Region D DMERC Advisory Committee
Questions to CIGNA Government Services for January 2006-Reviewed March 2006
EDI / EMC
Zena Jacobi, Leader, Sandy Carden, Asst. Leader
1)
Suppliers have begun sending NCPDP claims as required for retail drugs. Prior to that drug claims were forwarded to secondary payers with an MA07 or MA18 notification. Since converting to the NCPDP format, Region D has stopped crossing these claims over to Medicaid and all other supplemental insurers. It's our understanding that this is a carrier requirement for Medicaid’s and a complementary service for other insurers. Per the Supplier Manual "the transfer of Medicare claims to a Medicaid agency is required by the Centers for Medicare & Medicaid Services (CMS)".
Will this capability be reinstated? When?
Example: the following ICN was sent in 837 format and generated an MA18 note:
04252801057000
The following ICN was sent in NCPDP format and did not generate the MA18 note:
04343837996000
Answer: It should not stop crossing over to Medicaid unless (See Comments). If you have examples of current claims that aren’t crossing over to complementary insurers and Medigap, please forward those claims over so we can check the files. The examples provided were from 2004.
Medicaid
On the crossover NCPDP claims, DMERCs must enter the Medicare HIC number if the eligibility file received from a Medicaid State Agency or a trading partner does not have a Medicaid Beneficiary ID in the Supplemental ID field. If this not done, Medicaid cannot process the claim.
2)
Will supplier claims continue to be crossed over to ALL current crossover payers when the CMS mandated transition to the consolidated COBA process at the COBC is enacted starting 1/1/06? Will CIGNA be requesting any specific waivers on behalf of current trading partners?Written orders are acceptable for all transactions involving DMEPOS. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink document. (See Chapter 3, Section 3.4.1.1.B.)
All orders must clearly specify the start date of the order.
For items that are dispensed based on a verbal order, the supplier must obtain a written order that meets the requirements of this section.
Based on Section 5.1.1.2 – Written Orders of the PIM, a physician’s order can be electronic and must specifically state the "date of the order".
Answer: Based on the presented situations it does follow that both CSR’s are appropriate and non-conflicting. In the first scenario the supplier had already submitted a claim(s) for which reimbursement had been received. What is required as per the CSR, the supplier needs to document all attempts to find a new supplier to agree to render care and submit a written order and refund any monies paid for DOS under that period of time when no WOPD was in place. Reimbursement for services rendered is not allowable unless a new and valid WOPD under a new supplier has been received as a written and dated order and the previous course of events are well documented.
The latter sited scenario refers to the supplier who may have rendered the services prior to having a WOPD and has not yet billed for such services. Billing is allowable for only those services rendered after having obtained a WOPD. It does follow that the supplier can begin billing after having obtained a WOPD but only for those services rendered after the date of the RX.
Additional documentation was submitted with the claim in question and was reviewed by a nurse. Based on the documentation submitted, criteria was met and the KX modifier was added to the code. In no additional documentation is submitted and the KX modifier was not added that claim would deny.
6)
Pharmacies have the ability to obtain electronic information regarding beneficiaries. Could this access be granted to the HME providers?
Answer: All suppliers may sign up for Beneficiary Eligibility and/or Claim Status Inquiry. They would need to determine which company they would like to use, IVANS or Vision Share. Region D DMERC has an article that we have posted on our web site to give you contact information for both companies, you may access this article at www.cignagovernmentservices.com/articles/dec05/cope3453.html. Once you have determined which company you would like to use, please download and complete the DMERC EDI Customer Profile form.
7)
Some providers have received telephone calls from a Cert Contractor asking for patient information such as "was Jane Doe a customer in your store on 11/1/05?
With this new process how will providers be able to recognize that the call is in fact from an authorized representative from the Contractor?
Answer: According to the CERT 2 contractor (the primary one handling documentation requests) the caller identifies him/herself as being with the CERT contractor. If the callee questions the authenticity and/or authority of the caller, the callee is given the callers telephone number and to call back. Incoming calls come through the contractor’s switchboard, not directly to the caller.
1. Authorization must be reviewed if a new item is rented or purchased.
2. Once the supplier has obtained the patient’s one-time authorization, later claims for those same services can be filed without obtaining an additional signature from the patient. These claims may be on an assigned or non-assigned basis with the exception of durable medical equipment rentals. The one-time authorization for DME rental claims is limited to assigned claims only.
MEDICAL SUPPLIES
Pat Spanel, Leader, Mary Turner, Asst. Leader
9)
Providers are looking to determine how to prevent claims for items that "could" deny or be recouped, due to consolidated billing. In many cases, Cigna nor the provider knows, at the time of service, if a beneficiary is enrolled in a HHS/PPS episode.
a. What is the language of the beneficiary liability, when the provider has written documentation where the beneficiary states there is no HHS/PPS episode in place?
Answer: Since Medicare payment for services that fall under home health consolidated billing is made to the primary HHA, independent providers or suppliers of these services need to understand that Medicare will not pay you separately. Therefore, before you provide a homebound beneficiary any services, you need to first determine if they are being served by a primary HHA.
To get this information you can, first, ask the beneficiary (or their authorized representative) if they are currently receiving home health services under a home health plan of care. In fact, beneficiaries and their representatives should have the most complete information as to whether or not they are receiving home health care. But, beneficiary-derived HH information, in and of itself, does not shift liability to either the beneficiary or to Medicare. Region D DMERC Dialogue Winter 2006
b. Cigna has stated that it would not be valid to obtain an ABN because an ABN applies to "Medical Necessity". Would Cigna reconsider allowing an ABN based on the fact that it would not be medically necessary for the beneficiary to obtain supplies from both the Home Health/SNF and the DME supplier, constituting "too many supplies"?
Answer: DMERC Region D Supplier Manual Chapter 6 on the reasons a ABN may be obtained:
§
§1834(a)(17)(B) of the Act, violation of the prohibition on unsolicited telephone contacts for medical equipment and supplies;
c. There seems to be conflicting answers from the June 2005 Q&A #5b and the reference tools given at the end of that response (DMERC Dialogue Summer 2003). The answer given in the Q&A stated that should a claim deny or be recouped from the provider the provider should then turn to the HHS or SNF for payment of the services. Yet in the Summer 2003 Dialogue, it states "it is your (meaning the provider) responsibility to simply ask the beneficiary (or his/her authorized representative) if he/she is presently under a home health plan of care. Payment for the services denied by Medicare may be sought from the beneficiary, but you should advise them of their obligation for payment prior to delivering the service. Could you please clarify which is the correct response and explain how this should be documented prior to delivery (ie. Possible ABN?)?
Answer: Both answers are correct. If monies are recouped or denied, the supplier’s next step is to contact the HHA or SNF for payment consideration
d. What tool should the provider use to determine whether a beneficiary is receiving any comprehensive Medicare benefits, which could include the supplier’s service?
Answer: The Medicare program does not provide any such tool. It is up to the supplier to develop procedures which best suits their business practices.
e. When using this tool, is there a way to generate a denial that would be acceptable in obtaining a payment from the beneficiary (ie.. the provider is "without fault" and had no reasonable way to know the claim would either deny or be recouped)?
Answer: See answer to 9d
10)
Is it acceptable to provide a valid ABN when a same and similar denial could occur? It was understood that Dr. Hoover did not feel (per the CMS Open Door Forum) that this would violate the rule on giving an ABN out on every item. Please verify this response.
Answer: As long as the supplier genuinely believes that the patient had same or similar equipment, an ABN may be given for this reason.
11)
Is an Assignment of Benefits still required for claims where assignment is mandatory (ie. Medicaid crossover claims and Medicare Part B drugs)?
Answer: Providers need to be aware that on January 1, 2005, Medicare regulations at 42 C.F.R. 424.55 were amended to eliminate the requirement that beneficiaries formally assign claims to suppliers when suppliers are required by law to accept assignment. In other words, the beneficiary is not required to assign the claim to the physician or supplier in order for an assignment to be effective in "mandatory assignment" situations. Region D DMERC Dialogue Winter 2006, page 67
12)
Can providers indicate primary payer payment information in an HAO record for an MSP claim? If not, could this be a violation of the Paper Reduction act?
Answer: No, this is not the correct element to provide that information in. An MSP article was published in the EDI Edge, Summer 2002 that will break down where this information should be entered. The name of the article is "Utilizing the X12N 837 (Version 4010) When Submitting Medicare Secondary Payer MSP claims. If your software does not have MSP capability you are welcome to use our Free Billing Software until your software can be modified or as long as you like. This would not be a violation of the Paper Reduction Act since the ANSI Implementation guide provides the required segments.
13)
Does a valid ABN generate a "PR" denial?
Answer: Yes, a valid ABN will generate a PR denial
.
14)
In the Region D Supplier Manual Chapter 16, codes A4405 thru A4415 (ie. Ostomy skin barrier, with flange, with or without convexity, with or without filter, larger or smaller than 4x4) and A4422 (ostomy absorbent material) is under the category of 04 (Prosthetics and Orthotics). Will these items be excluded from CR3607 (the orthotic certification requirements for providing certain custom fabricated orthotics)?
Answer: CR3607 was rescinded and replaced with CR3959. The list of codes that are addressed in CR3959 are custom fabricated Prosthetics and Orthotics. Ostomy, Tracheostomy and Urologicals have a separate payment category (11). The ostomy codes in question were incorrectly listed with the payment category of prosthetics and orthotics (04) in Chapter 16 of the DMERC Region D Supplier Manual. This will be corrected in the next update.
ORTHOTICS & PROSTHETICS
Sharon Nichelson, Leader, Harry Brandt, Asst. Leader
No questions
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 policyREHAB
Leslie Rigg, Leader, Evan Call, Asst. Leader
15)
The E1161 for an adult tilt in space wheelchair does not list a weight limit. Other standard wheelchairs are defined with a 250 lb weight limit. For an individual with a weight over 250lbs needing a tilt in space wheelchair, would the chair be correctly coded as a K0009, other wheelchair base? If not, what code should be used?
Answer: This question is currently under discussion by the DMD’s and SADMERC.
RESPIRATORY
Yvonne Cordoza, Leader, Gemma English, Asst. Leader
16)
When a claim is submitted for medications above the monthly maximum quantity, CIGNA used to pay up to the maximum allowed quantity per month and deny the remainder as over-utilization. Currently, suppliers are receiving ADS Letters requesting additional documentation prior to any payment being received. If a patient is allowed up to a specific amount, why doesn’t CIGNA continue to pay the maximum amount, deny the remainder for over-utilization and allow the provider to appeal with supporting documentation? Example is available and will be faxed upon request.
Answer: This claim was developed by Medical Review. The DMERC has the right to request documentation at any time.
17)
A Medicare patient is bed-ridden and unable to go to the physician's office for the oxygen re-evaluation within 90 days of recertification. A home health nurse case manager evaluated the patient in question and reported findings to the treating physician. The physician wrote a note attesting to this and that the patient continues to need the oxygen. However, CIGNA customer service advised this is not acceptable and recommended that we find a physician who makes house calls. Can you advise what the supplier’s options are in a situation like this? Most physicians do not make house calls and the patient clearly needs continued use of oxygen.
Answer: It is my understanding that what is required is that a re-evaluation be performed only after a written order from the physician had been received and dated prior to the date the oxygen re-evaluation was performed. I am not aware of a specific CMS requirement that a physician make a home visit. Having a physician make a home visit would help support such services as reasonable and necessary.
18)
At the Seattle, WA CIGNA DMERC seminar on October 25, 2005, the subject of Oxygen testing for exercise was discussed. We were advised that all three tests must be performed on the same day in the same visit. When we questioned how this could happen when many physicians do not have oxygen in their offices, the response was that we could set the patient up for oxygen and have them return to the physician's office to perform all three tests on the same day. Previously, Dr. Hoover indicated that ideally, the tests would be performed on the same day, but recognized that physicians don't always have oxygen equipment as part of their practice. He advised that all three tests must be performed before suppliers bill the DMERC but not necessarily on the same day. Conflicting answers have been received at subsequent seminars. Would you please clarify the rule?
A copy of the DAC minutes from May 7, 2003 when Dr. Hoover clarified the above is attached. Please see Attachment: 1 in this document.
Answer: The following Oxygen supplement determination requirements under Group I criteria are found in the LCD:
LCD Information
1) An arterial PO
2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent taken at rest (awake), or2) An arterial PO
2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88 percent, for at least 5 minutes taken during sleep for a patient who demonstrates an arterial PO 2 at or above 56 mm Hg or an3) A decrease in arterial PO
2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5 percent, for at least 5 minutes taken during sleep associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, "P" pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or4) An arterial PO
2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88 percent, taken during exercise for a patient who demonstrates an arterial PO 2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89 percent during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.
Initial coverage for patients meeting Group I criteria is limited to 12 months or the physician-specified length of need, whichever is shorter. (Refer to the Documentation section for information on recertification.)
When both arterial blood gas (ABG) and oximetry tests have been performed on the same day under the same conditions (i.e., at rest/awake, during exercise, or during sleep), the ABG result will be used to determine if the coverage criteria were met. If an ABG test at rest/awake is nonqualifying, but an exercise or sleep oximetry test on the same day is qualifying, the oximetry test result will determine coverage.
It appears that the requirement of all tests being performed must occur on the same day. Unless the LCD is revised it does appear that this requirement remains in place.
No questions
Attachment: 1
Region D DAC Meeting with CIGNA
May 7, 2003 ��
3:00pm – 5:00pm
Las Vegas Convention Center
Las Vegas, NV
MINUTES
VI. A-TEAM LEADERS REVIEW ANSWERS PROVIDED BY CIGNA
G. RESPIRATORY
Joe McKnight asked for clarification to question #16. He stated, "Does the DMERC require that the third
test for hypoxemia during exercise with oxygen be done on the same day as the other two tests recognizing
that some physicians don't have oxygen present in their office at the time of the initial test?"
Dr Hoover responded that under ideal testing scenarios, for scientific accuracy, the test would optimally be
done at the same time as the other tests, but he recognized that some physicians and labs don't have oxygen
present and would need to contact a homecare company to initiate oxygen on the patient, on the order of a
physician to complete the test. That said, he saw no requirement that the test be done on the same day as
the other two. He further stated that this policy would, in all probability, be clarified with the new oxygen
guidelines.
Region D DMERC Advisory Committee
September 2006
EDI / EMC
Zena Jacobi, Leader
1)
Suppliers are receiving repeated denials of electronic submissions because of a "previous initial CMN on file". Medicare regulation requires that when a patient has an extended (greater than 60 days) break in service or the services change substantially that a new "initial" CMN as opposed to a "revised" CMN be submitted. A specific example would be a stationary oxygen patient with an existing CMN on file for stationary oxygen only, receives orders to add portable oxygen. This significant change in service by Medicare regulation requires a new initial CMN. The new electronic CMN is subsequently rejected for a "CMN already on File". When DMERC customer service is contacted on this issue they have responded with "No, it should accept the new CMN". When we prove to them that it is being rejected the response is "Well that’s not right, but there is nothing we can do because a glitch in the system is rejecting the new CMN". The only alternative we’ve been given is to submit the claim with the new initial CMN on paper.
The new policy stating there will be a 90-day window with denial of all paper claims without appeal becomes a Catch22 and certainly puts suppliers in an unreasonable position if there isn’t a way to submit the claim electronically and new CMN electronically. Can you provide a way for providers to submit a new "initial" CMN electronically?
We can provide sample ICN numbers (in a separate document) that have been denied because the new "initial" CMN was rejected.
NAS Response
: NAS will needs ICN examples so we can research. NAS will not have access to the "production" DME claims processing system until October 2.
5) Who will be the liaison from Noridian and/or IntegriGuard from the Provider Education Department for the DAC? We would also welcome the opportunity to review educational materials prior to publication as well as have input on educational topics. Also, we would like the opportunity to give feedback on the workshops.
NAS Response: Various NAS education staff will attend DAC meetings and fill the role of liaison between Noridian and the DAC. The opportunity to review educational materials and to have input on educational topics is the function of the Provider Outreach and Education (POE) Advisory Group. Several DAC members are also members of this group so NAS will not discuss these same topics at the DAC meeting. These topics are most appropriately discussed at the POE Advisory Group meetings.
IG Response:
Liaison from the DME BISC (IntegriGuard) will be Karolyn Osborn, 402.498.2444.
6) In the past, questions that were asked at the various workshops were gathered and published on the Cigna DMERC website as education for all providers. Will this be continued on the Noridian and IntegriGuard websites?
NAS Response: NAS will post questions asked at workshops on our website and will also do the same with IntegriGuard workshop questions, when requested by IntegriGuard. Questions of this nature are most appropriately posted on the NAS website, rather than IntegriGuard’s website. These questions will be posted in the Training section of the website and will also be published in bulletins and notification sent to the DME email list when new questions are posted to the website.
HOME MEDICAL EQUIPMENT
Barb Stockert, Leader, Kay Johnson, Asst. Leader
7)
A Roll-A-Bout can be found on the SADMERC web site coded as E0118 since 1-1-04. The Roll-A-Bout is a crutch type aid with a pad for one knee. It is on wheels. It allows the user to be non weight bearing on the injured leg by placing their knee on the pad. The other foot can then propel them with the aid of the arms.
This HCPC code (E0118) is listed in the Cane/Crutch medical policy however there is no coverage criteria listed. We have been denied by Medicare indicating that the patient's condition does not meet the criteria for the "crutch substitute, lower leg platform, with or without wheels."
We had an ABN completed by the patient documenting the reason for possible denial: "May not be considered a covered item with Medicare." We provided this reason because in our PMIC 2005 HCPCS code book, this code E0118 is listed as "not valid for Medicare."
Medicare has denied this because the reason we have listed on our ABN is not a valid reason.
Our first question is: If we believe that the patient's condition supports this level of equipment, there is no specific coverage criteria is documented with the carrier, and we do have documentation that indicates that the item/code is not valid for Medicare, what should the ABN say?
IG Response:
Please see the CMS ABN Decision Tree: http://www.cms.hhs.gov/MLNProducts/downloads/ABN_READERS.PDFIG Response:
Please see the CMS ABN Decision Tree: http://www.cms.hhs.gov/MLNProducts/downloads/ABN_READERS.PDFEX: #2 is a traditional prescription. Please note that this also meets the requirements of a written order but the date is also at the top of the prescription not next to the physician name.
The Paper Work Reduction Act of 1995 was established so agencies would reduce the amount of paperwork required by their departments. This was done so manpower, as well as cost could be reduced and operate more efficiently. The present requirement of having the date next to the signature seems redundant and unnecessary because it requires us to have to mail another written order to the physician just so the date can be added next to their name.
a. Why does the date have to be next to the physician name? With the requirement that the patient's medical records must be complete with the medical necessity information that verifies their need for the service, this information would be found there not exclusively by the date on the prescription.
b. Wouldn't the date at the top of the prescription also be indicative of when the physician wished the service to start, since most all of these prescriptions are written at the time of the patient visit?
c. How can we expect a physician or medical center to redo their prescription pads or electronic records so they are considered to be compliant with a requirement that seems outdated by today's documentation requirements?
NAS Response
: There is no written requirement that the physician signature and date must be located next to each other. If a form, such as a CMN or order, has items for these to be entered and they are located next to each other, we would expect these fields to be completed, as indicated and the date not indicated elsewhere on the form. However, there is not a requirement that the physician signature and date must be located next to each other on orders or prescriptions.
MEDICAL SUPPLIES
Pat Spanel, Leader, Mary Turner, Asst. Leader
9)
On the EDS website and there appears to be the beginnings of an MD corner, such as Dr. Hoover started on the Region D DMERC web site. Under Dr. Pilley's biography, it has an article clarifying diabetic monitors/supplies
http://www.edssafeguardservices.eds-gov.com/providers/dme/mdforum.asp
. Here is an excerpt:
"Implementations of the LCD revisions are for dates of service on or after July 1, 2005. Dates of service prior to July 1, 2005 remain under the guidelines of the prior Glucose Monitors LCD which requires a renewal order from the treating physician every 12 months."
Suppliers see multiple interpretations of this statement. Which is correct?
IG Response:
Blood Glucose Monitoring supplies billed to the DME MAC for dates of service prior to July 1, 2005 will be adjudicated according to the LCD that was in effect during those Dates of Service. Blood Glucose Monitoring supplies billed to the DME MAC for dates of services on or after July 1, 2005 will be adjudicated according to the revised LCD in effective on or after July 1, 2005.
Patients who received or were "set up on service" prior to July 1, 2005 are required to have an order for renewal of blood glucose supplies in 12 months. Since this renewal occurs after July 1, 2005, the revised LCD that is now in effect applies, indicating that if the physician writes a lifetime order it does not need to be renewed or reordered unless there is a change in diabetic medical management and/or frequency of blood glucose testing.
A. For patients set up on service prior to 7/1/05, suppliers should be obtaining a renewal RX every 12 months, regardless of how far into the future the patient continues to use supplies.
B. For patients set up on service prior to 7/1/05, the RX (written for lifetime) which was good only good a maximum of 12 months under the old rule is now good for a lifetime.
C. For patients set up on service prior to 7/1/05, the RX (written for lifetime), which was good only a maximum of 12 months under the old rule would expire. Upon expiration, the next RX would be good for a lifetime if physician writes the order that way.
10)
Suppliers are having difficulty in obtaining over utilization documentation due to the physician not documenting at the level of specificity that is needed and many physicians expressing their disbelief that information we are requesting is necessary. Would it be possible in the very near future, to have a physician education article on documentation requirements for over utilization?
NAS Response: NAS would recommend that the DAC address this concern to CMS and recommend that CMS educate physicians on the documentation requirements at a national level. A MLN Matters article or other CMS written publication would be a good way to get the same message out to all Medicare physicians.
ORTHOTICS & PROSTHETICS
Sharon Nichelson, Leader, Harry Brandt, Asst. Leader
11)
We are receiving electronically generated prescriptions for Orthotic and Prosthetic devices. These prescriptions do not have an actual signature by the physician but rather read, "electronically authorized by ____ MD." The RX further reads "signature derived from controlled access password" (password # followed by the MD’s name) and a date and time stamp. The Rx is very helpful in that it contains more information than we frequently receive on a dispensing Rx, such as a legible diagnosis and patient address.
a. Will CMS accept an electronic signature on a dispensing Rx as a valid signature?
b. Another possibility, which could occur, is a Physicians office could scan our detailed Rx into their system, and then generate an electronic detailed Rx. Will CMS accept this detailed Rx as valid if it contains all the required information as well as an electronic signature?
IG Response:
Electronic signatures are acceptable and must adhere to all privacy, security, and electronic signature rules and regulations promulgated by CMS and DHHS. The noted scenario does appear acceptable.
12)
A dynamic bracing company has established a Long Term Care Division that is calling on Therapy Departments in nursing homes. They are stating to the nursing home therapists that DynaSplint dynamic braces (SADMERC Product Classification List E1805, E1800, E1802, E1810, E1815) can be provided to nursing home patients and billed through Medicare Part B. These products are being placed in nursing homes throughout Region D.
a. If a nursing home patient has a permanent address which is a residence, but they are in a nursing home at the time of delivery, is the place of service home or nursing home?
NAS Response: POS is nursing home, either 32 for skilled (Part A stay) or 31 for non-skilled (Part B stay).
b. Is there any way that Medicare Part B will reimburse for a dynamic brace that is delivered to a patient in a nursing home?
NAS Response: Per Section 211 of the Medicare Claims Processing Manual, Chapter 20, DME cannot be paid in a SNF POS, unless the item is excluded from SNF consolidated billing. The E codes referenced above are not excluded. The DME supplier must look to the SNF for payment as the SNF receives payment from Medicare that includes payment for these DME items.
NAS needs to research further for the situation when a patient is a non-skilled level of care (in a Part B stay).
NAS would remind suppliers that all items ordered for a Medicare beneficiary must be medically necessary and meet the coverage criteria outlined in CMS guidelines and Local Coverage Determinations.
REHAB
Leslie Rigg, Leader, Evan Call, Asst. Leader
13)
Preface: The major concern of many Rehab suppliers currently is the recent code and allowable changes for cushions and backs. We realize that you may not have the authority to change aspects of this policy at this time. We do hope you will acknowledge our concern and help to deliver our message to CMS. We also have concerns regarding the 120 delivery time line as expressed in the following scenario: Hawaii Neighbor Island client. We order the chair, it builds, then ships by water (up to three weeks shipping time), arrives on Oahu to be assembled (after getting all the pieces from the different manufacturers), then has to be shipped to the neighbor island (4-5 days) before we go to do the fitting. We usually only go once a month to each island. If the timing on the arrival of the equipment is off, we'll miss the 120 day deadline - or have to schedule another very expensive trip to deliver one wheelchair.
IG Response: The section of the LCD referred to contains the following language: "The delivery of the PMD must be within 120 days following completion of the face-to-face examination. (Exception: For PWCs that go through the Advance Determination of Medicare Coverage (ADMC) process and receive an affirmative determination, the delivery must be within 6 months following the determination.)"
We realize that there may be instances when consideration to allow an exception to this time frame may be necessary; natural disaster, lost in transportation, unable to deliver. These instances are anticipated to be more of an exception to the rule as opposed to a regular occurrence.
14)
Now that the rental option has been eliminated from the capped rental program, does the supplier still need to send a rent/purchase letter to the beneficiary?
NAS Response: NAS interprets this change to mean that rental/purchase letters would not apply.
15) If we have a manual wheelchair CMN for 12 months that has expired, we were initially told by Medicare that we did not need to resubmit a new CMN for the extension but had to show medical necessity, so we did a new prescription and functional mobility questionnaire. Today we were told by four different people at Medicare that we would need to transmit a new CMN. Is this necessary now that CMN’s are no longer required for wheeled mobility devices?
NAS Response: Per CR5128, contractors shall not require a CMN for wheelchairs for dates of service on/after May 5, 2005. Prior to this date, CMNs are still required. See MLN Matters 5128 for more information.
16)
Is the date and time stamp recorded on the top of incoming faxes sufficient to meet the requirement for documenting the reception of Medical documentation for powered mobility within the 45 day limit?
IG Response: For receipt of the Medical documentation in and of itself this would appear acceptable. This information needs to be legible and readily identifiable on the document.
17)
Policy states that the initial prescription must be written by the physician or treating practitioner and contain the 7 elements- name, date of face to face, diagnosis, description of item, length of need, signature and date. Is it appropriate for the supplier to provide a form listing the elements for the physician or treating practitioner to complete?
IG Response: The following explanation is taken from the PMD Documentation Article and clearly answers this question.
"Many suppliers have created forms which they send to physicians and ask them to complete. Even if the physician completes the form and puts it in his/her chart, this is not a substitute for the comprehensive medical record as noted above. We encourage suppliers to help educate physicians on the type of information that is needed to document a patient’s mobility needs."
18)
New requirements of the PMD policy indicate that the supplier prepare a written document, termed a "detailed product description" that lists the specific base, HCPCS code and manufacturer name/model, and all separately billable options/accessories. For claims with dates of service on or after 8/24/06, the supplier must list their charge and the Medicare fee schedule allowance for each separately billed item. If there is no fee schedule allowance, the supplier shall enter "not applicable". The physician must sign and date the detailed product description and the supplier must receive it prior to the delivery of the power chair or POV.
Question: Providers already have to get two signed/dated documents (the prescriptions) from the physician. If one of the prescriptions meets the stated requirements of the "detailed product description", can it serve to act as both the prescription and the detailed product description in lieu of having the doctor sign a third document? If so, can a combination of documents signed and dated by the physician meet the requirements of the detailed product description or must it all be contained on one form?
IG Response: As per the PMD Documentation Article: "The signature on the detailed product description is to ensure that the practitioner is well informed about the equipment provided to the patient and has the information necessary to provide feedback to the supplier as necessary about any safety or functional concerns." This does not prohibit using the same document to also serve as the prescription provided it follows the requirements of a PMD order from a physician. This does not state that the detailed product description be required to be put on one form but presenting a detailed product description on multiple documents would necessitate that the physician sign all such documents and that it be readily apparent or known that all such documents together compose the detailed description and nothing has been inadvertently left out or inappropriately added.
Question: Policy states that a detailed order must list the specific power chair being ordered. Does this refer to the specific code or the manufacturer and/or the specific model?
Yes.
If it is the manufacturer or the model, what does the supplier do if it is necessary to change the specific chair within a HCPCS code category?
IG Response: Use the appropriate HCPCS code for the specific chair being supplied.
Question: Does the specificity noted above extend to the specific accessories?
IG Response: Yes.
For instance, cushions or backs within a specific HCPCS category or chest supports from different manufacturers?
19)
Policy requires that additional documentation be obtained above that contained in the OT or PT evaluation. Why is documentation from a credentialed OT or PT, cosigned by the physician not adequate documentation to validate medical necessity?
NAS Response: This is a CMS regulation. Prior to dispensing a PMD, the DME supplier must obtain from the physician or treating practitioner who performed the face-to-face examination the written prescription accompanied by supporting documentation of the beneficiary’s need for the PMD in the home. For more information, see MLN Matters 4372.
IG Response: The Final Rule requires a face to face examination by a physician. An OT or PT evaluation performed to assist the physician in completing a face to face examination must be reviewed and signed by the physician ordering and completing the face to face examination. This is clearly explained in the PMD Documentation article:
"The physician may refer the patient to a licensed/certified medical professional (LCMP) who has experience and training in mobility evaluations to perform part of the face-to-face examination. This person may not be an employee of the supplier or have any financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, an LCMP working in the inpatient or outpatient hospital setting may perform part of the face-to-face examination.)
If the report of an LCMP evaluation is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier. This requirement will be enforced on claims that are received by the DME contractor on or after 8/10/2006. (Note: Evaluations performed by an LCMP who has a financial relationship with the supplier may be submitted to provide additional clinical information, but will not be considered as part of the face-to-face examination by the physician.)
If the patient was referred before being seen by the physician, then once the physician has received and reviewed the written report of this examination, the physician must see the patient and perform any additional examination that is needed. The report of the physician’s visit shall state concurrence or any disagreement with the LCMP examination. In this situation, the physician must provide the supplier with a copy of both examinations within 45 days after the face-to-face examination with the physician.
If the physician saw the patient to begin the examination before referring the patient to an LCMP, then if the physician sees the patient again in person after receiving the report of the LCMP examination, the 45-day period begins on the date of that second physician visit. However, it is also acceptable for the physician to review the written report of the LCMP examination, to sign and date that report, and to state concurrence or any disagreement with that examination. In this situation, the physician must send a copy of the note from his/her initial visit to evaluate the patient plus the annotated, signed, and dated copy of the LCMP examination to the supplier. The 45-day period begins when the physician signs and dates the LCMP examination.
It is important to emphasize that even if an LCMP performs a major part of the mobility evaluation, there still must be a face-to-face examination by the physician."
20)
Regarding "in the home". Many people live in assisted living or apartments that require them to access meals, mail, laundry etc outside of their apartment. These services are often within the confines of the larger apartment complex or community living area, but some distance from the person’s apartment. A client may be mobile in their specific apartment with out power mobility but may not be independently mobile to meals, the laundry room, mail or even to get safely out of the building in the case of an emergency. In such a situation, would the individual meet the criteria for power mobility?
IG Response: Each request for coverage of a PMD for a Medicare beneficiary is considered on an individual basis and will be determined using the indications and limitations of coverage provided in the LCD. One of the requirements is that the PMD be needed to assist the beneficiary in performing MADLs in the home setting due to documented limitations of function.
RESPIRATORY
Yvonne Cordoza, Leader, Gemma English, Asst. Leader
21)
The Deficit Reduction Act (DRA) makes some changes to Medicare payments for rental arrangements for durable medical equipment. Prior to the DRA, "capped rental" items are rented by Medicare for up to 15
months; after 15 months, the supplier continues to furnish the equipment to the beneficiary as long as the beneficiary needs it but the supplier retains title to the equipment. Beginning with items newly rented on or after January 1, 2006, DRA changes the rental period to 13 months. After the end of the rental period, title to the equipment transfers to the beneficiary. This change implies that the Purchase Option Letter will no longer be used since it will automatically convert to a purchase. With that in mind, can suppliers now discontinue sending the Purchase Option Letters to beneficiaries for capped rental items?
NAS Response: See answer to #14 above.
22)
Currently, if an E0470 is billed and these criteria are not met but the coverage criteria in the DME MAC policy for CPAP are met, payment will be based on the allowance for the least costly medically appropriate alternative, E0601. The DME MAC policy also states that If an E0471 is billed and the criteria for an E0470 device are not met, it will be denied as not medically necessary. With the E0471, E0470 and the E0601 now in the same payment category, if an E0471 is billed and the criteria for an E0470 device are not met, but the criteria in the DMERC policy for a CPAP are met, will the DME MAC consider payment based on the allowance for the least costly medically appropriate alternative, E0601?
IG Response: The DME Medical Directors will update the LCD to allow downcoding. Please refer to the RAD LCD for further detail.
http://www.edssafeguardservices.eds-gov.com/providers/dme/lcdcurrent.asp
If the answer to the above question is yes, and an E0471 is down coded to an E0601, will the continued usage call requirements for the CPAP apply, or would the RAD documentation (physician certification and beneficiary statement) be required?
IG Response:
Considerations for coverage will be based on compliance with the indications and limitations of coverage for the actual device provided and not based upon downcoding.
Revision date 11/28/06
Region D DMERC Advisory Committee
Questions to Noridian for July 2006
a. Response: Dr Pilley indicated that it is a systems issue. There should be a way for the supplier to use it a particular way. Should be directed to the DME MAC. This is not payable under the DME benefit. It is an operational issue that would be accomplishable. Amy Barnes indicated there was a call that the DMERCS were on, and this issue came up. Their issues were with claims that were getting paid and CMS is looking into this scenario.
While the drug and supplies would continue to be paid on our long term inotropic patients would we be required to transfer ownership of the pump to the beneficiary? How would we handle this when our infusion pumps are typically a lease/rental arrangement? Would the patient then be responsible for all maintenance and annual biomed checks?
a. Response: Dr Pilley will be taking the question to the national teleconference and he will see. He also thinks CIGNA maybe able to provide clarification.
Response: Dr Pilley says it is an issue with access to the CWF, and understands it is a difficult situation. This issue should be continued to be pursued through CMS.
Response: Dr Pilley indicated that this would need to come from CMS on what the options are. He suggested to follow-up with them on the white paper, etc., to have access to CWF and not have a CO denial.
ORTHOTICS & PROSTHETICS
Sharon Nichelson, Leader, Harry Brandt, Asst. Leader
Other question: Sharon Nichelson asked for the Status of L Codes?
Response: This is still being considered and is in the topics under discussion.
a. Response: Not sure of the claims edits that may be in place and as to why they are being denied. Will defer to CIGNA. This will be discussed further down the road. If you have examples or more information.
RESPIRATORY
Yvonne Cordoza, Leader, Gemma English, Asst. Leader
10)
MLN Matters Number MM4223 notified providers on the implementation of RADs with back-up rates (E0471) changing classification from the Frequent and Substantial Servicing (FSS) category to the Capped Rental (CR) category effective April 3, 2006. MLN Matters Number MM5010, released 5/22/06, notified providers that Capped Rentals with DOS on or after January 1, 2006 will be paid for 13 months after which the title of the device will be transferred to the beneficiary.
Since E0471 was not classified as a CR until April 3, 2006, does the capped rental counter for E0471 begin on 4/1/06?
a. Response: Dr Pilley indicated that April 1
st
is a Saturday, and the 3
rd
was Monday. Dr. Pilley agreed that April 1st would be correct for that HCPC code.
The capped rental calculation will begin with the first date of service billed after 04/01/06
.
11)
The current LCD for RAD states the apnea-hypopnea index (AHI) in this policy is defined as the average number of episodes of apneas and hypopneas per hour of sleep. The polysomnogram must be based on a minimum of two hours of recording time without the use of a positive airway pressure device, reported by polysomnogram. The AHI may not be extrapolated or projected. To the contrary, as of 06/21/06, the LCD for CPAPs states the apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep without the use of a positive airway pressure device, reported by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected).
Why does the definition for AHI differ between the two policies?
a. Response: Dr. Pilley responded that they do not differ on the calculation of hypopnea index. Different policy than CPAP NCD that has been published.
Question: Which policy is correct for the definition of AHI?
Response: Dr. Pilley responded that the number of episodes that occur over a period of time. The NCD language calculating on 2 hours of sleep time, not the total recorded time.
No questions
Region D DAC/CIGNA DMERC/IntegriGuard/EDS
Q+A/Meeting Minutes
March 22, 2006
Las Vegas Convention Center, Room N262
9:00 am PST
Present:
Region D DAC Executive Committee Members:
CIGNA Government Services/Region D DMERC: Doug Frazier, and Kathy Brock.
IntegriGuard/EDS: Dr. Mark Pilley, and Missy Edison, Policy Coordinator.
Region D DAC Participants: see enclosed listing.
Meeting opened at 9:01 am
1. Introductions of all attendees ensued.
2. General Business:
a. Review of meeting protocols: Chair Val Taylor reviewed the meeting protocols.
b. Approval of meeting minutes: A motion to approve the October 18, 2005 meeting minutes as written by Sharon Nichelson. Second by Laura McIlvane. Motion carried.
3. Medical Director: Dr. Mark Pilley:
a. Dr. Pilley expressed that he appreciates the opportunity to work with the DAC. He plans to continue on with the interaction with the DAC and to keep an open line of communication. Their objective is to pay claims right and appropriate and be available to the industry.
b. Nebulizer policy will be released sometime next week for notice and comment. They will have open forums. The dates of the forum have not been set, but should be late April. The forum will most likely be in the Kansas City area and should have a teleconference option. The deadline to comment will be in May. Comments will be accepted through the following email address:
draftlcdfeedback@integriguard.org
Region D DAC Participants
Asela Cuervo
Barb Stockert
Barbara Strong
Carlos Reyes
Cheryl Stokes
Chuck Gunther
Connie Lind-Fraher
David Bryant
Dawn Jorgensen (representing Laura Steelquist)
Deanne Birch
Diana Guth
Don Hardin
Dorene Alderetti
Evan Call
Gemma English
Gene Salisbury
Joe McKnight
Joseph Rolley
Kay Martin
KC Cooper
Kimberlie Rogers-Bowers
Laura McIlvane
Leslie Rigg
M. Edwards
Marshall Pollock
Mary Jackson
Mary Turner
Mike Hayden
Paul Kesselman, DPM
Reid Bellis
Rich Pozesky
Rick Graver
Rosalie Weber
Rose Schafhauser
Scott Alberts
Sha Eppley
Sharon Nichelson
Sheila Showalter
Sheila Ross
Steve Treinen
Tami Joplin
Teri Jamison
Troy Paz
Val Taylor
Velma Goertzen
Wade Hendrickson
Wally Tschopp
Yvonne Cordoza
Zena Jacobi