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



Questions to Noridian/CEDI

Fall 2013

CEDI

Leader: Michele Hessler

Assistant: LeeAnn Ruber

EC Liaison: Sheila Roberson

66. How firm is the implementation date of ICD-10 looking? Rock solid! Any chance the deadline or dual use period will be extended? Do not think so, no. We are concerned about the readiness of many of the states.

The CEDI front end, including our edits, will be ready to process claims with ICD-10 codes with the current October 2014 implementation date. Any extensions or dual use periods will be decided and communicated by CMS. If and when we have any information to share from CMS for ICD-10, we’ll send this out via our listserv and the MACs will provide through their communication channels.

67. How is CEDI Medicare reverification coming?

The CEDI front end, including our edits, will be ready to process claims with ICD-10 codes with the current October 2014 implementation date. Any extensions or dual use periods will be decided and communicated by CMS. If and when we have any information to share from CMS for ICD-10, we’ll send this out via our listserv and the MACs will provide through their communication channels.

CEDIs 2013 Trading Partner recertification is 41.72% complete as of 9/24/13. We are sending emails directly to the Trading Partners who still need to complete the Recertification Form. We’ll provide an updated percentage at the meeting.

No follow-up.

EDUCATION

Leader: Carolyn Koster

Assistant: Cindy Coy

EC Liaison: Mary Stoner

68. Providers are receiving complaints from beneficiaries that Competitive Bid, contract providers are refusing to service them.

a. Are contract suppliers « required » to service Medicare beneficairies ?

Contracted suppliers must accept beneficiaries who meet coverage criteria up to that supplier’s financial capabilities.

b. What is the beneficiary’s recourse when they are refused service by the contract suppliers?

Beneficiaries should call 1-800-Medicare.

69. It was mentioned during a recent Noridian Face to Face, San Diego, workshop that: If the POD is missing any information, e.g. pt did not date the POD, POD was missing the relationship of the person who signed for beneficiary etc., that the patient must get “re-qualified”.

a. Is this correct ? If so…Please clarify what is required to « re-qualify » the beneficiary?

If proof of delivery (POD) documents are not valid, upon review the claim will be denied. A supplier may choose to re-deliver new/like-new equipment if the original delivery is not valid. This will change the date of service (DOS) on the original delivery and future anniversary dates on rentals.

If a claim is denied because coverage criteria are not met, the supplier may choose to re-qualify a beneficiary. If a supplier re-qualifies a beneficiary all new documentation is required including proof of delivery of new/like-new equipment.

b. Can the beneficiary validate the delivery information? If so…Would they do so by signing and dating a newly created POD, acknowledging receipt of services?

Proof of delivery is created at the time the item is either directly delivered or shipped. If this question is asking if the beneficiary can attest to receiving the equipment after the fact to serve as proof of delivery the answer is “no”.

70. When changes are made to the supplier manual, what is the process for notifying suppliers?

Updates to the Noridian Supplier Manual are made as published changes or articles are announced through the Noridian email listserv. The date last update is indicated at the bottom of each chapter:

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All previous versions going back to May of 2009 are available at the top of the supplier manual in PDF format:

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A summary of updates are tracked at the bottom of the supplier manual:

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71. December 2011 version of the Supplier Manual, Chapter 3, Detailed Written Orders states: Detailed written orders are required for all DMEPOS. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document. (Reference: CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3)

The elements required on all written orders include the following:

• Beneficiary name; and

• Detailed description of item (either a narrative description or a brand name/model number); and

• All options and accessories that will be billed separately or which require an upgraded code; and

• Signature of the treating physician and the date the order is signed; and

• Initial date of need or start date.

However, the June 2012, Supplier Manual, Chapter 3 versions through current all state:

A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

• Beneficiary’s name

• Physician’s name

• Date of the order and the start date, if start date is different from the date of the order

• Detailed description of the item(s) (see below for specific requirements for selected items)

• Physician signature and signature date

There is a notable difference with regards to the « date of the order ». Previously as shown in the Dec 2011 example it stated « initial date of need OR state date » the later versions all say « Date of the order AND the start date, if state date is different from the date of the order »

The PIM 5.2.3 merely states that « All orders must clearly specify the start date of the order ».

a. With no known changes to the PIM 5.2.3 since 03/01/2008, why would the documentation of the start date of the order be so drastically changed?

In June 2012 the supplier manual was updated to reflect the Standard Documentation Article published February 23, 2012. The four DME MAC Jurisdiction Medical Directors authored that article. This same language is being included in the Documentation section of all LCDs as they are updated. The change to the supplier manual was for consistency with that published article and other DME MACs.

b. When would the supplier community have been made aware that the dispensing orders would now need both the date of the order AND the start date ?

This has always been the case for the (relatively rare) situation where the start date was to follow the date of the order. The Standard Documentation Article was published as a clarification on February 23, 2012. Suppliers only need a start date if it’s different from the date of the order.

Changes such as these, and the lack of education provided regarding these changes, is causing providers problems when claims are audited. Most suppliers want to always be in compliance, but that is next to impossible when we are dealing with a moving target and a lack of communication that it has or is being moved !!

This was a clarification, not a new requirement, and was added to the Noridian Supplier Manual four months after notification was disseminated through the Noridian email listserv. Noridian education consistently announces and encourages suppliers to sign up for and read email notification during all educational events. In addition, this language has been included in all educational material since the publication date in February 2012.

Update from the meeting: Lelia Wilkerson asked Noridian to further explain.

Dr. Whitten further explained that this should only come into play when the physician specifically intends to have the order started on a specific date, rather than at the time the order is written. An example would be the physician orders a wheelchair today but asks that it not be provided until two weeks later. In that case two dates would have to be on the order. I specifically asked about an order that we receive via fax and the patient does not come in to the office until 1 or 2 days later and they said that was not what this was addressing. Their example was enteral that the provider wanted to start 7 days after the order date so they complete the supply they have before starting the new order.

72. We received a denial on a prepayment audit for urological supplies, that were provided in the supplier store front, referencing that we did not have “proof of exhaustion”. However, per the supplier manual, this information is only required if delivered or mailed or shipped to the beneficiary and does not apply for walk in patients. In this instance, the beneficiary picked up the supplies in person yet we were told when calling on the denial, that the Proof of Delivery POD shows as a “Delivery Ticket”. ALL of our PODs are labeled as such regardless of whether the item is shipped, picked up in the store front or delivered to the patient’s home. In June, Noridian published that a “delivery slip” is required but the folks who are processing the PPRs are denying when the POD is referenced as a “delivery ticket” when proof of exhaustion is not indicated.

a. How are providers expected to reference that a delivery was made in the store front in order to avoid an unwarranted denial and lengthy appeal/reconsideration process?

Noridian would need examples of unwarranted denials. The POD documents must indicate the delivery address, in these cases the retail store address. Recommend adding the supplier store front name when documenting the delivery address or ensuring that the POD indicates that item(s) were picked up at store front. Noridian will also accept an itemized sales receipt when items are picked up at a retail store.

b. Feeling this might be the result of misunderstanding or communication barrier, would Noridian consider providing additional education to the reviewer’s that what a provider names their « Delivery Tickets, Work Orders, Transaction Ticket, etc are all one in the same…that does not dictate how the beneficiary received their service ?

Review nurses and other review staff see many different formats for POD documents and itemized sales receipts. What is submitted for review must be clear and itemized so it is easily recognized to the reviewer that the item was picked up at a retail store. Noridian review staff are continuously educated and have breakout meetings regarding documentation concerns.

73. We received a denial on a prepayment audit for urological supplies that were provided in the branch referencing that we did not have “proof of exhaustion”. However, per the supplier manual, this information is only required if delivered or mailed or shipped to the beneficiary and does not apply for walk in patients. In this instance, the beneficiary picked up the supplies in person yet we were told when calling on the denial, that the Proof of Delivery POD shows as a “Delivery Ticket”. ALL of our PODs are labeled as such regardless of whether the item is shipped, picked up in the branch or delivered to the patient’s home. In June, Noridian published that a “delivery slip” is required but the folks who are processing the PPRs are denying when the POD is referenced as a “delivery ticket” when proof of exhaustion is not referenced. How are providers expected to reference that a delivery was made in the branch in order to avoid an unwarranted denial and lengthy appeal/reconsideration process?

Same as 72

74. Noridian has published audit results which often tend to include a certain percentage of “no response” in the mix. Last fall it was mentioned that Noridian would report no response providers to the NSC. Has that been implemented and if not, what does Noridian do with the providers who do not respond to audit requests?

Suppliers who routinely do not respond to documentation requests or other identified concerns may be reported to Benefit Integrity and/or the NSC. This is a requirement of the Program Integrity Manual, publication 100-8 Chapter 4.

a. To add to the question above, several providers have indicated that they have submitted a timely response on all audits received and have confirmation to prove submission. However, when looking at the results of the recent probe, there were several “No Response” items included in the mix causing the denial percentages to be overstated for this reason. When reporting denial statistics to providers, can Noridian provide us with the specific claim details and allow an opportunity to challenge the findings?

The denial statistics are updated to account for all documentation that is received within the time frame for MR review. We will consider your suggestion for including more information on the published review results.

75. Must a DME supplier obtain a revised Rx if, for instance, a doctor initially specifies a particular brand (e.g., “Coloplast catheters,”) and the patient later wants a different brand?

Yes. Any change in an order requires a revised detailed written order.

76. The new Face-to-Face Requirement that went into effect on 07/01/13, per the MLN MM8304 Revised (page 3) states the DWO needs to contain the elements of:

• The Beneficiary’s Name

• The item of DME ordered

• The prescribing practitioner’s National Provider Identifier (NPI)

• The signature of the ordering practitioner and

• The Date of Order

Problem 1: Again…it simply states the “Date of Order….not the Date of order AND start date of the order if different then the date of order.

MM8304 states “at a minimum” those are the requirement. Suppliers must continue to follow the standard documentation requirements as well.

Problem 2: The physician’s NPI is not shown as needed on a DWO in the Supplier Manual.

The supplier manual will be updated however notification has been disseminated. For items addressed in MM8304 the NPI is required.

Problem 3: The MLN does not indicate that the physician’s signature date is required.

MM8304 states “must follow the guidance in the CMS “Program Integrity Manual,” Chapter 5, Section 5.2.3”, which states the treating physician must “personally sign and date” .

Problem 4: The MLN does not state that it needs the physician’s name.

Same response as problem 3 above.

Problem 5: The MLN does not indicate that the item ordered needs a detailed description.

Same response as problem 3 above.

Since providers are being audited based on exact language written, it is imperative that language on all information disseminated to the provider community be EXACT.

a. Please describe exactly what documentation a provider needs, prior to delivery of items represented on pages 4-11 of the MLN8304 Revised, to meet the Face to Face Requirement?

Suppliers must have a completely detailed written order prior to delivery, which includes the ordering physicians NPI and a copy of the medical records that shows a face-to-face encounter occurred that supports the item(s) of DME ordered. The face-to-face encounter must have occurred within 6 months of the WOPD. In the event of an audit, there must be sufficient information in the medical records to show that all relevant coverage requirements have been met. The ACA 6407 F2F requirements are in addition to the standard, existing documentation requirements.

b. Can a provider still take a verbal order for these products, as long as the item is not dispensed until the DWO and proof of the physician’s documentation the face to face occurred?

Yes, but a verbal order is not necessary, since a WOPD is required prior to delivery.

c. Can you provide an example of what the “proof the face to face” occurred? Would this be copies of the Medical Records signed and cosigned, an additional signature (of the DO or MD) on the DWO, a separate document that is signed by the DO or MD indicating a face to face was done within 6 months of the order? Please clarify…

Medical records/chart notes supporting the face-to-face visit occurred are required. This includes encounters conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of telehealth (as described in Chapter 15 of the "Medicare Benefit Policy Manual" and Chapter 12 of the "Medicare Claims Processing Manual").

d. Would the DWO and documented face to face be required prior to delivery or prior to billing?

MM8304 requires the WOPD prior to delivery, and the face-to-face encounter prior to the WOPD.

e. Since the implementation was delayed until October 01, 2013, can the providers rest assured that future audits will not look for the additional Face to Face documentation for dates of service prior to October 01, 2013.

Medical review is currently not enforcing this requirement but it does remain a requirement and no such assurance is possible.

f. CMS has stated that they can add or delete items requiring the Face to Face documentation at least annually. If and when those items are added, would it be date of service driven? Example…oxygen ongoing rental…would it apply only to the dates of service post the CMS change? Also….What is the time frame that providers should expect to be notified that an item is being added or removed from the Face the Face requirement?

This requirement is date of prescription driven. The time frame is per CMS direction and not controlled by the DME MAC.

HME

Leader: Lelia Wilkerson

Assistant: Gloria Schulte

EC Liaison: Mary Stoner

No Questions At This Time

IV PEN

Leader: Rosalie Weber

Assistant: Jeff Schwindt

EC Liaison: Dave Hosman

77. Recently Suppliers are seeing denials in Region D for overlapping dates on TPN claims with two different remark codes:

Scenario ONE: Denials with OA – 18 and N111 for other adjustment/ duplicate claim with NO appeal rights.

Scenario TWO: Denials with CO-150 Contractual obligation for overlapping dates but with the MA01 remark allowing for appeal.

We believe the reason for these denials is due to the ship date being the “from” date on the claim. Most TPN patients receive a delivery weekly and since TPN patients cannot go without their formula, subsequent TPN deliveries must be shipped to the patient 1-3 days prior to the end of the patient's current supply, therefore there will always be at least one overlapping date on the claim. Part of the problem is the difficulty of shipping a next day delivery for a Saturday delivery (often cannot be done)…or weeks that have a Holiday. In most situations there will be at least one overlapping date on the claims.

a. In scenario one above, every other claim is denying due to overlapping date and supplier has NO Appeal rights – What can we do?

Noridian will need examples. Noridian received examples in July 2013 that were processed correctly.

b. In scenario two above, all or some of the line items are denying for overlapping dates, however the claims are overturned in appeal. Sometimes the items denied are only the supply and administration kits due to overlapping dates and not necessarily the formula or lipids.

Noridian will need examples.

We have been told by Noridian CS to correct the dates in order to get the claims through. However, we are concerned this will put us out of compliance with the POD instruction to use the “ship/delivery” date as the “from” date on the claim.

Noridian Education will provide clarification to the Supplier Contact Center. You must use the date of direct delivery or the date of shipment as the “From” date.

We understand that only one supply kit and one administration kit can be billed per each one day of administration, but with the 2-3 day shipping ahead scenario – How do we avoid this?

Our claim system allows for overlapping DOS.

**Update from the meeting: Deanne sent more examples to Jody last night and would like them reviewed. Jody explained on the ones she had previously reviewed it was pretty clear why they denied and that they had processed appropriately.

Rosalie asked about the span dates and how it can be managed better. Jody responded that the ship or delivery date is always the from date. Noridian would need examples of where this is not working correctly.. Oftentimes when we see overlapping dates it is because some are being sent as the to date and not as the from date.

78. Since TPN claims are difficult to fix via re-openings, these are going through redeterminations which uses a lot of manpower on both ends.

We have seen articles from Region A (attached) and Region B with direction on how to bill the date spans & units with the ship date as the “from” date, but generally these are claims that are filled/dispensed for a 28 or 30 day time frame, which is appropriate for Enteral. However for TPN, and in fact most drug claims such as Inotropic or pain management – seldom is a 28 or 30 day supply filled in one dispense due to patient monitoring, labs, levels, and changes to orders. Most prudent suppliers fill for no more than one week on TPN and drug claims via external infusion pumps.

Has Noridian published any similar articles on billing date spans for Parenteral Nutrition that may be helpful?

Noridian is currently writing an article to be consistent with the other jurisdictions regarding enteral nutrition. Weekly dispensing/billing is acceptable and will be included.

79. Teflaro (injection, ceftaroline fosamil, 10 mg) was assigned the J-code J0712 on January 1, 2012. Our company billed J0712 to Medicare, trying to get a denial in order to bill the secondary payor correctly; however, our claims to Noridian are being rejected.

We have been told by Noridian to use the generic code J3490. The secondary payor needs the correct code (J0712) and matching denial to be able to price it correctly and process it.

Whose responsibility is it at the Medicare contractor level to update J-codes for injectable medications?

We are currently researching this question.

80. If patient is on Enteral Tube feeds with a qualifying functional impairment and permanent condition for Enteral, however suddenly does not tolerate Tube feedings and requires TPN for short term (a few weeks or so) to further evaluate, in addition MD plans to re-start transitional Tube Feeds along with TPN to see if patient can tolerate tube feedings again… Is the TPN considered as meeting the test of permanence since in conjunction with the Long Term Enteral Therapy? In other words, when TPN and Enteral nutritional are administered interchangeably, and combined duration is 90 days or greater, therefore the test of permanence is meet for nutritional support… will both the TPN and ENT qualify or do they independently have to stand on their own in order to be considered for coverage?

In order to qualify for TPN coverage by Medicare, the criteria set forth in the Policy Article A37077 must be met. Permanent impairment is a requirement for both ENT and TPN but the additional required criteria must be met and stand on their own for consideration for TPN.

MED SUPPLIES

Leader: Gilbert Herrera

Assistant: Carolyn Koster

EC Liaison: Mary Stoner

81.     (This is a follow up to Question 76 from last round): We wanted to follow up to see if there has been any progress made by Noridian to correcting the claims processing issue we are having with ostomy denials?

76. Ostomy suppliers have identified over utilization denials when providing a 30 day supply, to ensure patient compliance, and then shipping a full 90 day shipment. We request clarification of the 90 day shipment within the LCD and in an update.

Addendum (09.05.11) Ostomy Supplies

We follow the current Ostomy LCD when providing ostomy supplies to our customers and billing them to Noridian. We are also continuing to provide and bill for ostomy supplies within the typical usage guidelines outlined in the LCD. However, even when providing quantities at or below the usual maximum quantity amounts specified in the Ostomy LCD we continue to see partial denials stating that over-usage was supplied when providing quantities that are allowed for a 60 and 90 day period. It appears that sometime in 2010 the manner in which ostomy claims were processed was revised and these denials began to be issued. Suppliers have been notified by NAS contact center that if we reopen or appeal these claims we will be paid. Would you provide clarification as to why quantities of ostomy supplies provided according to the guidelines are now partially denying requiring suppliers and NAS to dedicate resources to reopen and reprocess these claims?

If a 30 day supply is initially dispensed and then the following month a 90 day supply is dispensed the claim system will look back 90 days and forward 90 days and if additional claims are found it will deny. The claim system cannot read a narrative so if switching between a 30, 60 and 90 day supply the only alternative is to go through reopening to have the quantities manually counted. NAS will continue to research to find a better resolution. If possible staying consistent with quantities dispensed (not switching between a 30, 60 or 90 day supply) will help to resolve.

Bob Clock thanked Noridian for their responses and introduced Mary Stoner to address this question. The statement to stick with same regimen of dispensing may not be the best solution. Ostomies and wounds change and often we should not or cannot dispense 90 days right off the bat. However when they become stable, or long term this would work. Because of this it is hard to say that we should stick with the same dispensing regimen.

Secondly, Mary asked what the purpose is if the HAO record is not read or interpreted. What we would like to be able to do is dispense a 30 day supply until the patient becomes stable and once they do then we could dispense 90 days.

Mary asked if there was anything we could do to get claims to go through without denying?

Jody responded that only the 1st time should automatically deny. System will auto reject 30 days to 90 days. Providers would need to explain this and they will look at it. We do want providers to use the 90 days. Providers will have to do a reopening and this could be a telephone reopening. We are looking at ways that can make this easier or clearer. Mary stated that we do appreciate your efforts going forward.

Claims with quantities above normal utilization during any 90 day period will deny. Denials do occur because of a switch from a 30 day supply to a 90 day supply. Currently there is no way to prevent that from occurring. If a supplier indicates in the line-item narrative section of the claim that the additional quantities are due to a switch from a 30 day supply to a 90-day supply the denial can be easily adjusted by calling the Supplier Contact Center at 1-866-243-7272 or the Reopening Hot Line at 1-888-826-5708.

The above is accurate.

*** Mary asked if there was any further solution. Jody stated that we need to be careful what we ask for. The only solution available right now would slow down the processing of all these types of claims. Dr. Whitten asked for us to gather examples of this denial across the Jurisdictions and he would like to address this across all 4 Jurisdictions to see if they have a better solution.

No solution at this time.

82. (This is a follow up to Question 53 from fall 2013): We wanted to see if there was an update on the issue of the LCD policy versus PDAC coding for items coded HCPCS A4353 given the additional information provided to Noridian?

Suppliers have always been referred to the PDAC for proper coding. We have recently become aware that the PDAC is coding catheters without additional supplies as a HCPCS A4353 (catheter kit). The Urological Policy Article based on our review states that there must be sterile supplies in addition to a catheter for it to be billed using code A4353. We are requesting clarification on the potential results of a provider review on claims for items coded A4353 by the PDAC that are not sent with additional supplies.

Response: If the item is coded by the PDAC as A4353 it is intended for sterile intermittent catheterization per the LCD. A4353 must include the catheter and insertion supplies. As indicated in the Policy Article:

A urinary intermittent catheter with insertion supplies (A4353) is a kit which includes a catheter and all supplies necessary for sterile insertion (see below). Code A4353 may be used if either 1 or 2 is supplied:

1. A sterile intermittent urinary catheter plus a separately packaged sterile kit of insertion/collection supplies; or,

2. A single sterile package containing both a catheter and all insertion/collection supplies.

The PDAC must follow instruction given by CMS. When a decision is made by CMS to include an item within a particular code a precedence is set for coding same or similar products into that category as well.  A policy revision will be forthcoming to further address this issue.

**Follow-up from the meeting. A Team Leader Gilbert Herrera asked Noridian if they could expect an LCD update. Noridian responded that yes this was in the process.

O & P

Leader: Dan Sarria

Assistant: JR Brandt

EC Liaison: Leslie Rigg

83. Medicare has finalized the list of L codes they deem as “off the shelf”, and CMS will be creating additional codes for devices that require custom fitting by a certified Orthotist or an individual who has specialized training.

a. Will the new codes be available to suppliers and/or billers prior to January 1, 2014?

Coding guidelines come from CMS. When available, the DME MAC will publish.

b. Will CMS offer a definition of “specialized training”?

This definition comes from CMS not the DME MAC.

No Follow-up

REHAB

Leader: Rick Graver

Assistant: Paula Koenig

EC Liaison: Leslie Rigg

84. In our example, a beneficiary has had a motorized wheelchair K0823 which was billed to Medicare and funded for 10 months. The company went out of business without any proof that the title has transferred to the beneficiary, and no further months will be billed or have been billed. It has been more than one year since the last monthly rental bill was paid. Are there any mechanisms for the beneficiary to claim title or to have Medicare recognize that this item is now patient owned? Medicare will cover reasonable and necessary repairs to beneficiary-owned equipment but not to supplier-owned equipment under rental. Transfer of ownership to the beneficiary of equipment owned by a supplier is a legal matter which we are not able to further address.

a. The above beneficiary is now in need of repairs, what processes are available to the provider or the beneficiary that will allow coverage of necessary repairs? Only when the beneficiary owns the equipment will reasonable and necessary repairs will be covered.

***Update from the meeting: Paula Koenig stated that there are many scooters and pwc’s that are currently in a rental period with a provider that is no longer in business. There needs to be a recommendation or solution so beneficiaries will have access to repairs. Our only option is to pay cash or get an abn signed. CMS was able to find a way with O2 so there should be a way to do this with rehab equipment.

b. In our example, the beneficiary has a motorized wheelchair that is currently under rental. The company that provided the equipment is out of business. Would it be appropriate to use an ABN that states “Medicare does not pay for repairs to equipment that is under a rental agreement?”

If the item is still under a rental contract, an ABN is not appropriate because it is the responsibility of the supplier who owns the equipment to maintain their equipment in working order. Until CMS develops another alternative, if both the beneficiary and the new supplier accept that the repair is non-covered by Medicare, the service could be provided on that basis, and if a claim submission necessary (for denial), it should be billed with a –GY modifier.

**Update from the meeting: Paula Koenig responded that it is very important that this be looked at because there are many pieces of equipment that need repair, and a supplier’s options are limited. Adding the GY modifier and/or getting an ABN signed might not be the solution.

85. The Rehab A team provided NAS with a list of codes that we thought were applicable to MM8181 after the last round of questions. Was the list received and is it accurate?

The listing was not completely accurate. An email to Rick Graver explaining the inaccuracies was sent 09/23/13.

a. In regards to the above question, will there be any updates on the website or training provided to providers regarding MM8181?

Noridian currently has a competitive bid modifier self-paced tutorial and quiz available on the training page at:

**Update from the meeting: Dr. Whitten said he appreciated the response they got. There is definitely some problems with submitting and processing of claims and the modifiers that are used. Lots of training still needs to be done. Noridian has put information on the website to help suppliers in this. Jody further explained that there are monthly Web Ex’s done to help with this. They are also developing Q & A’s for suppliers to refer to.

86. Are there any “Dear Physician” letters planned for educating the physicians about upcoming Face to Face rules in regards to MM8304?

More information is planned regarding MM8304, however PMDs are NOT affected by MM8304.

87. When can providers expect more answers or education regarding the numerous issues raised and involving Face to Face rules in regards to MM8304?

Noridian has a self-paced tutorial coming soon. Additional information is to be forthcoming.

RESPIRATORY

Leader: Mary Jackson

Assistant: Linda Skiple

EC Liaison: Dave Hosman

88. Is it mandatory for a non-participating non-contract CB supplier to take assignment for non-Grandfathered items when Option 1 is checked on an ABN? We have been receiving Code 111: “Not covered unless the provider accepts assignment.” Example has been provided to Jody by Diana.

Noridian is currently researching this issue and hopes to have an answer at the fall meeting.

89. A PAP patient has been grandfathered in by a non-contracting supplier, fails their initial trial, then has another PSG and is re-qualified. If there is a break in service while the patient is re-qualified, can the non-contracting supplier continue billing for month 4?

Yes

90. What are the signature requirements when the old record, such as a sleep study, is unsigned and the interpreting/prescribing physician is deceased or no longer in the area? Can another physician now working with the lab/office sign an attestation and indicate the reason for the different practitioner?

For medical review purposes the medical records must be authenticated by the author. Claims reviewers will not consider attestation statements where there is no associated medical record entry or from someone other than the author of the medical record entry in question. Even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements. The Medicare requirements that are used are based upon those in effect on the DOS not upon the date the old record was created. Thus suppliers should assure that when old records are used in an audit response, they are in compliance with the applicable requirements.

91. "We have a vent patient who we delivered oxygen for but does not have saturation level due to the severity of their condition (the patient is unable to breathe without the vent). Can we bill for oxygen without saturation and get medical documentation to support the reason?"

The oxygen criteria must be met. Either an oximetry test or an arterial blood gas may qualify a beneficiary.

92. The policy from 2008 states that in order to qualify for a CPAP machine you must have a polysomnographic study performed in a facility based sleep study laboratory.  Pt has a diagnosis of OSA and meets the AHI 0f 15 events or with less addition documentation of hypertension, etc.  Along with theses qualification, the policy for continued use after the first three months was that you had to ascertain from either the beneficiary or the treating physician that the beneficiary is continuing to use the CPAP device no sooner then the 61st day after initiating the therapy.  My question is if the other company did not ascertain this or cannot prove that they have done this, can we ascertain from the beneficiary that they are continuing to use and benefit from the cpap machine as of today in order to qualify for supplies.

The beneficiary must meet the guidelines in place on the date of service. Retrospective statements are not acceptable.

**Update from the meeting: Mary Jackson asked how we document continued use after 3 months when we have a patient that is transitioning to us through Competitive Bidding. Is the date of service our date of service or their initial date? This should be the date you begin service but you will need to show that the beneficiary was eligible at the initial time they were set up. If you cannot produce the documents it will be deemed medically unnecessary. Mary said, “but, we are talking thousands of patients.” Noridian is aware of this and suppliers have to understand that re-qualifying the patient or getting an ABN are the only solutions that are acceptable if there is no documentation.

Dr. Whitten said he and the other Medical Director’s understand our situation but CMS is not getting a lot of information on the complaints. If you have specific examples of concerns or problems please submit these to him. They will be reviewed. This is what inspired CMS to change the rules on O2 suppliers that were going out of business.

PDAC

Leader: Sheila Roberson

Assistant: Julie Piriano

EC Liaison: Sheila Roberson

No questions submitted.

93. It has come to the PDACAC’s attention that there is a manufacturer indicating that a product has been code verified by the PDAC as K0800; however in researching this product we have found that the product name (Phoenix 3 Wheel Scooter) is not listed on the PDAC product classification list and the model number is associated with an entirely different product (Phantom 4 Wheel Scooter) that the manufacturer does not list as available on their website.

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It has also come to our attention that this same manufacturer has 2 products listed on the PDAC product classification list as being code verified K0801 (the Phoenix 3 HD and the Phoenix 4 HD) that, according to a DME supplier, does not meet the minimum dynamic stability incline requirement of 6 degrees, even at the minimal weight capacity. The supplier has alleged that these products are unsafe and is questioning how the devices ever received coding.

a. How often does the PDAC re-review and request a sample of any previously coded product if it determines the product may have changed, or coding guidelines have changed from when the product was initially code verified?

b. Would it be an appropriate use of the “contact us” communication tool for DME suppliers to alert the PDAC to issues such as the ones identified above as most suppliers do not know that the PDAC Advisory Committee exists?

94. Should a cantilever armrest that adjusts in height for individual patient placement that is then secured to the back frame of the wheelchair with a nut and bolt such that it allows the armrest to be removed for safe transfers by pivoting up and out of the way (flush with the back cane) be coded K0108, E0973 or E0020?

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95. If the armrest is secured to the back frame with a quick release pin as opposed to a nut and bolt does it change the code that should be used to describe the device?

96. How does the PDAC keep abreast of product changes and developments to ensure the most accurate HCPCS code and code descriptions are being communicated and applied?

97. We are concerned about the accuracy of the "additional search terminology" used to define sealed, lead acid batteries (E.G., Gel cell, Absorbent glassmat coded E2361, E2363, E2365 and E2371) used with power mobility devices. According to the Battery Council International (BCI), "batteries are classified into numbered Group Sizes according to their voltage, maximum overall dimensions, terminal arrangement, and special features that affect battery fit".  The reference is one of physical dimensions, not electrical properties. A 22NF, Group 24, U-1 or Group 27 battery, by physical dimension, remains constant regardless of temperature, humidity, state-of-charge, rate of discharge, voltage, or any other electrical definition.  Since there is a general correlation between the size of the case and ultimately the amps just due to physics, many people improperly use a battery size to refer to a level of amps.

We respectfully request the PDAC remove the “additional search terminology” from HCPCS detail included with the E2361, E2363, E2365 and E2371 HCPCS codes.

**Update from the meeting: Noridian confirmed that they were awarded the PDAC Contract again from CMS.

NSC

Leader: Sheila Roberson

Assistant: Peggy Walker

EC Liaison: Sheila Roberson

**Note from Administration. The questions from the NSC A Team are presented through the NSCAC at their meeting. Responses from the NSC will be provided to our membership at that time. Please be advised that the subject matter of the question submitted could be changed or updated once it is reviewed by the NSCAC. This would be done so a clearer response may be given.

**Update from the meeting: Peggy Walker asked if we would be able to get a new list of managers and customer service staff at the NSC? There have been a number of job changes so a current list would be appreciated.

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