For Review by Executive Committee

DACD Questions1

12/3/08

DAC-D

Questions from A-Teams

For review by Executive Committee

Submitted to Noridian 12/12/08

CEDI

The EDI team met briefly today. We have no questions to submit.

Education/Communication/PCOM

No questions were received.

IV/PEN

1. When we bill anti-infectives for denial, we append the “GY” modifier on each line, and we enter narrative on each line & indicate “billing for denial – statutorily non-covered”. This is per direction from Noridian when billing for denial.

Our remits continue to append the Co- 97 remark code to the codes J1642, J7030 for heparin and diluent. As we have secondary’s that pay for flush and sometimes the diluent (and this is a HIPAA directive to bill drugs separate) I believe we should be getting the PR patient responsibility remark code. With the CO 97, I cannot get the secondary to consider for payment.

When recently contacting re-opening to correct the remark code to “PR”, I was told that re-opening could no longer process these requests. We are being told to take these to re-determinations.

When the A4223, Jcode for the drug, and the A4216 are appropriately receiving the PR remark code – it should be consistent for the J7030, J7050, and J1462 as part of the Infusion Therapy to receive the PR remark code.

To take these codes to re-determinations creates a significant delay in claim processing to our secondary payor.

Examples attached in separate document.

NAS Response: The claim lines denied with a CO (contractual obligation) were denied by claims staff in error and should have been denied with a code that would have resulted in a PR denial. The claims submitted as examples have been adjusted to correct the denial. Feedback was also provided to the claims staff that worked these claims incorrectly. If other suppliers have similar denials, call the SupplierContactCenter to have the claim adjusted due to this contractor error.

Medical Supplies & Wound Care

1. Negative Pressure Wound Therapy (NPWT) supplies, specifically the wound care kits, appear to have remarks on the packaging that would indicate the kit should not be stored in temperatures below 77 degrees, and should not get wet. Given these warnings, the HME supplier cannot take back unused supplies since we cannot be certain how they were stored once outside our control. Therefore, can the HME supplier bill for wastage of these supplies?

Consider the following: the physician orders dressing changes of 2x per week, or 8 kits x month. The patient gives up the equipment before the month's billing is over and the patient has 4 unused kits leftover. If we cannot return the supplies to usable inventory, can we bill and receive payment for the quantity the physician ordered? Likewise, if the physician orders the large kits and the patient really needs the small ones, if the kits have been out of the supplier's direct control, we would not be able to return them to usable inventory.

Jurisdiction D written correspondence wrote back that the provider would be able to bill for the amount prescribed by the physician, and wound kits are single patient use items for one time sale only. NAS would not expect to request a refund for these kits, even in the event the beneficiary's treatment ceased. Can we depend upon this answer in regard to the subject of wastage?

NAS Response: Yes, we agree with the answer from written correspondence. Supplies provided should not exceed the anticipated need and may not exceed the physician’s ordered quantity. Once delivered in good faith, no further return or refund is anticipated for a situation that subsequently changes. Suppliers are encouraged to only provide one month’s worth or less of supplies for a patient who’s clinical situation is unstable or unclear.

2. What is the definition of "supervise or directly perform the NPWT dressing changes on a regular basis" (continued coverage requirement)? Does this mean that the licensed health care professional him/herself must perform every dressing change, or does this mean that a family member can perform a dressing change with supervision from the licensed health care professional? This question comes up because the physician prescribes 12 dressing kits per wound per month (3 dressings x week), but the home health agency visits are prescribed 2 x week. Since the HME supplier cannot control how often the home health agency is directly performing dressing changes, we wonder how "supervision" is defined. Can this be consultation between the caregiver and licensed health care supplier over the phone, periodic Q&A during scheduled visits, etc. or must it be direct, "over the shoulder" supervision?

We inquired with Jurisdiction D Written Correspondence but heard back that supervision must be face to face. Again, if the physician directs 3x week dressings and only 2x week HHA visits, should we the provider dispense less supply than the physician ordered, due to the inability of an RN to supervise face to face the remaining dressing change in that week?

NAS Response: Supervision for NPWT must be face-to-face. The frequency of dressing changes should be coordinated with the ordering physician and the nurse or home health agency performing the dressing changes so all are in agreement on the ordered and provided frequency.

National Supplier Clearinghouse (NSC)

1. We are experiencing many issues related to crosswalk and problems with addresses not being consistent between the various organizations, NSC, NPI, DME MAC. This question has been forwarded to the NSCAC team meeting with the NSC.

1. As we are trying to resolve the issues, we are contacting the NSC and the DME MACs and, depending on who we speak with, we are often getting conflicting information. We recently had issues where two TINs were listed for a provider number and after multiple calls they admitted that they had on file the correct TIN documentation we had submitted several years earlier. We had another situation where they claimed we did not have our President listed as Authorized Agent on record, when we have the documentation to prove we sent in the 855S to make him the authorized agent. Another example is that for one of our provider numbers, CMS is not releasing our cash because they claim someone put a forwarding address attached to our lockbox, and because Medicare won't allow forwarding, the cash is being held. We have no record of sending in a forwarding address and the NSC won't provide us a copy of the envelope so that our bank can try to help us identify how to stop the forwarding. These types of issues are causing us to be on the phone with the agencies constantly and we are frequently getting different answers to our questions.

3. Is there any consideration for the NSC providing an on-line "sign-in" where we can verify all the addresses and specifics of our current information? We need a way to quickly verify that changes we submit with the 855S are actually corrected in their system. We can do this with NPI, but not the NSC.

Orthotics & Prosthetics (O&P)

*Are there any updates to these questions?

1. In the new knee policy L2770has been deleted. This code however was being used and is still needed when fabricating a Subtalar control AFO (I.E. Arizona Type)when a nine inch device is medically necessary, is there a suggested replacement code? L2330 was also deleted in the new policy. Is there a recommended replacement code to use on the Subtalar control AFO?

NAS Response: Direction was provided on coding the Arizona Type Ankle-Foot Orthoses in an article posted to the What’s New Section of our website on on 12/4/08, as follows. L2770 is not an appropriate code for a subtalar control AFO. Code L2330 is currently listed in the knee orthoses policy and may be used for Arizona type AFOs. This is also referenced in the Arizona type coding article.

Ankle-Foot Orthoses – Arizona-Type – Correct Coding

Arizona AFO is a company that manufactures a line of custom fabricated ankle-foot orthoses. Other companies manufacture similar products. The Pricing, Data Analysis, and Coding (PDAC) contractor has recently reviewed the Arizona AFO line of products and determined the appropriate HCPCS codes to be used when billing for these and similar items.

For the Arizona Short, Arizona Tall, Arizona Extended, Arizona Unweighting, and similar custom fabricated braces, only the following codes should be used:

L1940 Ankle foot orthosis, plastic or other material, custom fabricated
L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
L2820 Addition to lower extremity orthosis, soft interface for molded plastic below knee section

L2330 is used whether the closure is a lacer closure or a velcro closure. L2820 is used only if a soft interface, either leather or other material, is provided.

The following codes must not be used for these braces:

L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated
L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2280 Addition to lower extremity, molded inner boot

For the Arizona Partial Foot model or similar orthosis, use codes L1940, L2330, L2820, and L5000 (Partial foot, shoe insert with longitudinal arch, toe filler).

Questions concerning the coding of other orthoses should be referred to the PDAC contractor.

Suppliers who have incorrectly coded these orthoses should submit a voluntary refund to the DME MAC.

2. L2820 per knee policy states that you must use a KX modifier when billing. We are asking what documentation is needed per medical policy for the L2820 code when using on an custom AFO or a off the shelf L1932 that is not included in the cost of the device and must be purchased separately for both cases andthe Dr orderstate the type of AFO and the soft interface for skin integrity, decrease pain and protection?

NAS Response: Per the policy article for Knee Orthosis,

“Either a nonremovable soft interface (L2820, L2830) or two (2) removable soft interfaces (K0672) are included in the allowance for a knee orthosis. Soft interfaces billed separately at the time of initial issue will be denied as not separately payable.”

If the question is what type of medical documentation is required in these instances, the documentation mentioned, i.e., an order for the type of AFO and a soft interface and the reason why, would be acceptable. You would need to have documentation that supports the medical necessity for the codes billed. Currently there are no specific requirements for the L2820 for documentation outlined in the policy.

1. L2275per knee policy, you must use KX modifier and we would like clarification on the medical policy/ documentation requirements when using with a Subtalar control AFO. The policy speaks about the usage with Knees.

NAS Response: The KX modifier requirement will be added to the AFO policy in the future. The fact that it was not added at the same time as the knee policy was purely an oversight and the intent is that the KX modifier guidelines apply to both policies.

The same guidelines as the response in #2 would apply. Medical necessity for the codes billed, along with an order, is required.

Rehab

No questions to submit at this time.

Respiratory

1. The new PAP LCD effective 11/1/08 requires the patient to have had a face to face evaluation prior to the sleep study. How is this supposed to be handled when the sleep study date is prior to 11/1/08 and they were not required to have a face to face until the new LCD rules effective 11/1/08? Example: Sleep study dated 9/24/08, patient had a face to face evaluation to review result on 11/8/08 and a referral was received after that visit to the physician. Sleep study date falls within guidelines prior to 11/1/08 but setup date falls after 11/1/08. Should we be billing with KX modifier to indicate patient does qualify? If not, what should the supplier be doing in this scenario? (All assumes the sleep study does qualify the patient.)

NAS Response: The CMS National Coverage Decision, which was effective 3/13/2008, requires “a clinical evaluation”. The LCD clarifies that this “clinical evaluation” should take the form of a face-to-face examination for dates of service after 11/01/08. For dates of service prior to 11/01/08, other documentation showing a clinical evaluation occurred is acceptable.

2. We recently received a response from a CERT request stating that we needed to supply documentation that the patient has seen the treating physician within 6 months prior to claim date of service and continues to need oxygen therapy. Length of need on initial CMN was 99 and testing was a Group I qualification. Why would Cert be requesting that type of documentation? We are providing the example along with questions.

NAS Response: DMEPOS suppliers areencouraged to direct concerns of this type regarding decisions made by the CERT contractor directly to the CERT contractor, as well as to representatives from CMS.

3. The new proposed payment for oxygen states that contents will be paid after oxygen equipment has reached the 36 months capped at various rates depending on the type of system. Will the contents only be paid if tanks are delivered during that month or is it considered to be like a rental code and can be billed monthly to average out the cost of tank delivery over time?

NAS Response: Similar questions were posed on the NAS DME Ask the Contractor Teleconference on 12/10/08 and below are these questions and answers provided by NAS and Joel Kaiser from CMS:

Q1. Is the allowance for oxygen contents one unit per tank or per delivery?
A1. Reimbursement for oxygen content is one unit per month. The supplier must provide whatever quantity of oxygen the patient uses. Medicare's reimbursement is the same, regardless of the quantity of oxygen dispensed.

Q12. Once oxygen equipment has capped, what will Medicare be looking for as far as proof of delivery for the contents and do we bill when contents are provided or do we wait until the end of the month?
A12.CMS Response-Joel Kaiser: The supplier should bill for oxygen contents on the typical anniversary date, the day the system/content was first provided to the beneficiary. This is the same way capped items have been billed in the past and the rules have not changed and apply to contents as well.

4. Can providers bill the beneficiary for supplies on an unassigned basis, such as cannula and tubing once oxygen has reached its cap?

NAS Response: No. Per MLN Matters 6297, as referenced below, suppliers cannot bill for any accessories or supplies after the 36 month cap. If a claim is billed for such supplies, the claim will be denied with reason code 223 (Adjusted code for mandated federal, state or local law/legislation that is not already covered by another code and is mandated before a new code can be created).

As indicated in section 30.6 of Chapter 20 of the Medicare Claims Processing Manual (Pub. 100-04), the monthly payment amount for oxygen and oxygen equipment covers equipment, contents, supplies and accessories. Section 144(b) of MIPPA caps the all inclusive oxygen and oxygen equipment monthly payments at 36 months and does not provide for payment of replacement oxygen supplies and accessories following the 36-month cap. The supplier who received payment for furnishing the oxygen and oxygen equipment during the 36-month rental period is responsible for continuing to furnish any accessories and supplies necessary for the effective use of the equipment for any period of medical need following the 36-month rental cap for the remainder of the reasonable useful lifetime of the equipment. Therefore, separate payment shall not be made for replacement of supplies and accessories for use with oxygen equipment that are furnished on or after January 1, 2009. This applies to any supply or accessory billed under a miscellaneous HCPCS code, any codes added to the HCPCS in the future, or under the following current HCPCS codes:

HCPCS Code / Descriptor
A4608 / Transtracheal oxygen catheter, each
A4615 / Cannula, nasal
A4616 / Tubing (oxygen), per foot
A4617 / Mouth piece
A4619 / Face tent
A4620 / Variable concentration mask
A7525 / Tracheostomy mask, each
E0555 / Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter
E0560 / Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery
E0580 / Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter
E1353 / Regulator
E1354 / Wheeled cart for portable cylinder or concentrator (Added to HCPCS effective January 1, 2009)
E1355 / Stand/Rack
E1356 / Battery pack/cartridge for portable concentrator (Added to HCPCS effective January 1, 2009)
E1357 / Battery charger for portable concentrator (Added to HCPCS effective January 1, 2009)
E1358 / DC Power adapter for portable concentrator (Added to HCPCS effective January 1, 2009)

5. We understand that after the patient has had the equipment for 5 years, they can receive new equipment from the provider and start the 36 months again. There has been no publication that it is to be replaced only if the equipment is not working or the cost would be too high to repair.