Questions to Noridian/CEDI
Summer 2013
CEDI
Leader: Michele Hessler
Assistant: LeeAnn Ruber
EC Liaison: Sheila Roberson
No Questions Submitted
EDUCATION
Leader: Carolyn Koster
Assistant: Cindy Coy
EC Liaison: Mary Stoner
47. 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?
Response: Medical record authorship is generally accomplished through a handwritten or electronic signature (signature stamps are not acceptable); however, when the author of a record is unclear, document(s) must be authenticated. Signature logs or attestation statements are two acceptable methods to authenticate a record (excluding orders and Certificates of Medical Necessity (CMNs)).
If the author is deceased then authentication by that author would not be possible. In that case, there should be a new treating physician with records to support on-going medical necessity. Keep in mind that Medicare can only request records up to seven (7) years old for services covered by Medicare. If a physician has simply left the area, it may be necessary to contact them to verify their records for the beneficiary in question. In the case of a sleep study, it may also be necessary to obtain a new interpretation to determine that the coverage criteria in effect at the time the service was met.
No further questions. Thank you.
HME
Leader: Lelia Wilkerson
Assistant: Gloria Schulte
EC Liaison: Mary Stoner
48. The recent Medicare ABN webinar reminded us that we need to note the relationship to the patient if someone other than the patient signs the ABN. If we have that information on file (such as on the delivery ticket) do we also need it on the ABN form? Also, since this is a requirement, can we submit a request to have the form updated to show this information as a prompt for staff so it is not forgotten? Could this be taken to CMS for consideration?
Response: If someone other than the beneficiary is signing the ABN, then they must include the word “representative” next to their name. You can write to CMS, if you have suggestions for improving the form at the following address: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
49. When the new face to face requirements come to play, is it necessary to have a physician sign F2F documentation when signed by a PA, ARNP, etc? This is contradictory to our state regulations that allow a PA or ARNP to practice independently.
Response: Yes. CR830 states:
In the case of a DME ordered by a PA, NP, or CNS, a physician (MD or
DO) must document the occurrence of a face-to-face encounter by
signing/co-signing and dating the pertinent portion of the medical record.
Lelia Wilkerson explained that there are software systems that will not
allow any additional documentation added within the document once the
original author completes their portion. Dr. Whitten said he had a difficult
time understanding that a software program could not be updated to do this.
But, if this is the case the record that is written and signed by the original
physician should be copied and pasted to an addendum that can be
signed by the physician that is co-signing it.
50. If a Medicare patient wants to purchase an item normally covered by Medicare as a cash item, is an ABN necessary? Example: A family asked to purchase a wheelchair and chose to pay cash. An ABN was signed that showed the patient was aware this would not be covered and that they paid cash. In addition, the patient did not meet medical criteria for the chair. The claim was submitted as a courtesy claim and denied by Medicare because this item is not a purchased item and must have been submitted as a rental. How should this have been handled? This was debated all the way to ALJ and was still denied.
Response: An ABN would be necessary to protect the supplier from financial liability. If the beneficiary request a formal determination and a claim is submitted, all claim submission/payment rules must be followed. Items reimbursed on a rental basis cannot be processed by Medicare as a purchased item.
IV PEN
Leader: Rosalie Weber
Assistant: Jeff Schwindt
EC Liaison: Dave Hosman
51. Medicare denies the entire claim due to lack of B4154 medical necessity. The supplier sends the claim to all levels of appeal and ultimately is still denied at the ALJ level. The claim is now beyond timely filing to re-bill as a Least Costly Alternative B4150. Is there an exception to the timely filing when Medicare causes the supplier to miss the deadline due to being behind in their appeal decisions?
Response: Per the Internet Only Manual, Publication 100-4 Medicare Claims Processing Manual, Chapter 1, section 70, claims must be filed no later than 12 months or 1 calendar year after the date the services were furnished. Section 70.7 goes on to state that the following are exceptions to the filing of claims: Administrative Error, Retroactive Medicare Entitlement, Retroactive Medicare Entitlement involving State Medicaid Agencies, and Retroactive disenrollment from a Medicare Advantage plan or PACE organization. This situation would not fall under any of the above exceptions listed in the IOM.
It is important to note that the LCD was revised as of 02/04/11 to state that least costly alternative is no longer allowed for special Enteral formulas and that if the medical record does not document why the B4154 is medically necessary, it will be denied as not reasonable and necessary.
52. In reference to Q. No. 5 from IVPEN on the Q&A that were distributed for the meetings last week, We noticed that we did not receive answers to the additional questions that we asked Dr. Whitten on the January Teleconference (copied below) and we are requesting the answer in writing, and/or acknowledgment that our recollection of the response given by Dr. Whitten is accurate as we have written below. Since Noridian’s reply only responded to Enteral, we need a response for TPN admin. Kits and supply kits and the External Infusion Pump admin and supply kits. This is all very specific in the “whole body” of Question No. 5.
Q. 5 Request clarification regarding Request for Refill documentation requirement for the following “kit” codes. (This is a very lengthy question so please refer to the original handout)
R. NAS Response: The supplier does not have to document the remaining individual supplies. Enteral supplies are based on a daily allowance to supply all necessary supplies to maintain the Enteral administration. Suppliers need to confirm the remaining quantities of supplies on-hand are sufficient to allow administration of the Enteral nutrients.
Minutes sent following the call:
Additional Question for January 9, 2013: Does the same guidance that they have provided for Enteral pertain to IV kits and TPN kits? If so, is the following statement correct?
Response: This same guidance would apply for the TPN kits and IV kits as they are based on a daily allowance to supply all necessary supplies to maintain the TPN or IV administration.
The supplier does not have to document the remaining individual supplies. Enteral supplies, External Infusion pump supplies, TPN supplies and Catheter Care supplies are based on a daily or per contain allowances to supply all necessary supplies to maintain drug and/or nutrition administration
Dr. Whitten’s answer was “YES” and Noridian has made an effort to educate their reviewers that “kit” means a daily allowance and they need to distinguish between a daily allowance and additional items sent that would be considered for payment.…so “YES” if supplier documents the need for additional formula, TPN, drugs, etc. it would warrant the supplies needed to support the “base product”.
Dr. Whitten stated this Q. was discussed with both Dr. Hoover and Dr. Hughes and all agreed. Dr. Brennan was not part of this discussion.
F/U Example 1: If the supplier asks the beneficiary “will you need the administrations supplies necessary to deliver each of the doses/TPN Bags we are sending”? And they respond “Yes”, this will be considered as sufficient documentation?
No Answer was given
Response: Yes, suppliers should monitor the usage to ensure beneficiaries have sufficient supplies.
F/U Example 2: Will you need the supplies to maintain your catheter on this next shipment
No answer was given
Response: See Answer above for Example #1
*** 6/26/13 Iv/PEN Asked an additional question to Noridian to consider revising/updating the PEN & EIP LCD with a similar statement that was revised in the Enteral LCD as noted below….
“Supply allowance HCPCS codes (B4034-B4036) are daily allowances which are considered all inclusive and therefore refill requirements are not applicable to these HCPCS codes. Refer to the Coding Guidelines section in the Policy Article for further clarification.”
Example from the current TPN LCD:
If the coverage requirements for parenteral nutrition are met, one supply kit (B4220 or B4222) and one administration kit will be covered for each day that parenteral nutrition is administered.
Example from the current EIP LCD:
Supplies for the maintenance of a parenteral drug infusion catheter (A4221) are covered during the period of covered use of an infusion pump. They are also covered for the weeks in between covered infusion pump use, not to exceed 4 weeks per episode.
Supplies used with an external infusion pump, A4222 or K0552, are covered during the period of covered use of an infusion pump. Allowance is based on the number of cassettes or bags (A4222) prepared or syringes (K0552) used. For intermittent infusions, no more than one cassette or bag is covered for each dose of drug. For continuous infusion, the concentration of the drug and the size of the cassette, bag, or syringe should be maximized to result in the fewest cassettes, bags, or syringes in keeping with good pharmacologic and medical practice.
MED SUPPLIES
Leader: Gilbert Hererra
Assistant: Carolyn Koster
EC Liaison: Mary Stoner
53. 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.
Gilbert Herrera thanked Noridian for their response to the question. However, he explained that the team continues to have concerns.
Our question was intended to focus on the reliability of the PDAC coding and not the medical policy. He explained that we’ve invested resources to train our staff to use the PDAC coding when it is available. In addition, there are several HCPCS that require the use of the PDAC for coding. He explained that it seems as if the PDAC coding in this case does not matter and we need to follow the policy and ignore the PDAC coding. If the PDAC coding does not matter we need to know that.
Jody & Dr. Whitten – responded that we are required to follow policy. If a catheter kit the supplies are provided and billed it must be included as stated in the policy. Jody mentioned that in this case the concern is that these catheters had no supplies included and were coded as A4353 by PDAC.
Gilbert explained that what Jody stated is what is happening. Dr. Whitten explained that when the PDAC finds they have coded something incorrectly they will go back and make the necessary corrections. They have done this with other policy coding issues.
Dr. Whitten and Jody asked that examples of items that we find which are coded this way. They agreed that product coding should be in agreement with policy and this should be brought to the PDAC.
Sheila Roberson, PDAC A Team Leader asked that any examples be sent to the DAC Office. They will be compiled and can be brought to the PDAC Team.
O & P
Leader: Dan Sarria
Assistant: JR Brandt
EC Liaison: Leslie Rigg
No Questions Submitted
REHAB
Leader: Rick Graver
Assistant: Paula Koenig
EC Liaison: Leslie Rigg
54. In regards to repairs to patient owned equipment, we know that repairs are covered for patient owned equipment as long as the equipment is medically necessary. For a patient who has equipment from another vendor who is no longer in business and whose medical records are not available, would the documentation process be equivalent to what they would have to go through in order to receive a new piece of equipment? In other words, when phrasing the process to the beneficiary in this scenario, would it be appropriate to say that the provider is qualifying the beneficiary for the repairs as if they were getting a new chair?
Response: This would be a supplier’s business practice decision. Medicare will cover repairs to reasonable and necessary beneficiary equipment.
Rick Graver Rehab A Team Leader asked what kind of med necessity documentation would a provider need to submit in the case of an audit if we repaired (parts and labor) a chair for the beneficiary who did not buy it from us and we did not have the med necessity documentation on file.
He also asked if chart notes documenting the med necessity would be enough to satisfy the requirement. Is it different for manual versus power (i.e. the 7 element order and the other med necessity for power versus manual?)
NAS validated our concern but will not advise on providers’ business practices. NAS indicated that upon audit the medical necessity would be expected to be on file.
55. What if we find out if the equipment was not medically necessary, yet it had been funded by Medicare? Would it be appropriate to use an ABN, or collect from the beneficiary and bill non assigned?