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Questions to Noridian/CEDI

Fall 2012

CEDI

Leader: Michele Hessler

Assistant: LeeAnn Ruber

EC Liaison: Gemma English

No questions submitted.

EDUCATION

Leader: Connie Lind-Fraher

Assistant: Cindy Coy

EC Liaison: Leslie Rigg

No questions submitted.

HME

Leader: Lelia Wilkerson

Assistant: Gloria Schulte

EC Liaison: Dave Hosman

66. The Medicare LCD states that the patient must be room and/or floor confined with no toilet facilities. Are there conflicting pieces of DME that disqualify the payment of the commode? Urologicals/Ostomy We have situations that patients may suffer from urgency issues and/or other medical issues that could result in urinary or fecal accidents without the use of the commode. With proper documentation would a commode be covered even if a walker or other ambulatory item is ordered? Yes as long as the coverage criteria are met:

A commode is covered when the patient is physically incapable of utilizing regular toilet facilities. This would occur in the following situations:

1. The patient is confined to a single room, or

2. The patient is confined to one level of the home environment and there is no toilet on that level, or

3. The patient is confined to the home and there are no toilet facilities in the home.

No Follow-up.

IV PEN

Leader: Deanne Birch

Assistant: Rosalie Weber

EC Liaison: Dave Hosman

Deanne did ask for clarification on a previous asked and answered question from the DAC IV PEN A Team.:

We understood that if billing for a Competitive Bid item for denial ( eg; Enteral – does not meet medical necessity ) with a properly completed ABN and the GA modifier, a non contracted CB supplier should be able to receive a PR denial.

We have several examples of Enteral claims that have denied with the C0-96 and other CB denial codes incorrectly. The N211 denial states we have no appeal rights.

Q. Can we get these reprocessed via re-openings vs having to go through redeterminations?

Q. Is there any way to get the correct PR denial with the initial claim when the item is billed with the GA modifier to avoid having to appeal?

Jody requested examples and will look into. The Iv/PEN a Team will provide examples.

MED SUPPLIES

Leader: Gilbert Hererra

Assistant: Mary Stoner

EC Liaison: Sheila Roberson

67. (This is a follow up to Question 34 from last round): We wanted to once again follow up and see if there has been any progress made on resolving the ostomy denial issue we are having?

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.

68 a. There appears to have been some verbiage changed in the supplier manual regarding a verbal order. Previously, it was not stated that the supplier had to sign a verbal order. However, now the verbiage states a supplier signature is required. Where did the need for a supplier signature derive from? This was a clarification and not a change. The information was clarified in the standard documentation language article written by the four DME medical directors and is based on longstanding, unchanged CMS policies. The clarification is intended to reduce errors that occurred because some have not been aware of this requirement.

b. PIM Chapter 5, Section 5.2.2 (see below) does not state a need for the supplier's signature.

In addition, could we get the effective date of this change to the supplier manual? This was not a change but a clarification.

c. Would it be possible for the supplier manual to be updated to reflect the date that ANY verbiage is changed/added? All previous versions and a summary of changes of the supplier manual are available at:

Our concern is that we be held to changes/additions for dates of service prior to the date of change/addition.

Dispensing Orders

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.2

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

• Description of the item

• Beneficiary’s name

• Prescribing physician’s name

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

• Physician signature (if a written order) or supplier signature (if verbal order)

5.2.2 - Verbal and Preliminary Written Orders

(Rev. 242: Issued: 02-22-08; Effective/Implementation Dates: 03-01-08)

Except as noted in chapter 5 section 5.2.3.1 suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. This dispensing order must include: a description of the item, the beneficiary's name, the physician's name and the start date of the order. Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to the DME MACs, DME PSCs, or Zoned Program Integrity Contractors (ZPICs) upon request. If the supplier does not have an order from the treating physician before dispensing an item, the item is non-covered.

For items that are dispensed based on a verbal order or preliminary written order, the supplier must obtain a detailed written order that meets the requirements of section 5.2.3 before submitting the claim.

***Mary Stoner stated to Noridian that many orders are taken electronically (indicating date/time and person taking the order, but NOT a supplier signature. Dr Whitten stated that "signature" is used very loosely here and it is expected suppliers should know who took the order and when. It was asked if the language could be changed to "Supplier Authentication" vs "Supplier Signature". Dr Whitten stated if we had any examples of audits denying due to this he would like to see them and they will look to reword/further clarify the language regarding the supplier signature.

O & P

Leader: JR Brant

Assistant: Janet Malinowski

EC Liaison: Leslie Rigg

No questions submitted.

REHAB

Leader: Rick Graver

Assistant: Roni Burns

EC Liaison: Leslie Rigg

69. Providers are experiencing routine denials for K0108, here are some examples of claims where the narrative was included and then claims were still denied. What can providers due to help claims for K0108 process correctly the first time? Examples attached separately.

***NAS confirmed that the narrative is being looked at for K0108, and that in regards to our examples some of the items were deemed not covered because they were considered part of something else. The example that was reviewed was referencing a footbox, which was thought to be part of the footplate, or equivalent to the footplate. Because NAS did not understand the difference between a footplate and a footbox, the footbox was denied. During our follow up, there was some discussion about the differences between a footplate and a footbox, however the better job we can do as providers to explain why the accessory is not the same as part of the basic equipment package the better chances of having the claim adjudicated properly. NAS does look at the narrative, and providers need to continue to give as much information as possible to document the medical necessity on accessories.

70. Are there any updates on HCPCS coding for power center mount articulating elevating legrests? No (due to the current requirement that no such changes occur while competitive bidding is under initiation).

71. Are there any updates on the test claim for K0822 with E2601 based on the information submitted? Please see information below. If this is regarding the K0823 billed with the GL and a narrative indicating a K0822 was provided, and a GA on the E2601, this is currently being discussed internally. There are difficulties with treating as an upgrade which we will discuss.

*** See Below Question #78

72. Other regions will have a cover sheet for the PMD prior authorization demonstration, will Region D have one? NAS does have a coversheet and it is interactive. The coversheet can be found:

73. Under the PMD prior authorization project, will providers be required to submit when Medicare is secondary? Yes (these are CMS instructions)

74. Regarding previous question, if providers don’t submit for PMD prior authorization when Medicare is secondary, will they be subject to a reduced payment? Yes (these are CMS instructions)

75. Can we clarify that codes under the PMD prior authorization demonstration project will not be subject to the RAC pre pay demonstration project? Any PMD claim may be selected by the Recovery Auditor Contractor or CERT program. However NAS will not develop ADRs on PMD claims that have gone through the prior authorization process.

***We asked for an update on how the project is working, and NAS indicated that they are about 50/50 in terms of affirmed and non-affirmed determinations for PA for PMD.

76. If a provider uses the PMD prior authorization for a chair coded K0835 to K0843, would it be redundant to pursue ADMC? Yes

77. What is the rationale behind PMD prior authorization for chairs coded K0835-K0843 if the medical documentation that justifies the powered seating portion is not part of the prior authorization process? The medical justification for the base chair is what’s being reviewed. If the seating system is part of the justification for that base chair, then medical records supporting that must be submitted and reviewed.

PROVIDING A K0822 PWC AS A FREE UPGRADE WITH AN E2601 CUSHION

There are instances when a beneficiary’s condition prevents them from tolerating a standard Captain Seat or Back and the beneficiary does not a have a qualifying diagnosis for a specialty cushion/back. To be able to service the beneficiary’s medical needs, providers need a mechanism to be able to compliantly bill for the appropriate equipment required.

78. Will the DME MAC system be able to process the following example claim for payment as a K0823 base and a denial for the E2601 cushion (denied for lack of KX modifier)? See 71 above. In the example below the E2601 would need either a GA or GZ.

EXAMPLE

K0822 PWC w/ E2601 Cushion – UPGRADE AT NO EXTRA CHARGE

|24A |24B |24C |24D |24E |24F |24G |24H |24I |24J |

|From To | | | | | | | | | |

07 l 01 l 12 |07 l 01 l 12 |12 |K0823 l RRKHKXGL |1 |$558.79 |1 | | | | | |07 l 01 l 12 |07 l 01 l 12 |12 |E2601 l NU |1 |$56.52 |1 | | | | | |

• The appropriate HCPCS code for the non-upgraded base would be billed using the GL modifier

• The supplier would report the make and model of the K0822 base that is actually furnished, explaining why the K0822 base was provided

Jazzy Select 2-SS provided w/ E2601 cushion. Pt.’s condition prevents them from tolerating standard captain seat cushion

• An ABN is not required for providing an upgrade at no extra charge

***The test claim did go through, and with the addition of a GA or GZ modifier to line 2, which is the E2601, this claim would be compliant, and this would be a compliant way to provide a K0822 with an E2601. We thanked NAS for their help on this issue, and it was mutually agreed upon by the Rehab A team and NAS that we can attribute this accomplishment to the joint work that the DAC and NAS are doing.

RESPIRATORY

Leader: Mary Jackson

Assistant: Linda Skiple

EC Liaison: Gemma English

79. Please see the information below on High Altitude Simulation Testing (HAST). Would Medicare consider this qualifying testing for continuous oxygen usage? This type of test does not necessarily fall into the category of at rest or at exercise, however many physicians are beginning to use this testing to prescribe oxygen to patients, especially for travel. This type of testing is outside of the DME benefit category (high altitude airplanes, automobile) and doesn’t meet the in-home use criterion. We therefore cannot accept. The only three testing conditions are: at rest, at sleep and during exercise.

High Altitude Simulation Test (HAST)

This test will enhance safety for passengers with lung disease when traveling by automobile to high altitude and/or airplane.

A large number of patients with underlying pulmonary disease travel to high altitudes or by air each year, putting them at risk for significant cardiopulmonary effects of induced hypoxia. HAST provides a simple way to identify those patients at risk by simulating conditions encountered at high altitude. By having the patient breathe a mixture of gases containing approximately 15.1 percent oxygen, the test approximates the Fi02 at an elevation of 8,000 feet and allows the physician to screen for hypoxia, significant symptoms, and arrhythmias. Repeating the test with supplemental oxygen ensures adequate treatment of those patients who have a decrease in the alveolar pressure of oxygen, significant symptoms, and/or arrhythmias.

The California Thoracic Society recommends that patients with any of the following diagnosis may benefit from having HAST: Severe airway disease; cystic fibrosis; neuromuscular disease; kyphoscoliosis; those hospitalized for acute respiratory illness within the previous six weeks; previous air travel intolerance with respiratory symptoms such as, dyspnea, chest pain, confusion or syncope; or a condition worsened by hypoxemia such as cerebral vascular disease, coronary artery disease, or heart failure. To take the high altitude simulation test the patient must be in stable respiratory condition and a non-smoker. A physician referral is required.

The protocol for HAST is to obtain patient baseline blood pressure, heart rate/rhythm, Sa02, and dyspnea rating. The patient is then placed on the hypoxic mixture for 20-30 minutes or less, depending on symptoms. The patient is closely monitored during rest and mild exertion, and vital signs and dyspnea ratings are recorded. A report and summary of the test is sent to the referring physician.

80. We understand the audits will continue until the pass/fail rate improves. We assume that the pass/fail rate is based on the initial audit inquiry, but is the ratio then recalculated as claims are taken through the appeals process and approved? Yes

81. The supplier manual from June 2012 says that items provided on a periodic basis, including drugs, the written order must include the # of refills. 

a. What was the effective date of that?  Where was it published? Same answers as 68.

b. Does that include CPAP supplies? Yes

c. Are the old orders grandfathered or do we need to get new orders? This was a clarification; no grandfathering required.

d. The length of need is no longer required for rental items on the written order?  Length of need is now a recommendation not a requirement.

Detailed Written Orders- Supplier Manual June 2012

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.3

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

For items provided on a periodic basis, including drugs, the written order must include:

• Item(s) to be dispensed

• Dosage or concentration, if applicable

• Route of Administration

• Frequency of use

• Duration of infusion, if applicable

• Quantity to be dispensed

• Number of refills

For the “Date of the order” described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).

Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or “as needed” utilization estimates for replacement frequency, use, or consumption are not acceptable. (PIM 5.9)

The detailed description in the written order may be either a narrative description or a brand name/model number.

Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

The DWO must be available upon request.

A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.

If a supplier does not have a faxed, photocopied, electronic or pen and ink signed order in their records before they submit a claim to Medicare (i.e., if there is no order or only a verbal order), the claim will be denied. If the claim is for an item for which an order is required by statute (e.g., therapeutic shoes for diabetics, oral anticancer drugs, oral antiemetic drugs which are a replacement for intravenous antiemetic drugs), the claim will be denied as not meeting the benefit category and is therefore not appealable by the supplier (see CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 29, for more information on appeals). For all other items, if the supplier does not have an order that has been both signed and dated by the treating physician before billing the Medicare program, the item will be denied as not reasonable and necessary, with the exception of items requiring a written order prior to delivery as indicated below.

Detailed Written Orders – Supplier Manual December 2011

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.

If the written order is for a rental item, the length of need is also required.

If the written order from the physician is for supplies or accessories that will be provided on a periodic basis, the detailed written order should include the following appropriate information:

Quantity used; and

Frequency of change; and

Duration of need.

(For example, an order for surgical dressings might specify one 4 x 4 hydrocolloid dressing that is changed 1-2 times per week for 1 month or until the ulcer heals).

If the supply is a drug, the order must specify:

Name of the drug; and

Concentration (if applicable); and

Dosage; and

Frequency of administration; and

Duration of infusion (if applicable).

Someone other than the treating physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.

The supplier must have a detailed written order prior to submitting a claim. If a supplier does not have a faxed, photocopied, electronic or pen and ink signed order in their records before they submit a claim to Medicare (i.e., if there is no order or only a verbal order), the claim will be denied. If the claim is for an item for which an order is required by statute (e.g., therapeutic shoes for diabetics, oral anticancer drugs, oral antiemetic drugs which are a replacement for intravenous antiemetic drugs), the claim will be denied as not meeting the benefit category and is therefore not appealable by the supplier (see CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 29, for more information on appeals). For all other items, if the supplier does not have an order that has been both signed and dated by the treating physician before billing the Medicare program, the item will be denied as not reasonable and necessary, with the exception of items requiring a written order prior to delivery as indicated below.

Medical necessity information (e.g., a diagnosis code, narrative description of the patient's condition, abilities, or limitations) is NOT in itself considered to be part of the order although it may be put on the same document as the order.

*** Mary pointed out that the 2012 requirements for DWO indicates # of refills needed, yet 2011 does not. It is given that if a supplier knows the LON and the Frequency of Use...the # of refills should not be required. Dr Whitten agreed to further clarify in a future article.

NSC

Leader: Sheila Roberson

Assistant: Peggy Walker

EC Liaison: Sheila Roberson

**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.

No questions submitted.

PDAC

Leader: Sheila Roberson

Assistant: Julie Piriano

EC Liaison: Sheila Roberson

82. a. We are providing a bariatric power tilt system that has a maximum tilt capability of 40

degrees

with a maximum weight capacity of 450#. Since this does not meet the minimum tilt requirement

to be coded as E1002 are we correct in listing this as K0108 on the detailed product description and claim?

b. Is the PDAC looking at developing HCPCS codes for bariatric power seating functions (tilt, recline and tilt/recline combination) that are in line with the weight capacities of the power mobility bases in the future?

83. According to the PMD Policy article all PWCs must have the specified components and meet the following requirements:

• Length - less than or equal to 48 inches

• Width - less than or equal to 34 inches

If I have a power wheelchair that is code verified as K0829 through the PDAC and I need a seat width of 32" for an end user the overall width of the chair is close to 40". (This is outside of the parameters established for any power wheelchair, regardless of the group).

a. Does the length and width requirement only apply to the base of the device without seating or footrests/leg rests/foot platform or does this measurement include the seat and front rigging?

b. What is the compliant code to use when a chair is provided for an individual who is excessively wide or tall where the seat/footrest configuration is greater than these maximum parameters?

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