Questions for Teleconference
January 27th, 2015
- It was suggested that Question # 18 below from last Round Q&A should be forwarded to Jim Ralls, along with the prior question sent from IV PEN for possible updates/answers from CMS on our next Teleconference or Medtrade meeting…which ever you feel is best.
No.18. If a patient wants to switch to another company for PAP supplies but the
documentation is not available because the original setup was done over 7 years
ago in 2002:
a. Is it sufficient to document a statement that medical records older than 7
years are not required to be produced in the event of an audit?
b. Are we still required to prove the patient qualified at setup?
c. What are the minimum number of elements necessary to justify in an audit?
The billing for ongoing supplies for an “archived medical record” patient? (e.g.
current office notes documenting DX of OSA along with use and benefit, a
new script, a copy of the original sleep study, etc.)?
Response: The DME MACs are asking CMS for guidance on this issue. In the interim, see MLM SE1022.
- Question RE: Enteral DWO requirement for frequency presented during Noridian’s last Enteral Webinar in November, 2014.
WE understood from the November Enteral Webinar that for patients receiving enteral nutrition via a pump, the ml/hr are NOT required on the DWO; stating that if the Formula, number of cans per day, calories per day, administered via a PUMP continuous over _____/ hours is indicated on the DWO this would be acceptable.
Can we confirm this will be accepted for CMR’s and Level I appeals?Yes…I confirmed during our Enteral internal meetings that it is acceptable. Duration of infusion is still a requirement of the detailed written order. However, it is not required that ml/hr be included on the detailed written order. For example, it would be acceptable for the order to indicate “over 24 hours, infuse for 1 hr 4x/day, etc. If the detailed written order indicates both calories per day and ml/hr, we should not deny for a reasonable amount of conflicting calories that are based off differences in calculations.
- Recently it has been brought to our attention that beneficiaries that are admitted to a SNF are allowed a Special Enrollment Period to change from MA plan, MAPD plan, to Traditional Medicare and vice versa. Additionally, they are allowed to change enrollment again for up to two months following their discharge from the SNF starting with the 1st day of the month following their discharge.[See reference link below]
If a beneficiary was with a MA plan prior to being admitted to a SNF, enrolled in Traditional Medicare while in the SNF, and then discharges on Traditional Medicare for the remainder of the month until they can opt back into the MA Plan the following month, are Suppliers required to treat these situations as a NEW Medicare admit, and meet all of the standard documentation requirements? For example, we would need to provide a new pump or statement that the equipment they are receiving is in good working condition, complete a NEW Initial DIF/CMN, and obtain all of the documentation to meet LCD requirements?
Some concern here that documentation required by the MA plan to meet coverage criteria is not quite as stringent as Traditional Medicare requirements, and therefore the beneficiary may not meet all of the requirements for coverage that they were receiving prior to the admit to SNF.. Would an ABN be appropriate in these situations?Yes, if FFS Medicare coverage criteria are not met either a Mandatory or Voluntary ABN would be acceptable depending if the criteria are statutory or an expected not reasonable and necessary denial.
Below is copied from the Medicare.gov website:
Special enrollment periods (SEP) with Medicare
I just moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital).
What can I do?
•Join a Medicare Advantage Plan or Medicare Prescription Drug Plan.
•Switch from your current plan to another Medicare Advantage Plan or Medicare Prescription Drug Plan.
•Drop your Medicare Advantage Plan and return to Original Medicare.
•Drop your Medicare prescription drug coverage.
When?
Your chance to join, switch, or drop coverage lasts as long as you live in the institution and for 2 full months after the month you move out of the institution.
- Suppliers need to know how to handle situations where a patient has been ordered to receive oxygen but does not qualify. The patient may not have had a blood gas taken or had one that did not meet criteria.
At one point JD B had issued guidance but it has since been removed. Currently there is no guidance available to guide suppliers.
This issue is also being brought to CMS by AA HomeCare but we need to know the best way to proceed in these situations.There are various ways of identifying the oxygen should be denied. If the CMN comes in with non-qualifying results the oxygen should deny. Sometimes the CMN appears to be qualifying but the supplier may still be expecting a denial because the testing was not appropriate (i.e. only 2 tests taken during exercise) and in those circumstances a narrative stating such is recommend however claim may still pay and then the supplier will need to send funds back via the Refund to Medicare form and at that time we can place the CMN in a denied status. FYI…The DAC requested a article similar to what’s on JB sites…I sent to Tiff to see if she would like to consider a Joint DME MAC article.