new code for pediatric power chairs (E1239). Will existing pediatric power chairs coded as K0014s be automatically recoded or is it up to the manufacture to initiate a re-review of an existing product?
Answer: The new power wheelchair codes (including pediatric and POVs) require extensive testing to RESNA standards and submission of the test results to the SADMERC for coding verification before a code is assigned. It is the responsibility of the manufacturer to perform the testing or have it done and submit the results to the SADMERC. There will be no crosswalk and all previous power wheelchair codes will become invalid and non-payable as of January 1, 2006.
22)
Will a change in motor type necessitate a re-review for a power chair if the change will in no way affect the chair classification (based on the current K-codes)?
Answer: Under the current K codes the type of motor does not affect the assignment of a code. The weight capacity of the chair and presence of customized features differentiate the K0011 from K0014 chairs. Under the new codes for power wheelchairs, the performance features, weight capacity, functional characteristics and other criteria affect code placement. If the motor type does not change the speed, range, weight carrying capacity, or other performance criteria, then the code would not change. However, only testing by the RESNA standards would determine if the change really had no affect on the chair’s performance.
23)
If a cushion that has been assigned a HCPCS code is "modified" by simply removing an inch of foam to size it differently, a provider has been told by a CSR at the SADMERC that this cushion must be billed using the miscellaneous cushion code which will auto-deny as not medically necessary. Is this the case or can the cushion be billed using an existing code since the cushion itself is only being altered by size and not makeup or content? Since it is considered a custom item it will not have a part number but will still have all the characteristics of a cushion that does have a part number.
Answer: If the device is a prefabricated cushion that has been coded by the SADMERC, subsequent removal of one inch of foam is a major alteration of the cushion configuration and would require retesting to confirm its proper code placement. If the product is a fabricated device, then the SADMERC only codes the process as being adequate to bill the custom code. Trimming or fitting changes are not determinate of the final code and would not affect the code assignment.
24)
An issue with code A4221 for insulin pump supplies. Based on the information we researched, a provider can use this code correctly and if they are participating providers with DMERC. However providers trying to get a PR96 denial so they can bill the patient for the difference between their URC and the Medicare allowable (they feel the compensation is not adequately covering their costs to provide the necessary supplies that are included in the A4221) is not allowed. Most policies state to change the tubing for the pump every 48-72 hours as ordered by the physician, and of course the $21.00/ week Medicare allowable does not adequately cover the costs. After reviewing Medicare policy, seeing we cannot balance bill the patient if they accept assignment and they can not get a PR96 denial as it is a covered code for the purpose they are using. We got some manufacturer information supporting the life of the tubing, and supplied medical documentation that would support changing the tubing every 48-72hr's.We wondered if an ABN could be used, if in fact supplying 2-3 tubing per week was over the standard allowable...but we don't know if the DMERC expressly addresses the number of tubing's per week that are to be included? Could a provider tell a patient that only 1-2 tubing's are included in the A4221 and then get an ABN for any extra tubing that is provided? I know we had this same dilemma with Enteral Therapy and exactly what is included in the Kit Codes. I'm wondering if they could appropriately/correctly use the A4222 code for Insulin pump supplies.
Answer: Please refer this question to the DMERC for further for clarification.
Attachment #1
CUSTOMER:____________________________________ EQUIPMENT:__________________________
ASSIGNMENT OF BENEFITS
I___________________________________authorize and request payment of any Health Insurance benefits be made on my behalf to YES I CAN for any services or products furnished to me by YES I CAN. I authorize any holder of medical information about me to release to YES I CAN and its agents any information needed to determine these benefits or the benefits payable for related services. Please assign my benefits for services provided by YES I CAN for the period prescribed by my physician.
SAME OR SIMILAR EQUIPMENT
It has been explained to me that my Health Insurance carrier will not pay for 2 pieces of the same type of equipment at the same time. This includes but is not limited to Manual Wheelchairs, Power Wheelchairs or Power Operated Vehicles (scooters), Walkers, Hospital Beds, Commodes etc. I attest that I do not have any other equipment similar to the equipment that I am now receiving from YES I CAN, that is either being rented or has been purchased by Medicare or any other Insurance Carrier.
It has been explained to me that if the above statement is incorrect that I will be responsible for the purchase, rental or forfeiture of YES I CAN’S equipment and this Assignment Agreement. I also understand that any denial for Same or Similar Equipment cannot be reversed and that I am fully responsible for the entire purchase price.
BILLING PRACTICES
This notice is to inform you of YES I CAN’S policies and procedures regarding billing. As a courtesy to you, we will bill your primary and secondary insurance, provided we are given the correct and current billing information. If you do not have a secondary insurance, you will be responsible to pay for your estimated copay at the time of service. It is YES I CAN’S policy to obtain a Certificate of Medical Necessity (detailed prescription) and/or a Doctors’ Prescription for each item a customer receives. In some cases this may delay billing until the information is obtained from your physician. Once this information is received your insurance will be billed promptly. Should the Certificate of Medical Necessity or Prescription not qualify for reimbursement by my Insurance Carrier I agree to return the equipment immediately and exchange it for the equipment that may qualify or elect to keep the equipment and sign an agreement to be responsible for any difference between the qualifying equipment and the equipment which is provided to me herein. A statement will be sent to all customers monthly. This statement will reflect the amount for which you are responsible. Outstanding customer balances are subject to finance charges at 1.5% per month (18%annually). Ultimately you are responsible for payment of services provided to you by YES I CAN. If after 90 days, YES I CAN has not received payment from your insurance company, you are responsible for payment in full.
I ACKNOWLEDGE AND UNDERSTAND THE ENTIRE CONTENTS OF THIS PAGE FRONT AND BACK.
_______________________________ ________________ __________________
Beneficiary Signature Date Insurance Id #
_______________________________ ______________________ __________________
Representative Relationship to Beneficiary Date
Reason Beneficiary Can’t Sign
Region D DMERC Advisory Committee
Questions to CIGNA Medicare for June 2005
1. a. Does Cigna DMERC allow multiple submitter ID's to be used for one provider number?
Answer: CIGNA provided the answer to this question in the Q&A from the 10/27/04 meeting:
New Questions
5) Many providers are seeing recoupment letters for "Consolidated Billing" supplies that were billed during Home Health episodes and SNF PPS episodes. Providers do not have access to the "Common Working File"; therefore they rely on information given to them by the beneficiaries.
a. Is there a way to change a "CO" denial to a "PR" denial, when the provider was given documented misinformation from the beneficiary, in regards to "Consolidated Billing" supplies? If so, what would be the proper procedure to change the CO denial to a PR denial?
Answer: Home Health and SNF consolidated billing denials receive OA (Other Adjustment) denials. These types of denials would never receive CO or PR denials.
b. Would CMS create a modifier to append to the code, to inform Cigna that the Provider was not informed of any Home Health, SNF/PPS episode?
Answer:
This is a question for CMS. However, under the SNF consolidated billing provisions of the Social Security Act the Medicare billing responsibility is placed with the SNF itself for most of its residents’ services. The SNF must provide any Part A or Part B service that is subject to SNF consolidated billing either directly with its own resources, or through an outside entity (e.g., a supplier) under an "arrangement," as set forth in Section 1861(w) of the Act. If an outside entity provides a service that is subject to SNF consolidated billing to a SNF resident during a covered stay, the outside entity must look to the SNF for payment (rather than billing under Part B). In these situations, Medicare’s payment to the SNF represents payment in full for the arranged-for service, and the SNF in turn is responsible for making payment to an outside entity that furnishes a service which is included in the SNF’s prospective payment system (PPS) per diem payment.
The same holds true for services that are subject to the Home Health Prospective Payment System. The law states that payment will be made to the primary home health agency whether or not the item or service was furnished by the agency, by others under arrangement to the primary agency, or when any other contracting or consulting arrangements existed with the primary agency.
Before providing beneficiary services, the supplier should determine whether the beneficiary is receiving any comprehensive Medicare benefits (e.g. SNF or Home Health) which could include the supplier’s services.
For more information regarding skilled nursing facility consolidated billing, please refer to the articles titled Skilled Nursing Facility Consolidated Billing, Skilled Nursing Facility Consolidated Billing Service Furnished Under An "Arrangement" With An Outside Entity in the Spring 2005, DMERC Dialogue. For more information regarding home health prospective payment system, please refer to the article titled Independent Therapists And DME Suppliers – Billing For Therapy Services Or Supplies That May Be Part Of A Home Health Stay in the Summer 2003 DMERC Dialogue.
6)
In regards to "Same/Similar Equipment", Cigna has advised Providers that if we asked about "Same/Similar Equipment" upon delivery and the beneficiary gives misinformation to the provider (that is documented and signed by the beneficiary), and the claim denies on a CO-57, the claim is then sent to the review department with the supporting documentation. (Reference: Oct 2002, Q&A, HME A-Team, Follow-up Request for Same or Similar Issue).
a. What are the guidelines in documenting what the provider was told when the beneficiary was asked about "Same and Similar" equipment?
Answer: Redetermination decisions are based on all documentation provided with the redetermination request along with any information contained in the patient’s history record. Unless, it is a valid ABN, signed statements do not play a part in making a redetermination decision.
b. Can a provider obtain a PR denial vs. a CO denial if the patient has signed a statement indicating that they have not received same/similar equipment?
Answer: The only way a CO denial would be given is to have a valid ABN.
7)
Several trade journals have had small articles announcing the news that an Assignment of Benefits is no longer required for claims where assignment is mandatory. For example: Medicaid crossover claims and certain drugs. I have been unable to find mention of this change on the CMS and DMERC web sites. Please clarify to whom this change applies and whether this is an option for DMEPOS suppliers.
Answer: This instruction appeared in the Code of Federal Regulations (CFR); however, CMS has not issued instructions to the contractors for implementation. CGS will provide those instructions on our Web site, bulletins and listserv when they are available.
8)
As a Pharmacy provider, many are approached with beneficiaries that have both Medicare and a prescription drug card (such as Express Scripts), that is "on line" adjudicated. Unfortunately Express Scripts EOB’s only have the RX number vs. patient’s name, etc. Express Scripts has refused to reformat their EOB’s to include the patient’s name, etc. The beneficiaries are forced to pay out of pocket, either the Express Scripts copay or the 20% Medicare copay. Express Scripts can not be billed as a Secondary Payor! Please see attached examples in attachment A.
Per the Cigna DMERC website…I found the following: Routinely, the paper claims are returned to the provider, stating inadequate information to process the claim.
Electronic claims submitted to Medicare for secondary payment must contain the primary payer insurer’s payment information in the designated electronic fields. Paper claims must be accompanied by an explanation of benefits (EOB) or other documentation from the primary payer, which shows how they processed the claim.
Answer:
The attached EOB is acceptable if the member ID is identified on the MSP record for Medicare. Remember: In order for Medicare to pay secondary to a prescription plan the plan must meet the Medicare Secondary Payer guidelines as stated in Chapter 11 of the Region D Supplier Manual.
In our last meeting with CIGNA we were led to believe that a new policy regarding knee orthosis would be forthcoming shortly.
Would CIGNA give us an update as to the status of the new knee orthosis policy
REHAB
Leslie Rigg, Leader, Evan Call, Asst. Leader
Previously submitted Q/A from April 2005
12) The wheelchair seating policy states: A solid support base for a seat cushion is a rigid piece of plastic or other material which is attached with hardware to the seat frame of a wheelchair in place of a sling seat. A cushion is placed on top of the support base. Use code E2618 for this solid support base. If a supplier chooses to bill separately for mounting hardware, either nonadjustable or adjustable, for a seat or back cushion or solid support base, code A9000 must be used.
However, in the WCS policy it defines the following:
A9900 miscellaneous DME supply, accessory, and/or service component of another HCPCS code
E2618 Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting hardware.
Can the hardware be billed separately?
Answer: The hardware is included in the reimbursement of E2618, if hardware is billed A9900 should be billed.
How is the allowable for the A9900 determined?
Answer: There is no reimbursement, it would deny as included in the base code (E2618).
How is the allowable for the E2618 determined?
Answer: Currently there is no fee schedule for this code. Payment will be gap-fill based on the manufacturers suggested retail price submitted on the claim
Thank you for your response clarifying the billing for the E2618 and A9900 codes. We understand that, as a supplier, the responsibility for an overpayment will remain with the supplier even when a valid ABN is obtained as long as the claim is sent assigned. A nonassigned claim would not have this responsibility.
16) The Rehab A-Team would like to reiterate our concern regarding the change from EACH to PAIR as the designation for Power Elevating Legrest with no consideration regarding the allowable.
New Questions:
14)
Is it appropriate to use the E0956 code for a lateral support pad that will be used with swing away hardware (E1028)?
Answer: Yes, that is acceptable. Refer to SADMERC’s website under the product classification for wheelchair accessories, for acceptable code combinations.
15)
Is It appropriate to use the E0955 code with a headrest pad that will be attached to removable hardware (E1028)?
Answer: The removable hardware is for the joystick; however, if you are using E1028 as a manual swing away, yes that is acceptable. Refer to Chapter 9 of the Region D Supplier Manual under the Wheelchair Accessories LCD for the use of E1028 (swing away). Not all headrest have swing away hardware. Refer to SADMERC’s website under the product classification for wheelchair accessories, for acceptable code combinations.
RESPIRATORY
Joe McKnight, Leader, Yvonne Cordoza, Asst. Leader
No Questions
SADMERC
Wade Hendrickson, Leader, Reid Bellis, Asst. Leader
Previously submitted Q/A from April 2005
16) A recent list-serve announcement indicated that the E1010 code is now a pair code. The allowable was not changed. As an each code, the allowable provided adequate compensation and allowed the supplier to supply only what was needed, left versus right or both. We are concerned that current compensation levels will limit access to certain products. We are also concerned that there was no prior notification of this change. Suppliers who had products in process will have to change products or be unable to provide the product. The consumer may be affected by being provided with 2 leg rests when potentially only one was needed. What is the process by which the E1010 allowable definition changed from "each" to "pair"? Why does the allowable not reflect an increase in reimbursement with the increase in product number?
Answer: In investigating the reimbursement of code E1010 we found that the original description of the code had "each" and majority of the products used to price this code were based on a "pair". The description of the code was changed in 2005 and the fee was adjusted to delete the "each" products from the pricing array.
Follow up question is we do not feel that when the pair was redefined that the proper consideration was given to the reimbursement and will have a negative effect on this item as explained above. Can the allowable be researched further?
Answer:
E1010 code change from each to pair. Part One of the question deals with the reimbursement that did "not reflect an increase". Pricing issues must be addressed to CMS under Joel Kaiser. We have nothing to do with that. We were informed that the reimbursement would be changed to reflect the change in the code description. If that change has not occurred it may be a timing issue, or it may not have yet reached the status of priority. So that question should be directed to the CMS Pricing team.
Part Two of that question seems to indicate there is a problem now with billing of a single leg rest. E1010 is for an entire system, including all the pieces needed to attach it and control it. E1009 is for a single leg rest that is mechanically linked to an operating system. If there is a need for a single leg rest not mechanically linked, then we need to know that and have some idea of the volume of use.
Answer: Pediatric Mobility Codes-The Alpha Numeric Work Group at CMS decided that these codes were not needed for Medicare. The reimbursement category was changed to make them invalid for Medicare, but valid for other third party payers. So the code remains in place and valid for use under the rules of HIPAA. As invalid for Medicare, however, there is no longer a fee schedule for the Medicare side of the house. Other payers may use any payment formulae they wish. This may be more of a Medicaid issue and probably just an educational issue for a few people.
Clean denial codes--this issue is constant. DMERCs (and other Medicare
carriers) are restricted by SSA 1861 and other legal language to only a few categories of denials. Some items are statutorily non-covered-that means that certain items may never be reimbursed under the Medicare system of healthcare reimbursement. These decisions are legal and binding and not subject to legal challenge at less than congressional level. Other items are not paid because there is no benefit category under which they can be considered for payment. Other items are determined to be invalid for billing to Medicare because of the patient population or condition served, or they do not meet the definition of DME. Some items are not paid because they are in another carrier's jurisdiction. All these denials result in some action code that is considered by suppliers as a "good" denial because it allows them to go to another 3rd party payer and say this item was never considered for payment by Medicare, would you consider it?
ll other denials for payment of DMERC equipment must be medical necessity denials. This is where the problem lies. If a product is denied with an action code that indicates medical necessity, it implies that consideration was given to payment of a device that met all the other rules of DME but was deemed as not necessary for this patient at this time. Other 3rd party payers may, or may not, consider that item separately and make an independent decision. Short of a complete set of duplicate codes for every item of DMEPOS, and some system of crosswalk to handle the change from the HCPCS code denied by Medicare to another national code covered by other 3rd party payers, I do not know of a way to solve this problem. If there are specific examples of high volume items affected by this problem, submit them to the DMERCs and the SADMERC for consideration of remedial action. No assurance is given that such action will take place or even be possible.
24) An issue with code A4221 for insulin pump supplies. Based on the information we researched, a provider can use this code correctly and if they are participating providers with DMERC. However providers trying to get a PR96 denial so they can bill the patient for the difference between their URC and the Medicare allowable (they feel the compensation is not adequately covering their costs to provide the necessary supplies that are included in the A4221) is not allowed. Most policies state to change the tubing for the pump every 48-72 hours as ordered by the physician, and of course the $21.00/ week Medicare allowable does not adequately cover the costs. After reviewing Medicare policy, seeing we cannot balance bill the patient if they accept assignment and they can not get a PR96 denial as it is a covered code for the purpose they are using. We got some manufacturer information supporting the life of the tubing, and supplied medical documentation that would support changing the tubing every 48-72hr's.We wondered if an ABN could be use