Region D DAC/Noridian Administrative Services (NAS)/IntegriGuard
Q/A & Meeting Minutes
January 30, 2007
Via Teleconference
Please note: There are several updates provided by Dr. Pilley and Janet Kirsch after this conference call. They are noted in plum italics.
Region D DAC Executive Committee Members:
DME Medicare Administrative Contractor (MAC) Noridian Administrative Services (NAS):
Education Teamleader: Janet Kirsch
Education Representatives (Fargo): Tracy Schutt and Sheryl Mandigo
Education Representative (Boise): Jody Whitten
Contact Center Team Leader: Laurie Severtson
DME Appeals Office (Grand Forks): Various
Program Safeguard Contractor (PSC) IntegriGuard:
Medical Director: Mark Pilley, MD
Medical Review Manager: Joan Madsen, RN, BSN
Medical Review Supervisor: Karolyn Osborn, RN
LCD/HCPCS Coordinator: Melanie Addison, RN, BSN
CERT Coordinator: Michelle Davis, RN,
Lead Claims Analyst: Amy Barnes
Medical Review Nurses: Mary Park, RN and Patricia Marshall, RN.
Region D DAC Participants: see enclosed listing at end of minutes.
Meeting opened at 9:10 am PST
1. General Business: John Kenney
a. John announced that this call is being recorded for consistency in note taking and also for those that missed the call so they can go back and listen at a later time.
b. Chair, John Kenney opened the meeting with a review of the meeting protocols.
c. Approval of the meeting minutes from September 19, 2006 in Atlanta. A motion to approve the meeting minutes as written by Laura McIlvaine. Second by Barb Stockert. There were no oppositions. Motion carried.
2. Teamleader Update: Janet Kirsch
a. IVR Update: Noridian did have some difficulties when the contract was first taken over and have quickly resolved those issues. Over the last several months they have not heard of any new issues. 70% of calls are now handled by the IVR. If you are having problems please call Customer Service at the time of occurrence so they can troubleshoot.
b.
Payment timelines update: A couple of weeks ago, an article was posted on website. Also there is a home page graphic "Important-Click here to find out more about NAS DME Claims". They do have a high inventory and are working on corrective plans of action. As of 1/29/07, 67.3% of the suspended claims are less than 30 days old. Only .35% of all suspended claims are 90 days or older. They have a process via the DAC to work with cash flow issues and are meeting with Joe and Barb on almost a weekly basis. An updated article is expected to be posted in the next week or so to the Noridian website.
This was posted on 2/12/07.
c.
"Re-opening" status of claims and how to move these thru the system most efficiently: This is an area where there are a lot of re-openings that are pending. Many are due to system issues that they have had. Also, due to provider clerical errors. They have not had the opportunity to do an analysis at this time. But, Janet can look at doing this in the future. Janet suggested that providers look at website regarding the difference of redetermination and reopening. A plan of action has been put into place to reduce reopenings (phone and written).
Update to information from conference call: Written reopenings are current being worked in the 60 day timeframe.
d.
Matrix - John Kenney reported that the Matrix is also being posted to DAC website, approximately every 2 weeks. Update coming next week from Janet.
An updated matrix was provided to the DAC on 2/12/07 and posted to the DAC website on 2/13/07.
3. Medical Directors Update: Dr. Mark Pilley
a. Many issues have surfaced re: local coverage determination (e.g. power mobility devices).
b. Joe McKnight from Executive Committee asked what the relationship is between IntegriGuard and DME MAC? Dr. Pilley responded that IntegriGuard (PSC) is a subcontractor under EDS (the prime contractor) and the statement of work includes medical review, post and pre-payment claim review, assistance with developing local coverage determinations, revisions to local coverage determinations, re-consideration requests for local coverage and provide medical support for program integrity (EDS). EDS is the prime data analysis provider (for claim utilization). Contractor error rate testing assessment is owned by DME MAC and PSC. There is a new process in last few months with local coverage determination and that involves a unique relationship will full PSC and DME MAC. The PSC is still charged with development and revision of local coverage determination and articles. But, the DME MAC has accountability of adopting and implementation of local coverage policies. The PSC also reviews appeals and redeterminations (if over turned – they need to review and understand why). There is a good working relationship with Noridian and they have identified no barriers yet with the two working together.
c. Maureen Hanna asked if Dr. Pilley was aware of the expected announcement dates for competitive bidding sites. The PSC has not been informed either. CMS Central and Regional Office are very actively engaged in this process. These are all new processes and these are not without controversy and complexity. CMS would want to implement with as much forethought as possible so as to reduce any kinds of problems and errors.
d. John Kenney asked what the Medical Directors priorities are for the near future?
i. Nebulizer policy being considered now and is in review and consideration by DME MACs. A notice is expected in the not so distant future.
ii. In process now of reviewing and revising the knee orthosis policy. Comment period ended 10/15/04. Working with AOPA and others on it.
iii. Capped rental on oxygen – currently working on policy articles.
iv. Committed to getting back on quarterly publication schedule. Next one due around March 1st.
v. Education article regarding the use of GK and GL modifiers for PMD (with and without ABN) and additional automation for submitting these claims. Goal is to allow suppliers to provide a beneficiary with higher grade model chair when they meet requirements for lower model and then have the claim automatically adjudicated.
vi. They see a need for providing documentation guidance for glucose testing.
e. John Kenney asked if LCD for nebulizer, knee orthosis and oxygen capped rental will be published as a policy or a draft for review?
i. Per Dr. Pilley responded:
1. Capped rental – will be a published article.
2. Nebulizer – will be final policy.
3. Knee orthosis – may have to be released as draft because of time period since initial published draft (2004) and new codes that may be added.
4. DAC-D CMS Work Projects: John Kenney
a. Same/similar eligibility information: no update.
b. HH PPS White Paper: no update.
John asked for Dr. Pilley’s assistance on this as our previous CMS DAC contact is no longer over DME.
i. Dr. Pilley will attempt to identify this and get back to John.
1. Jim Underhill, CMS RO X, was contacted with regard to this issue. He related that the DAC has received a reply from CMS with regard to this request. It is my understanding that CMS has responded as follows:
a. Due to HIPAA and Confidentiality law suppliers can not have access to the claims processing system. This is in statute and to provide access would be a violation of Federal Law
b. CMS has provided a process whereby suppliers can obtain information regarding same and similar devices and this process has been communicated by CMS to suppliers in response to the White Paper.
ii. Janet has also expressed a need to CMS Central management and has copied them on meeting notices and the agenda for this call. She also invited them to be on the call today but there was a schedule conflict. Larry Young is their Contract Officer.
5. Provider Outreach and Education (POE) Update: Janet Kirsch
a. Provider Outreach – Their last meeting was in December. A list of members and minutes are under the Training section of their website.
b. All remaining Ask the Contractor teleconferences for this year are posted on the website, in training section.
c. Something new for small suppliers (less than 10 FTE equivalents) is that they will have their own Ask the Contractor teleconferences. They will be held every other month beginning in February.
d. CMS-1500 Workshops conducted since December because of NPI. They have not scheduled any for February or March. But, if there is enough interest they will consider doing.
e. Webtours – Have been very popular and well attended.
f.
Bulletins (first one was in December) and Listserve messages. Second bulletin coming soon
. Update: Second bulletin was posted to website on 2/6.
g. They have assigned an Education Staff person for both the National and State Associations involved in the DAC. They just started making calls to them and the calls have been very well received. The purpose is to strengthen the relationships. A calling tree will be established to address concerns. Janet will forward the contact list to DAC Executive Committee in the next week or so.
6. A-Team Leaders review of answers provided by NAS and IntegriGuard:
a. EDI/EMC
i. Not applicable – no questions were submitted.
b. Education/Communication/POE (Cindy Coy)
i. Question 1 – Suppliers are tasked with current rules/regulations as well as past ones (on post-payment audits). Now that manuals are on-line is there a plan to post past issues? If so, will suppliers have access?
1. Janet reported that Noridian does not have archive copies of the Supplier Manual posted. Starting approximately one month ago, there is a list at the top and it indicates what has changed (e.g. chapter, section, what was added/deleted). Janet does not anticipate a lot of the manual changing unless there is a CMS directive. Chapter 16 does have a lot of changes due to HCPCS codes. They do have some of Cigna’s files (CD-ROMS) and providers can call Customer Service and request copies on a case by case basis.
ii. When audits are done – how do auditors know what the past requirements were?
1. Janet responded that if IntegriGuard or other CMS entities need it, they can approach Noridian and ask for copies of the archive files.
c. HME (Marshall Pollock)
i. Question 4 – re: E0118 the DAC is still gathering additional information that has been requested.
1. Janet was given the HIC# information by Maureen last week and did research before the call. The initial claim was downcoded and paid. Then the claim was appealed and the modifier "GA" was removed.
ii. Is this considered a covered item? Does this require an ABN?
1. Dr. Pilley will do additional research with SADMERC.
2.
Janet to send claim specifics over to Dr. Pilley.
Completed on 2/10.
a.
IntegriGuard, LLC is currently researching additional information regarding this claim
.
3. Dr. Pilley stated, if not covered as a device it seems providers could issue ABN for non-covered device and collect money from beneficiary.
a. Further research reveals that E0118 is considered "not valid for Medicare" and would therefore require a valid ABN in order for the supplier to bill the beneficiary.
iii. Leslie Rigg provided more information re: PMIC HCPCS book. The E0118 was in this book and the code was in noted in red (meaning not a valid code). She gave an ABN that stated "may be considered non-covered".
1. IntegriGuard feels that the appeal did not uphold ABN because the ABN was not specific enough.
d. IV/PEN (Deanne Birch)
i. No further questions at this time.
e. Medical Supplies and Wound Care (Mary Turner)
i. No further questions at this time.
f. O&P (Sharon Nichelson)
i. Question 8 – Can dynamic orthotic items be placed in a nursing home as a capped rental if medically necessary? If not, then what HCPCS code should be used? HCPCS codes E1800 – E1840.
1. Per Janet, the language is provided by CMS. The Item must be medically necessary and they would need equipment in the nursing home.
ii. John provided some additional clarification. Historically, dynamic orthosis in the SADMERC description were listed as dynamic orthosis. Approximately 5 – 6 years ago the L codes were changed to E codes and the description changed from orthotics to dynamic devices. The general understanding in the industry was if it had an E code it was considered DME and was therefore not eligible to be placed in an institutional setting such as nursing home, even though it is an orthotic device. We are now seeing that dynamic orthotics are being billed under E codes for dynamic braces and placed in nursing homes on a very frequent basis. Our question, Is this OK (assuming medical necessity is met)?
1. As per discussion with the DME PSC Medical Directors and SADMERC, E1800 and E1840, dynamic Orthosis, are considered DME and therefore non-covered in the SNF setting.
iii. In the past, the L3964 SEWHO was denied in POS 31 and 32. The L3964 SEWHO attaches to a wheelchair, and has thus been considered to be durable medical equipment by Medicare not an orthosis. Does the rationale that the DME exclusion does not apply to orthotics, prothetics, and supplies be applicable to this HCPCS code? If not, please explain.
iv. Question 9: This is in regards to a Medi-Cal claim and the retro of beneficiary claims submitted to prior to 9/2006 that was submitted to Cigna via CMS-1500.
1. Top of claim states "DHS Health Insurance Payment Demand – M991 and their Medi-Cal provider number.
2. Box 9 – states Medicare retro billing
3. Box 30 – amount paid by Medical is noted
4. Box 31 – tax number
5. Box 32 – provider information
6. Box 33 – states to remit payment to DHHS
Claims submitted after September have been denied by Noridian due to (education status 610) due to extraneous information 24a – 24k on CMS-1500. Provider called and was told to re-submit claim.
a.
Janet to research if there were directions from previous contractor. She will discuss with claims processing. Update:
Received examples on 2/6/07.
g. Rehab (Leslie Rigg)
i. Question 11: In the response you document that "it is anticipated that the physician’s order is received prior to the supplier’s completion of the product description". For many suppliers, this information is readily combined on one order. The physician may receive an initial order that is prior to a face to face evaluation or the supplier may not receive an order because the order has been written for an evaluation and that has gone to the therapist. Again this may be prior to the face to face. The policy does not appear to specifically state that these must be separate documents. More generally policy would appear to indicate that documentation must include all of these elements.
1. Per Dr. Pilley – the physician order itself should be signed after the face-to-face examination has been completed. This can be the same day. There must be an indication for need of PMD in home setting (via assessment) and if home setting is accommodating. There must be documentation in medical records (e.g. progress notes) in addition to supplier or PT evaluation exam. Two documents are not required. An article has been published by all PSCs. Supplier initiated forms are not considered part of the medical record. They are looking for accountability from physician in terms of face-to-face exam documented in progress notes. MDs who perform physicals document this as the purpose of why they were in the office. Often patients are in for a chronic condition and there is no documentation of an independent exam taking place. They are looking for face to face with a functional assessment.
ii. Question 14: We do not feel that this answer addressed the question. Val Taylor provided the following for further clarification: Please refer to the ADMC case # 2304. We understand that the ADMC specifically addresses the medical necessity of the equipment and that it is not a guarantee of coverage. Our question is in regard to the medical necessity of the power positioning needed for a C-5 quad ICD-9 (344.04). The finding that the equipment does not meet medical necessity requirements for the power base or any other power positioning system is the issue. If the process is specifically designed to address medical necessity, it would seem that a power chair is medically necessary in this case. The supplier would need to understand that the payment, if any, would be based on the allowance for the least costly Group 2 or Group 3 PMD. Then the medical necessity for the other power seating needs, power tilt, power recline, specialized back or positioning armrest would be addressed as well .
1. Per Dr Pilley, an ADMC is not a claim. As a result, they do not adjudicate the same as a claim in terms of downcoding. Cigna may have downcoded device in the past. But they do not see this as ADMC the process.
Further information provided by Val: The chair was chosen by the podiatrist due to size (height and weight), father of 4, very active outside the home. This is his 3
rd
power base and he has a 20 year history in a power chair. They knew the chair would not be covered but wanted the accessories covered.
1. IntegriGuard response (Karolyn) – cannot give affirmative on ADMC for base.
Val asked if base is denied how are accessories addressed?
2. IntegriGuard Response (Dr. Pilley) - There are a set of modifiers that can be used to pay the difference between level 3 and 4 (e.g. line 1 "GA" and line 2 "GL" to on claim). There are new modifiers that are going to be released soon (GK?).
Val stressed that on crossover claims – when denied "not medically necessary" then the secondary follows and does not pay even with a prior authorization.
iii. Question 16: Joe McKnight asked if this means that the safety evaluation must include entry and exit concerns – and the equipment should not be provided if safe entry or exit cannot be assured from the standpoint of safety?
1. Dr. Pilley responded – If you cannot get in/out of residence you may not be able to respond to an emergency. ADA laws require "open access". Two issues: medical necessity and accessibility (not covered by Medicare). In some states the Medicaid programs put out RFPs to companies that can do home modifications to make accessible. Normally the home assessment is done by the supplier and they see ramp and/or door enlargement is done. Beneficiary safety needs to be addressed (which is not currently in policy). It is anticipated the beneficiary or caregiver "safely use in home" (does not address entrance/exit). Dr. Pilley will check with other medical directors. Dr. Pilley feels this is a provider issue and they need to involve social services due to quality of care.
iv. Question 17: Does this mean that the initial Product Description can be amended or is a second document needed with the additional information? Can providers add the omission then have MD initial and date addition?
1. Yes, as long as documented by MD. However, indications need to be supported in the medical record too.
h. Respiratory (Yvonne Cordoza)
i. Question 21c – The dilemma is suppliers cannot bill the beneficiary and we cannot reuse the medications (under state pharmacy law). If there is documentation to support that the provider checked with beneficiary before shipping (e.g. in notes) can we bill and get paid for this?
1. IntegriGuard will need to research further. Currently, if "not deliverable" then it is "not payable". An ABN cannot be given as it must be written and needs a witness.
7. New Business:
a. Next DAC meeting – Medtrade Spring (Las Vegas) April 24-26, 2007.
i. Noridian and IntegriGuard state that the afternoon of 24
th
works for them.
ii. Maureen will contact AAHomecare and request meeting rooms. Updated information:
1. DAC only meeting has been scheduled for 4/24/07 from 9:00 am – 11:00 am (Vegas time) in room N264.
2. DAC meeting with NAS and IG has been scheduled for 4/24/07 from 1:00 pm – 3:00 pm (Vegas time) in room N264.
iii. John Kenney reviewed the timeframe for the April Q&As.
1. March 23 – The DAC will have the questions to Noridian and IntegriGuard.
2. Noridian and IntegriGuard will have responses back by April 11
th
so that both the Executive Committee and A-Teams will have sufficient time to conduct their conference calls.
Motion to adjourn at 12:00.
Region D DAC Participants
A-Team Leaders & Assistants
Deanne Birch
Yvonne Cordoza
Cindy Coy
Sha Eppley
Wade Hendrickson
Zena Jacobi
Sharon Nichelson
Marshall Pollock
Duane Ridenour
Leslie Rigg
Cheryl Stokes
Mary Turner
State Representatives
Kimberlie Rogers-Bowers (Alaska)
Teri Jamison (Arizona)
Laura McIlvane (California)
Lelia Wilkerson (Iowa)
Sheila Showalter (Kansas)
Dave Hosman (Missouri)
Mary Rogers (Nebraska)
Rich Pozesky (Nevada)
Sha Eppley (Oregon) – already noted above
Deanne Birch (Utah) – already noted above
Val Taylor (Washington) – already noted above
Other (by Executive Committee invitation only):
Rose Schafhauser (MAMES)
DACD 013007 minutes.doc
Last updated 02/13/07
Jurisdiction D DAC
Combined Meeting with Noridian Administrative Services, IntegriGuard, and the DAC
Q/A & Meeting Minutes
17 July, 2007, 12 Noon Via Teleconference
Present:
DACD Exec Committee
John Kenny – Chair
Barb Stockert – Vice Chair
Mike Hayden – Secretary
Sharon Nichelson – Treasurer
Val Taylor – Past Chair
Noridian:
Janet Kirsch
Jodie Whitton
IntegriGuard:
Introductions and Announcements of Changes in the Executive Committee: John Kenney announced the change of Barb Stockert
to fill the role vacated by Joe McKnight as Vice Chair when Joe assumed his new role as DAC Executive Manager. John welcomed Sharon Nichelson to her role as treasurer, Karl Lindborg to his role as A-team leader for O&P replacing the role vacated by Sharon. John reviewed the meeting protocols that require listen only, asking that only the A-team leaders speak during the Q &A sections.Approval of Minutes from April 24 th meeting: Noridian and CMS have received the meeting
minutes and they have been reviewed . Janet noted her changes were incorporated. DR. Pilley motioned the minutes be approved, this was seconded by Barb Stockert. The motion carried.Medical Directors Update: Dr. Pilley opened the discussion with
information that there will be a change in medical review. This function of the PSC will be moved to the DMEMAC with the transition to be completed by October 31. The new medical director will be Dr. Robert Szcyzs. Work however is business as usual. No major change in availability or the availability of his staff. There will be continued work on policy articles. Dr. Pilley didn’t know if he or his staff will be at MedTrade. John Kenney offered that if at all possible it would preferable to have him there even via teleconference. Dr. Pilley said he is continuing to work on the Knee Orthosis policy. He has been doing ongoing work on codes with AOPA. They (IntegriGuard) have revised the draft again. His goal is to have it published before end of transition period. IntegriGuard is continuing to publish on website and notes on website.
We are currently emphasizing correct completion of Item 11 and Item 29 on the CMS-1500. Item 11, used to report insurance information, must be completed, with either the word "None" if Medicare is the primary insurance or a group number when Medicare is secondary. If Medicare is secondary, an EOB must be attached.
Item 29 is for reporting amounts that patients have paid on the claim. Many times this is completed in error to represent coinsurance, deductibles, or primary payer payments. Any amount submitted in this field may result in the beneficiary receiving payment even on an assigned claim.
A-Team Leaders review of answers provided by NAS and IG
EDI/EMC
Zena Jacobi, Leader
Duane Ridenour, Assistant Leader
Executive Liaison, Val Taylor
1. The Medicare FFS NPI Contingency Plan Roundtable on 5/10/07 indicated that there would be changes to 835s when an NPI is sent on a claim. It wasn’t clear what the changes are or when they’ll be implemented. Please clarify when these changes will occur and which loop and segment will contain the NPI once the change is made. Also, please clarify whether the supplier number will still be included in the 835 as a contingency once these changes are made.
Submitted NPIs will be crosswalked to the Medicare legacy number(s) for processing. Medicare's internal provider files will continue to be based upon records established in relation to the legacy identifiers. The crosswalk may result in three scenarios:
Scenario I- Single NPI, cross walked to single Medicare legacy number
Scenario II- Multiple NPIs, cross walked to single Medicare legacy number
Scenario III- Single NPI, cross walked to multiple Medicare legacy numbers
Scenario I- Single NPI Cross walked to Single Legacy Number
Electronic Remittance Advice (ERA)- Medicare will report the NPI at the Payee level as the Payee primary ID. Medicare will report the TIN (Employer Identification Number (EIN)/Social Security Number (SSN) (EIN/SSN)) in the REF segment as Payee Additional ID. Medicare will report any relevant Rendering Provider NPI at the claim level if different from the Payee NPI. Carriers, Part A/B Medicare Administrative Contractors (A/B MACs), and DME Medicare Administrative Contractors (DME MACs) (as appropriate) will also report relevant Rendering NPI(s) at the service line level if different from the claim level Rendering Provider NPI. There will be one remittance advice and one check or Electronic Funds Transfer (EFT) per NPI.
Standard Paper Remittance (SPR)- Medicare will insert the appropriate Payee NPI at the header level. The ERA reporting requirements apply to the corresponding SPR fields.
PC Print Software- Medicare will show the Payee NPI at the header level and add the relevant Rendering Provider NPI at the claim level if different from the Payee NPI.
MREP Software- Medicare will show the Payee NPI at the header level and add any relevant Rendering Provider NPI at the claim level if different from the Payee NPI. Medicare will also add any relevant Rendering NPI(s) at the service line level if different from the claim level Rendering Provider NPI.
Scenario II- Multiple NPIs Cross Walked to Single Medicare Legacy Number
ERA- Medicare will report the NPI at the Payee level as the Payee primary ID. Medicare will report the TIN (EIN/SSN) in the REF segment as Payee Additional ID. Medicare will add any relevant Rendering Provider NPI at the claim level if different from the Payee NPI. Carriers, A/B MACs, and DME MACs (as appropriate) will add any relevant Rendering NPI(s) at the service line level if different from the claim level Rendering Provider NPI. Adjudication will be based on the unique combination of NPI/legacy number. There would be multiple remittance advices, checks, or EFTs based on that unique combination.
SPR- Medicare will insert the appropriate NPI number at the header level. The ERA reporting requirements apply to the corresponding SPR fields.
PC Print Software- Same as Scenario I.
MREP Software- Same as Scenario I.
If we are billing to Medicare and Medicaid. Why would we need two codes.
Scenario III- Single NPI Cross Walked to Multiple Medicare Legacy Numbers
ERA- Medicare will report the NPI at the Payee level as the Payee primary ID. Medicare will report the TIN (EIN/SSN) in the REF segment as Payee Additional ID. Medicare will add any relevant Rendering Provider NPI at the claim level if different from the Payee NPI. Carriers, A/B MACs, and DME MACs (as appropriate) will add relevant Rendering NPI(s) at the service line level if different from the claim level Rendering Provider NPI. Adjudication will be based on the unique combination of NPI/legacy number. There would be multiple remittance advices, checks, or EFTs based on that unique combination.
SPR- Medicare will insert the appropriate NPI number at the header level. The ERA reporting requirements apply to the corresponding SPR fields.
PC Print Software- Same as Scenario I.
MREP Software- Same as Scenario I.
Follow up – we are trying to understand where the unknown NPIs are coming from? We were referred from EDI to NPPES. NAS Responded. EDI sent you back to NPPES to verify the information and because taxonomy is related to claim information.
Education/ Communication – No Questions
HME – No Questions
IV / PEN – No Questions
Medical Supplies and Wound Care – No Questions
O&P
Karl Lindborg thanked everyone for their responses and asked if there was any further follow up along with John Kenny to both the questions asked in this round of Q&A and the follow up from the previous round.
Dr. Pilley commented: Some of these will be answered with the new orthotics’ policy. Dr. Pilley went in May to HANGER and Mitchell Dobson looking at products and codes. Many of these questions will answered with the new policy and codes.
Regarding Question 15 from the previous meeting Sharon Nichelson asked why must we have the mfg name and part number since each one is made custom, by each Ocularist. John suggested that an O&P A team leader could perhaps contact Dr. Pilley on this issue or perhaps and Ocularist. Dr. Pilley was most amenable to this. Dr. Pilley pointed out that there are changes to the policy that will be released over the next couple of days that should clarify this. He later clarified that the new policy no longer requires that a mfg and Part # be provided that this has been rectified. Dr. Pilley did however express interest in discussion with an Ocularist or A-team leader to follow up on the manufacturing process.
Regarding question 16 C from last meeting on the dynamic braces, John Kenny noted to Dr. Pilley that some supplies state they are being paid for under E1800 to E1840 codes and Dr. Pilley said that he would speak with the other Medical Directors and agreed to follow up on this question.
Regarding Question 16D from the previous meeting, (SEWHO) is this reimbursable. Dr. Pilley felt statute allows that it should be payable under the L3964 but would follow up and issue a response.
Rehab
Question # 6 Leslie Rigg Leslie thanked NAS and IG for their response but reiterated the cumbersome nature of the redundant paperwork necessary for PMDs and asked if there was any further interpretation.
We would suggest sharing these concerns with CMS and/or IntegriGuard for further consideration. Currently, CMS guidelines do not allow for backup equipment in this situation. It appears the only option is for the beneficiary to pay for the backup equipment or for the supplier to provide this "as a service".
Gemma English A-team leader asked: - You noted that we should share this with CMS or IntegriGuiard, how would you suggest we share this issue with them. NAS response: Likely the best way would be a white paper on this issue to address a long term back up scenario. Joe McKnight (former A-team leader and liaison) inquired about code K0462 for DME rental replacement during the repair items such as NVS. Dr. Pilley said he will review the KO462 code.
New Business: Next meeting in Orlando: October 2-4. DACD will provide the room assignments very soon to all involved for meeting information.
Meeting was adjourned at 1PM.
List of additional attendees: (captured – stated)
Rose Schafhauser
Shelia Showalter
Dave Hosman
Zena Jacobi
Leslie Rigg
Cindy Coy
Connie Lind Frayer
Gloria Peterson
Shay Epley
Gemma English
Karl Lindborg
Rich Pozesky
Mary Turner
Marty Libovitch
Kay Johnson.
Region D DAC
Questions for IntegriGuard and Noridian
Medtrade Fall – October 3, 2007
Follow up – we are trying to understand where the unknown NPIs are coming from? We were referred from EDI to NPPES. NAS Responded. EDI sent you back to NPPES to verify the information and because taxonomy is related to claim information. Party with the question stated they had received two different NPIs at the request of Medicaid.
NAS Response: We would need specific examples to provide further assistance. Please review the various NPI articles that have been published regarding NPI/NSC # situations where information is not cross-walking correctly and how to troubleshoot these errors. Many times the information in the NPPES files needs to be corrected.
Education/Communication/PCOM
Cindy Coy, Leader
Connie Lind-Fraher, Assistant Leader
Executive Liaison, Barb Stockert
1. What notice is given to suppliers when there is a correction to a Q&A that appears on either the Noridian or IntegriGuard website? If a supplier read an answer today and it was changed tomorrow, how would they know it was changed and that the information they had read was incorrect?
2. This supplier is suddenly being denied for 2 units of TENS leads. The current Medicare Policy for billing supplies for TENS is still posted on the website as of today's date 7/23/07. We have been billing and receiving reimbursement for 2 sets of supplies for several years.
The LCD states "Separate allowance will be made for replacement supplies when they are medically necessary and are used with a TENS unit that has been purchased and/or approved by Medicare. If 2 TENS leads are medically necessary, then a maximum of one unit of Code A4595 would be allowed per month; if 4 TENS leads are necessary, a maximum of two units per month would be allowed. If the use of the TENS unit is less than daily, the frequency of billing for the TENS supply code should be reduced proportionally."
On 7/16/07 we received denials for 9 patients for supplies with DOS 7/5/07. The EOB denial codes were: 1. Patient Responsibility, 2. non-covered charges and 3. Number of days or units exceeds acceptable maximum.
We have spoken to 4 representatives of Noridian and received a variety of answers. We were first told it was a mistake and to file for a reopening. We did that on 7/16/07 for the 9 patients. Today we got another EOB dated 7/17/07 with all 9 patients with the same denial codes. When we asked why we not paid for at least 1 set of electrodes, no one
could give us a solid reason. We have been told that CMS is "thinking" of changing the 2 sets of supplies per month to 1 per month. However, this should not constitute a change in policy. We were also told that some CMN image files were lost in transition from CIGNA to Noridian and this may be the issue. That's difficult to understand because we were being paid up until July 2007.
Examples are available from this supplier. Why is the LCD guideline not being followed for TENS supplies?
NAS Response: These denials occurred to the incorrect implementation of a Medically Unnecessary Edit (MUE). This was corrected in late July and claims denied in error were adjusted in August. Suppliers should have received payment for these adjusted claims as all claims were to be worked by the end of August.
3. Please confirm that items under Maintenance and Service (MS) prior to January 2006 is still payable? Suppliers are experiencing take backs and denials for grandfathered MS charges. Examples are available for this issue. I have not gotten Troy’s examples.
NAS Response: Yes, maintenance and service prior to January 2006 is still payable. However, it should be noted that maintenance and service cannot be paid until the entire 15 months of rent have been paid. Furthermore, the maintenance and service must be submitted to NAS on a separate claim from the last month of capped rental. NAS would appreciate examples for further research.
IV/PEN
Deanne Birch, Leader
Cheryl Stokes, Assistant Leader
Executive Liaison, Mike Hayden
There are no questions at this time.
Medical Supplies/Wound Care
Mary Turner, Leader
Robert Clock, Assistant Leader
Executive Liaison, Sharon Nichelson
There are no questions at this time.
O&P
Karl Lindborg, Leader
JR Brandt, Assistant Leader
Executive Liaison, Sharon Nichelson
4. The Jurisdiction D O&P "A" DAC Team desires clarification from Noridian/IntegriGuard as to the limit of Mastectomy bras are allowed in a year. If there is a limit, is it January to December (Calandar Year) or 12 month time span (July 30, 2006- July 29, 2007).
Would the response from TriCenturion and Q2 Administrators given to the Jurisdiction B Council A Team (see exerpt below) be the same response Noridian/IntegriGuard would provide?
http://www.adminastar.com/Providers/DMERC/SCOM/2007/files/JurisdictionBDMEMACCouncilQA051007.pdf
Jurisdiction B Council A Team Questions May 2007
Sorted by A Team
Disclaimer: The Jurisdiction B Council A Team participants have provided the following questions. The answers and references cited are correct as of the publication date. TriCenturion and Q2 Administrators have provided input on questions pertaining to Medical Policy, Benefit Integrity and Reconsiderations denoted with an *.
Please note: As of March 1, 2006, TriCenturion was granted Program Safeguard Contractor (PSC) responsibility for Jurisdiction B DME MAC (formerly Region B DMERC). PSC responsibilities include Medical Policy, Medical Review, and Benefit Integrity. Please refer to our Website www.adminastar.com, TriCenturions Website www.tricenturion.com, or visit the Centers for Medicare & Medicaid Services (CMS) Website www.cms.hhs.gov for recent updates.
Prosthetics/Orthotics
7. Is there a limit as to how many are Mastectomy bras are allowed in a year? If
there is a limit, is it January to December (calendar year) or 12 month time span
(April 4, 2006 – April 3, 2007)?
*Traditionally 12 mastectomy bras per year is considered a reasonable, usual amount. Suppliers are encourage to track units per calendar year (January to December).
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There is no formal policy regarding the number of mastectomy bras allowable per year. If a claim is selected and medically reviewed then general medical necessity criteria would apply.Follow Up
Regarding question 16 C from last meeting on the dynamic braces, John Kenny noted to Dr. Pilley that some suppliers state they are being paid for under E1800 to E1840 codes and Dr. Pilley said that he would speak with the other Medical Directors and agreed to follow up on this question.Ø
These items are considered durable medical equipment, not covered under the orthotic benefit, and not eligible for separate payment in a SNF.
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E1800 |
Dynamic adjustable elbow extension/flexion device, includes soft interface material |
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Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material (Eff. Date 1/1/2002) |
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L3964 is considered durable medical equipment, not covered under the orthotic benefit, and not eligible for separate payment in a SNF.
Rehab
Leslie Rigg, Leader
Evan Call, Assistant Leader
Executive Liaison, John Kenny
No questions so far….. J
Respiratory
Gemma English, Leader
Colleen McKenna-Shaw, Assistant Leader
Executive Liaison, Barb Stockert
5. With the change in payment categories for a respiratory assist device with back-up rate (E0471) from frequently serviced to capped rental, it becomes increasingly difficult for a patient on service with one provider to transfer to another provider if they move outside of the original provider’s service area. Another provider is often hesitant to provide this type of equipment for less than 13 months reimbursement due to the cost to the provider. When this scenario occurs, what responsibility does the initial provider have for this patient’s ongoing care considering this is life sustaining equipment?
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A physician’s order containing the diagnosis would meet this requirement provided the diagnosis and the ICD-9 coding meet the indications for coverage.
Follow up Question: Frequently patients with ALS and other chronic respiratory diseases will use a Respiratory Assist Device with a back-up rate and are fully dependent on the equipment to breathe. Equipment failure can result in immediate life threatening consequences for the patient. Now that E0471 has been removed from the Frequent and Substantial Servicing payment category, and the patient owns the unit after 13 months, what options are available to the beneficiary for backup equipment? Under the CMS Backup Equipment rule, backup is at the supplier’s discretion when the device is under FSS, not when it is rent-to-purchase. (Follow up Question for Dr. Pilley, he was going to research…)
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The Medicare beneficiary is not restricted from purchasing backup equipment. Medicare does not provide payment for backup equipment for a Respiratory Assist Device with a back-up rate. A Respiratory Assist Device is used to "assist" the patient having difficulty in breathing to breath with less effort. Discontinuance or stoppage of the device should not cause respiratory failure because the patient can still breath on their own.There are no questions at this time.