Questions for Noridian
February 27, 2009
HOME MEDICAL EQUIPMENT (HME)
Leader: Lelia Wilkerson
Assistant Leader: Sha Eppley
Executive Committee Contact: Barb Stockert
(Follow-up to previous question)
1.The Medicare Supplier Manual merely says that electronic RXs are acceptable. As an HME provider seeking approval with Medicare for E-CMNs and E-RXs, we were required to demonstrate both tamper-proof and electronic postmark verification. Some of the electronic forms physicians are asking us to accept omit a length of need or an ICD-9 code, etc, despite being told “Medicare approves of our form”.
We also have physicians’ offices who advise that if we don’t accept the form they’re now using, we won’t be taking their referrals.
a.Where can we direct physicians’ offices to in order to demonstrate any more explicit and current requirements for electronic RXs?
b.Are the requirements imposed on HME providers the same as for other entities?
c.To what extent do HME providers have to verify each electronic prescription we receive? Many times this is an electronic prescription printed by the physicians’ group or hospital and faxed to us. Does that still make it electronic? Sometimes these types of documents just look like “stamped signatures” over the fax.
NAS Response: We will respond more in depth at Medtrade but would appreciate seeing examples for c of electronic prescriptions that look like stamped signatures.
Education/Communication/PCOM
Leader: Cindy Coy
Assistant Leader: --
Executive Committee Contact: Connie Lind-Fraher
- We would like to check on accuracy of IVR same/similar information. Providers continue to report some frustration about the capabilities of the system. We have illustrated three examples. Please advise if you would like HICN and identifying information on the two cases:
Pt #1:Two locations from a national company have shared the following patient. Both have billed NAS and have been paid for an E0601 at different times in the calendar year, the most recent date of service 12/28/08 also having been paid. As early after the last payment as mid-February 2009, IVR reports no same/similar for E0601.
NAS Response: Services billed were for Maintenance and Service. M/S is not subject to same and similar rules; only the equipment hits for same and similar edits. In addition, the original E0601 was billed with an initial date of 9/28/00. Once the equipment is over five years old, the code/claim will not hit for same and similar as the item can be replaced after five years.
Pt #2:In June 2008, we called IVR same/sim for a wheelchair and received no same/similar info. Months later, we have denials because per one of the CSRs at NAS, they could confirm a history of K0001 and an initial CMN on file with another provider from January 2007, and a history of 6 payments.
NAS Response: Our system currently shows the K0001 on file and shows that this information was entered on 4/8/08. When entering this information into the IVR, the system provided information on this piece of equipment on file and provided all the correct information on this equipment. The only explanation we can provide is that possibly information was entered incorrectly into the system in June, 2008 resulting in no response.
Pt #3:In September 2008, we called IVR same/sim for w/c codes: K0001, K0003, K0004, K0007, and K0011. Through denials, we later found that the patient had both an E1161 purchase (which we suspect would not have normally shown up on same/sim) and was currently renting a K0001 from another provider. Could you explain if we are understanding the correct utilization of the IVR same/similar function?
NAS Response: When NAS checked for a K0001, K0003, K0004, K0007, andK0011 with both an RR and NU modifier,the IVR provided the E1161 on file with correct information.There is no K0001 listed on the screen we load to track rental payments, but rental payments on this code are in the beneficiary’s claim history from July 2006-December 2006.All of these claims were recouped as a billing error, except for the DOS for July of 2006.It’s possible that the K0001 dummy CMN was deleted due to the billing errors. Our IVR only checks the screen where we load dummy CMNs to do same and similar checking, not the claim history so the IVR functioned correctly.
NAS advises providers to make sure that they are speaking clearly and don't have the IVR on a speaker phone; if there is too much background noise, the IVR will pick that up.We would also advise to make sure to provide a modifier, such as theRR or NU,when the equipment they are checking requires one of those modifiers when billing.
ORTHOTICS AND PROSTHETICS (O&P)
Leader: Harry “JR” Brandt
Assistant Leader: Janet Malinowski
Executive Committee Contact: Sharon Nichelson
3.We have recently been told that the Arizona brace may have been incorrectlycoded by providers and that we should not have used the following codes forthese braces:
L1960 Ankle foot orthosis, posterior solid ankle, plastic, customfabricated
L2275 Addition to lower extremity, varus/valgus correction, plasticmodification, padded/lined
L2280 Addition to lower extremity, molded inner boot
This code was given to us years ago by one of the national orthoticassociations. If providers did incorrectly code this brace and/or anyadditions what recourse(s) do we now have available to us?
NAS Response: The article that provided the correct coding for these orthoses stated that suppliers who incorrectly coded these orthoses should submit a voluntary refund to the DME MAC.
For how long of a time period back is a provider responsible to refund for? Providers are required to hold Medicare records for seven years. What if wehad situations prior to that but we do not have the records available?
NAS Response: Medicare will accept voluntary refunds for any length of time in the past. There is not a set number of years after which suppliers are exempt from refunding. If records for more than seven years ago are no longer available to verify the coding, one could not submit a refund.
If we refund the money paid, will we be allowed to go back and re-bill theseclaims even if the time limit for claims has expired? Ex: if this waspaid in 2006, would we be able to send a corrected claim for that DOS now?
NAS Response: Our recoupment team can adjust the procedure codes on the claim and recoup the difference. This eliminates the need for a “new” corrected claim and prevents timely filing issues. This is the normal recoupment procedure.
Suppliers should clearly indicate on the refund form which “incorrect” code should be changed to the appropriate code, i.e., L1960 should be L1940. If there are “extra” lines, state that these were billed in error. It is NAS’ understanding that most often a 5 line claim was billed for the Arizona AFO, when correct coding should have been a three line claim. NAS encourages suppliers to not refund the “estimated” difference, but rather to allow NAS to calculate the overpayment and send a demand letter. Each claim should also be submitted as a separate refund, rather than as a batch of claims to allow for faster processing of the individual claims.
Rehab
Leader: Leslie Rigg
Assistant Leader: Evan Call
Executive Committee Contact: Barb Stockert
4.Is it acceptable to chargethe beneficiary for a service call, forbeneficiary owned equipment, when the service isperformed for the convenience of the beneficiary? For example, the beneficiary believes their power chair isn’t functioning properly (or wants air put in the tires) and does not want to bring the chair in to have it evaluated and would rather we go totheir home to take a look at it. This "service" is not part of a new delivery. We see this as a service request on customer owned equipment that is outside the scope of the supplier's service obligations to a beneficiary and would not be a covered benefit according to Chapter 3 of the supplier manual, but would be chargeable to the beneficiary.
Reference
Delivery and Service Charges
[CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 20, § 60]
Delivery and service are an integral part of oxygen and durable medical equipment (DME) suppliers' costs of doing business. Such costs are ordinarily assumed to have been taken into account by suppliers (along with all other overhead expenses) in setting the prices they charge for covered items and services. As such, these cost have already been accounted for in the calculation of the fee schedules. Therefore, separate delivery and service charges for DMEPOS items will not be allowed except in rare and unusual circumstances when the delivery is outside the normal range of a supplier's sphere of operation. For example, a reasonable delivery charge might be allowed if a supplier had to deliver a DMEPOS item to a beneficiary who lived outside the supplier's usual customer area and who had no access to a supplier located nearer. The supplier should fully document these "unusual circumstances" on claims filed for delivery charges.
NAS Response: NAS feels that it is acceptable for suppliers to charge for a service call for beneficiary owned equipment when the service is for the convenience of the beneficiary, i.e., they want service at home, rather than bringing the chair in, or want routine service, such as air in the tires. If the visit results in repairs to the equipment which is then billed to Medicare, travel time to the home is not included in calculating the time for labor. NAS also encourages suppliers to have written policies on service charges that are disclosed to the beneficiary when the equipment is provided to address these types of requests.
5.We have noted that some “telemarketing” organizations are calling to contract with individuals or companies close to their customers residences to provide set up and delivery of PMD’s. Are these companies in violation of any Medicare statutes by using a contracted delivery service to perform the setup and delivery of power mobility? Are they in violation if the contracted entity is not a Medicare Provider? What if the contracted entity is not trained or qualified to provide the delivery and setup according to Medicare guidelines?
NAS Response: The Supplier Standards and quality standards for accreditation do not directly address these questions. A supplier can contract with other entities to provide services such as set up and delivery of PMDs, but is still ultimately responsible for the services provided to the beneficiary and must provide quality set up and delivery. An entity that only delivers and sets up PMDs would probably not be a DME supplier if this is all the services they provide, but this is not a requirement. There are no Medicare guidelines that state that the delivery and setup must be done by the supplier directly or their employees. Suppliers are encouraged to only contract out services to those entities qualified or trained to provide service to Medicare beneficiaries, as again the supplier is responsible for these activities. Contracting these services out to an inexperienced company will only result in beneficiary complaints about service.
The quality standards state the following:
“Technical personnel shall be competent to deliver and set-up equipment and items and train beneficiaries. Professional personnel shall be licensed, certified, or registered and function within their scope of practice as required by the State standard under which the professional is licensed. The supplier shall maintain copies or other verification of licenses, registrations, certifications, and competency assessments for personnel who provide beneficiary services.”
6.We have noted that Medicare has determined that procedure code E2213 is not medically necessary.Per an ADMC denial,“Medicare has determined that flat free inserts in wheelchair tires are not medically necessary for use within the home.These chairs (a K0005 in this case) come standard with solid propulsion tires (E2220) that do not require inserts and do not go flat. For additional billing guidance please refer to local coverage determination number L11462 and Policy article number A19846.”I do not see anything in either of these documents to support a change. Can you direct us to documentation where this change has been initiated? Is this an interpretation of CMS policy by Noridian or is this a CMS directive? Previously, suppliers have been billing for and being paid for inserts, E2213, for all levels of Manual wheelchairs, K0001 – K0009. We would also submit that the physical properties of pneumatic tires with inserts are quite different than those of solid tires. Pneumatics with inserts provide greater flotation and facilitate mobility over such surfaces as thick carpet.
NAS Response: A flat-freeinsert is considered a convenience item and benefits the user outside of the home, therefore not medically necessary.A flat-free insert does not add to the physical properties of the pneumatic tire, it only prevents it from going flat as it maintains the shape of the tire with foam rather than air in caseof puncture or damage to the tire. You are correct in stating that the physical properties of pneumatic tires are quite different than those of solid tires. They are more comfortable and shock absorbing, but the foam insert is not necessary to achieve this. It is the standard removable tube (air) that allows for this. The flat-free insert (foam) achieves this as well but, again, the flat-free insert is to prevent the tire from going flat.
- Suppliers are noting that some codes such as E2210 (bearings) and E1340 (labor) have limits as to the number of units that can be billed. Can the supplier find out the limits for various codes? Are these limits set by Noridian or CMS and are they negotiable? Many times suppliers bill 8 or more bearings. The limit appears to be 4. The claims can be paid thru redetermination; however, we would like to suggest that a higher limit might help alleviate the number of claims having to go to redetermination.
NAS Response: In general, to determine if there are limits as to the number of units that can be billed, check the LCD and policy article for the item in question and then next check if there is a Medically Unlikely Edit (MUE), which can be accessed on the CMS Web site at: There is not a published MUE for E2210 so examples are needed for the E2210 limit of four being denied initially but then paid upon appeal for further research.
There will never be an established limit for E1340, other than those common repair times, just published, as this code applies to labor for many different types of repairs. The DME MACs just published allowed units for various types of repair labor. See the article titled “Repair Labor Billing and Payment Policy”, published on 2/25/09. Other repairs are reimbursed based on the actual time spent.
Respiratory
Leader: Colleen McKenna-Shaw
Assistant Leader: Anna Weinstein
Executive Committee Contact: Gemma English
(Follow-up to previous question)
8.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.
A-Team Response: We are still not clear based on this response. We would like to provide an example of the scenario and get some direct clarification. Say patient has a qualifying sleep study done on 1/5/08 but did not have a face to face evaluation prior to the sleep study. Now in December 2008, they go to their physician and he/she orders a CPAP based on that 1/08 sleep study results. Does this patient qualify under Medicare guidelines?
NAS Response: Since this claim is being billed with a DOS on/after 11/1/08, the coverage guidelines in effect at the time apply. Therefore, the patient would need a face-to-face evaluation followed by a sleep study that qualifies in order for Medicare to pay for the PAP device. You could try appealing this claim and if there was some type of evaluation done before the sleep study, this may make the claim payable. One would question why the patient waited 12 months to try the PAP therapy after the sleep study.