DAC - Region D Advisory Committee - DAC - Region D ...



Questions to Noridian/CEDI

Winter 2011

CEDI

Leader: Edwin Wahjosoedibjo

Assistant: Duane Ridenour

EC Liaison: Gemma English

1. As a DME Provider many patients are still billed M/S. and have life time CMNS on file.  Since the equipment may have been ordered many years ago and that physician may no longer be practicing and would not have updated their information in the PECOS system.  Would these physicians be grandfathered or how should they be handled?

03.08.11 Stacy reported that she had not received an answer from CMS yet. As soon as she does she will notify the DAC so it can be added to this question. **Administration

EDUCATION

Leader: Connie Lind-Fraher

Assistant: Cindy Coy

EC Liaison: Leslie Rigg

2. Please clarify who can be a representative with legal authority to sign the ABN on the beneficiary’s behalf. It would appear based on the information below; any of the examples listed in 40.3.5 would qualify as an authorized representative, is this correct? This is what is written in 100-4, Chapter 30. For clarification on legal matters NAS recommends consulting a legal professional.

50.4.3 – Representatives of Beneficiaries

Notifiers are responsible for determining who may act as a beneficiary’s representative under applicable State or other law. A representative is an individual who may make health care and financial decisions on a beneficiary’s behalf (e.g. the beneficiary’s legal guardian or someone appointed according to a properly executed durable medical power of attorney).

If the beneficiary wishes to appoint a representative to file an appeal on his or her behalf, a valid Form CMN-1696 or a conforming written instrument must be signed by both the beneficiary and the prospective representative and filed with the appeal request. See Chapter 29, 270 for specific instructions related to the use of Form CMS-1696 and the appointment of representatives.

40.3.5 Authorized Representative

(Rev. 1, 10-01-03)

An authorized representative is a person who is acting on the beneficiary’s behalf and in the beneficiary’s best interests, and who does not have a conflict of interests with the beneficiary, when the beneficiary is temporarily or permanently unable to act for himself or herself. A notifier’s inability to give notice to a beneficiary directly or through an authorized representative does not allow the notifier to shift liability to the beneficiary.

An individual authorized under state law to make health care decisions, e.g. a legally appointed representative or guardian of the beneficiary (if, for example, the beneficiary has been legally declared incompetent by a court), or an individual exercising explicit legal authority on the beneficiary’s behalf (e.g. in accordance with a properly executed durable medical power of attorney statement or similar document), may be the authorized representative of the beneficiary with respect to receiving notice.

An authorized representative should have beneficiary’s best interests at heart and should be reasonable expected to act in a manner which is protective of the person and the right of the beneficiary. In the absence of some more compelling consideration, the order of priority of authorized representatives is:

A. The spouse, unless legally separated.

B. An adult child.

C. A parent

D. An adult sibling

3. With the elimination of the least costly alternative what do we do with a beneficiary that does not meet the weight criteria for a heavy duty walker or commode but need the extra wide part of that type of equipment due to the need for the extra wide- can we do an upgrade and bill it unassigned? If the beneficiary does not meet the coverage criteria the supplier must obtain a properly executed ABN to shift liability to the beneficiary, regardless of assignment. Follow the upgrade rules and use appropriate modifiers.

 

4. When a beneficiary gets a four wheel walker with a seat & back E0144-it is considered non-covered by Medicare but is currently paid as a standard walker with wheels (E0143).  The current LCD states it will be down-coded from an E0144 to a E0143.  How will this type of equipment be paid for with the elimination of the least costly alternative? The LCD for Walkers, revised 2/4/2011 states: The medical necessity for a walker with an enclosed frame (E0144) has not been established. Therefore, if an enclosed frame walker is provided, it will be denied as not reasonable and necessary. Upgrade rules/modifiers are recommended.

Connie Lind-Fraher thanked Noridian for their responses and there was no follow-up.

HME

Leader: Lelia Wilkerson

Assistant: Sha Eppley

EC Liaison: Teri Jamison

5. With the increased scrutiny on beds in particular, we would like to request that Dr. Whitten and/or other medical directors) publish a Dear Physician letter emphasizing the LCD requirements.  It is frequent that physicians do not detail requirements of the LCD in their medical records to the exhaustion of the LCD criteria, including a specific reason for the need of the bed. It is typical for a medical record to include a general sense of the patient’s condition, which does not appear specifically enough to address each criterion. The letter should include, but is not limited to the following points:

A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if one or more of the below criteria (1-4) are met:

a. The patient has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or

b. The patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or

c. The patient requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges must have been considered and ruled out, or

d. The patient requires traction equipment, which can only be attached to a hospital bed.

And one or more of the following:

a. Requires frequent changes in body position

b. Has an immediate need for a change in body position.

Education will work with Dr. Whitten to create.

Lelia Wilkerson thanked Noridian for their response although this was not a direct question she wanted them to know their attention to it was appreciated.

IV PEN

Leader: Deanne Birch

Assistant: Rosalie Weber

EC Liaison: Sheila Roberson

6. Local Coverage Determinations – Elimination of Least Costly Alternative

e. Enteral Nutrition for Diabetic Patients

• Special Enteral nutrients (B4149,B4153-B4157,B4161,B4162) (Type 2)

• Pump supply kit (B4035) (Type 2)

• Upgrade modifiers: GK and GL

• Denial modifiers: GA, GY and GZ

We are very concerned about how the Least Costly Alternative elimination affects enteral feeding, especially for provision of diabetic formula.  Most disease specific formulas can be readily documented except for diabetic formula.  We have understood that the diagnosis alone will not justify the specialty diabetic formula.

In its September 2009 DME News, the DME MAC published that “there needs to be clinical documentation, such as patient blood sugar levels, laboratory results, medication lists, weight, or other physician documentation to substantiate why a patient with diabetes requires a special enteral formula.”

• Specifically, please provide examples of cases in which such clinical documentation would justify the specialty formula and would not.

• Will lab tests that demonstrate that the disease is and has been under control for a patient on a specialty diabetic formula be adequate documentation?

Deanne mentioned the fact they had not answered the two bullet questions above. Using a real case scenario, I asked if a long term Enteral patient with diabetes mellitus, on a diabetic formula with ongoing lab work done during physician office visit would be sufficient justification for Diabetic Formula. For example, lab tests such as Fructosamine blood level, fasting glucose , Metabolic Panels, Chem/Urine tests that demonstrate the diabetic condition is being controlled by the current diabetic formula would be considered adequate documentation? Also what time frames would be considered now that the LCA has been eliminated? Would there be any grandfathering for these patients?

• If we can demonstrate that the patient is stable with current specialty diabetic formula, is this appropriate documentation for an ADR?

• Could this be considered a “look back period”

• Going forward, we would like to see some examples of what the DMEMAC would consider as acceptable clinical documentation for Diabetic Formula.

• I also brought to Dr. Whitten’s attention that the IV/PEN team had sent him a draft copy of our “Dear Physician Letter for Enteral, and hope he could take a look for future discussion during our MedTrade meetings.

• Sha Eppley also asked Dr. Whitten if he had looked at the 3 scenarios that were presented by Apria in regard to > 2000 calories that was brought forth as an individual provider issue vs a DAC issue.

Jody and Dr. Whitten said they would look at these and discuss in more detail in Las Vegas.

When a supplier has determined that coverage criteria are met for a specialty diabetic formula and has clinical documentation supporting it, then should the supplier bill without using any upgrade (GK, GL) or denial (GA, GZ, GY) modifier and expect to receive full payment on the specialty code from the DME MAC? Yes Does the DME MAC agree that in such a case that the supplier would in effect be attesting that the patient is qualified for the additional coverage criteria and therefore none of these modifiers are to be used? Yes

External Infusion Pumps

• Infusion pump used with subcutaneous immune globulin (E0781, E0791) (Type 1)

7. With the elimination of LCA for the pump used to administer SQ Immune Globulin, the Type 1 denial will always result in “Not Medically Necessary”. We would like to confirm that under the three scenarios stated below, we would be correctly using the upgrade Modifiers.

Scenario One: If supplier uses E0781 or E0791 to administer SQ Immune globulin based on their business decision and do not plan to bill the beneficiary, they would be expected to bill as follows:

Use the E0779 code with the GL Modifier - supplier will be paid based on the allowable for the covered item per the LCD instruction. Correct and in the narrative indicate the actual pump provided.

• No ABN is required. Correct

Scenario Two: If the supplier uses the E0781 or E0791 to administer the SQ Immune globulin based on the physician or beneficiary request, and decide to provide it at no additional charge they would be expected to bill as follows:

Line one HCPCS E0781/E0791 with Modifier GZ – supplier will receive a medical necessity denial.

Line two HCPCS E0799 with Modifier GK – supplier will be paid based on the allowable for the covered item.

• No ABN is required.

This is correct if beneficiary ordered. One line with the GL modifier and the item that meets coverage criteria and a narrative of the item actually provided if physician ordered.

Scenario Three: IF the supplier uses the E0781 or E0791 to administer the SQ Immune globulin based on the beneficiary request, and decide to bill the beneficiary the upgrade charge they would be expected to bill as follows:

Line one HCPCS E0781/E0791 with Modifier GA – supplier will receive a medical necessity denial with the PR patient responsibility message.

Line two HCPCS E0799 with Modifier GK - will be adjudicated and paid based on the allowable for the covered item.

• A properly executed ABN is required for this situation.

Correct. Be sure to indicate the full charge for each items bill. The first line must be a higher dollar value than the second line. The claims system does the math.

MED SUPPLIES

Leader: Teresa Brammer

Assistant: Robert Clock

EC Liaison: Sharon Nichelson

8. The future revision of the urological LCD and Article effective 2/4/2011 are specific to A4353 sterile intermittent catheter kits.  CMS has removed the A4353 from column 1 and 2 “bundling” reference table. Additionally, the revised language in the Article under coding guidelines suggests that a provider can no longer “bundle” individual components if they are provided as separate items such as sterile insertion tray A4310, sterile packets of lubricant A4332 with a sterile catheter A4351 or A4352 then bill as A4353. To bill an A4353 sterile intermittent catheter kit the product would have to be provided as a single sterile package.

We would like clarification on the CMS definition of a “single sterile package”. Additionally, please provide clarification if a provider can no longer "bundle" a sterile insertion tray A4310, lubricant packets A4332 with a sterile catheter A4351 or A4352 if provided as separate components and bill as an A4353 rather must bill each component (A4351, A4310 and A4332). This is being re-written in the Policy Article. If the supplier provides a sterile catheter in a separate packet from a sterile insertion tray, the supplier may bill for an A4353. Refer to “What’s New” article posted February 1, 2011.

Sharon Nichelson, Liaison for the team thanked Noridian for their response and had no follow-up.

O & P

Leader: JR Brant

Assistant: Janet Malinowski

EC Liaison: Sharon Nichelson

No Questions Submitted

REHAB

Leader: Rick Graver

Assistant: Mike Osborn

EC Liaison: Leslie Rigg

9. If a wheelchair back cushion is coded E2620, and it was medically necessary to have a separate lateral trunk support in addition to the back cushion, would it be appropriate to bill for E0956 in addition to E2620. The back cushion in our example is a Pride Synergy Tru Comfort standard back cushion, which has been coded by the PDAC as E2620. Yes, the LCD for W/C Seating says:

A positioning seat cushion (E2605,E2606), positioning back cushion (E2613-E2616, E2620, E2621), and positioning accessory (E0955-E0957, E0960) is covered for a patient who meets both of the following criteria:

1. The patient has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the patient meets Medicare coverage criteria for it; and

2. The patient has any significant postural asymmetries that are due to one of the diagnoses listed in criterion 2b above or to one of the following diagnoses: monoplegia of the lower limb (344.30-344.32, 438.40-438.42) due to stroke, traumatic brain injury, or other etiology, spinocerebellar disease (334.0-334.9), above knee leg amputation (897.2-897.7), osteogenesis imperfecta (756.51), transverse myelitis (323.82).

10. If a Medicare recipient who resides in a Skilled Nursing Facility requires a claim to go to Medicare (they are seeking denial showing patient responsibility in order to pursue other secondary funding), would it be appropriate to use modifiers NUGY? If the SNF is being covered by Medicare Part A the beneficiary is receiving reimbursement through consolidated billing by Medicare Part A and this would not be appropriate. If the SNF is not being covered by Medicare Part A this is correct if the wheelchair can be purchased. If the payment category only allows for rental the RRGY must be used.

11. Same scenario as above in #2 would it be appropriate to use an ABN and append NUGAGY? If we’re talking about the question directly above (#10), a GA would not be appropriate as it’s not a medically necessary denial but a statutory exclusion to provide a wheelchair outside what Medicare defines as the home. An ABN could be voluntarily used as a Notice of Exclusion of Medicare Benefits. (NEMB)

12. In our example, a Medicare beneficiary resides in a skilled nursing facility and has been approved for funding through a state Medicaid program for the purchase of a K0004 wheel chair. What would be the appropriate way to submit the claim to NAS so that the denial would show patient responsibility for the purchase of the wheelchair? This example can also apply to other secondary insurances who desire to purchase the wheelchair for their beneficiary, but require an EOB showing patient responsibility for the purchase price. If the stay is covered by Part A you will never get a PR denial. If the stay is not covered by Part A, the item is noncovered by Medicare because the SNF is not considered the patient home. You must submit the claim according to the payment rules for the item (i.e. capped rental must be submitted as rental – RR modifier) and if the item is to be used outside the home the GY modifier is appropriate. An ABN is voluntary.

13. In regards to K0040 angle adjustable footplates, what is the rationale for not funding this item on a group 2 power wheelchair but funding it for a group 3 power wheelchair? The K0040 is included in the basic equipment package for Group 2 and not Group 3 per the PDAC

14. Under the new capped rental system for group 2 power wheelchairs, if a beneficiary would like a group 2 power wheelchair with a power seat elevator, would it be appropriate for the beneficiary to purchase the power seat elevator as an upgrade? Can the power seat elevator be billed as an accessory for purchase with an ABN? No. A seat elevator is a statutorily noncovered option on a power wheelchair. If a PWC with a seat elevator (K0830, K0831) is provided, it will be denied as noncovered.

15. According to the LCD, Group 2 no power option PWCs (K0820 - K0829) must have the specified components and meet the following requirements:

• Non-expandable controller

• Incapable upgrade to expandable controller

• Incapable of upgrade to alternative control devices

• Incapable of accommodating a power tilt, recline, seat elevation, standing system

• Accommodates non-powered options and seating systems (e.g., recline-only backs, manually elevating legrests) (except captain’s chairs)

If a power base that has been coded K0823 was capable of accepting power seating, and the beneficiary had a change in condition that required powered seating, would it be appropriate to add powered seating to the K0823 base? Yes

16. In another scenario, the beneficiary originally only qualified for a Group two power mobility device, after 9 months the patient’s medical condition changed to the point that now they medically qualify for a group 2 with a single power option with a tilt in space.  Due to the medical condition change will Medicare pay for the newly prescribed group 2 with a single power option with a power tilt in space? Yes as long as the change in condition is fully documented in the beneficiary’s medical record. Group 2 with SPO and above require additional criteria (i.e. specialty evaluation, provided by a supplier with a RESNA APT etc.)

17. For claims with a date of service after February 4, 2011 is it permissible for a supplier to provide a PWC (K0813, K0815, K0820, K0822, K0824, K0826, K0828, K0835, K0837, K0841, K0848, K0850, K0852, K0854 or K0858) with sling/solid seat/back and a General Use Cushion and/or General Use Back as an upgrade in place of a corresponding base with a Captains Seat either as a physician ordered upgrade, patient requested upgrade or supplier provided upgrade per the instructions outlined in the December 16th update on "Use of Upgrade Modifiers"? Yes

** Post meeting note: Jody notified Rick and she would like to research this question further and get more input from Dr. Whitten. She will report back to the DAC when this is done.

RESPIRATORY

Leader: Mary Jackson

Assistant: Linda Skiple

EC Liaison: Gemma English

18. Under Competitive Bidding for oxygen, our understanding is that if a patient transfers from a non-contracted provider to a contracted provider, the provider is to be paid up to 36 months or at least 10 months, whichever is greater. Is the Noridian system set up to handle paying the 10 months if the remaining cap rental is less than 10 months or is there a special billing requirement via modifier or narrative needed? No modifier is required. Claim system is set up to accommodate.

19. How would a supplier re-qualify a patient that has failed the qualifications under the RAD policy? For example, if a patient has been non-compliant with therapy, what must be done to re-qualify the patient for treatment? The RAD policy does not have re-qualification language. If the requirements for continued use are not met, the KX modifier must not be used. A properly executed ABN is recommended.

Mary Jackson thanked Noridian for their answers and no follow-up was presented.

NSC

Leader: Emmie Guinn

Assistant: Peggy Walker

EC Liaison: Teri Jamison

**Note from Administration. The questions from the NSC A Team will be presented through the NSCAC at their meeting. Responses from the NSC will be provided to our membership at that time.

20. An O & P company wants to set up a satellite office that will just be open once day a week for final fitting only. What is the process?

PDAC

Leader: TBD

Assistant:

EC Liaison: Sheila Roberson

No Questions Submitted

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