Questions to Noridian/CEDI
Winter 2013
CEDI
Leader: Michele Hessler
Assistant: LeeAnn Ruber
EC Liaison: Sheila Roberson
No questions submitted.
EDUCATION
Leader: Connie Lind-Fraher
Assistant: Cindy Coy
EC Liaison: Mary Stoner
1. Ref. Face-to-Face Requirement
Can the co-sign requirement by a physician on the face-to-face assessments be waived? We are concerned about the ability of beneficiaries, especially those in rural areas, to obtain medically necessary equipment in a timely manner after the face-to-face requirement goes into effect July 1, 2013. The limitations (co-signed by a physician requirement) on physician assistants, nurse practitioners and clinical nurse specialists assessments could cause delays for the beneficiaries in obtaining needed equipment in many rural areas that have a shortage of physicians.
Response: CMS recently issued a final rule with comment as part of the annual Physician Fee Schedule Update. The notice outlined requirements for detailed written orders and face-to-face examinations for a list of HCPCS codes. These requirements are proposed to be effective as of July 1, 2013. CMS has not issued any additional information regarding these requirements or responded to comments submitted as part of the final rule with comments process. As CMS communicates implementation plans for these provisions to the Medicare contractors, NAS will notify and educate the provider community.
2. Ref. MNL Matters #MM8009
Where do providers obtain information on Medicare beneficiaries that will inform us as to the "legal" status of that beneficiary? It is unrealistic to expect suppliers to know that a beneficiary is "illegal" if Medicare and the social security administration recognize them as being eligible at the time supplies and equipment are dispensed.
Response: This is a requirement of Section 401 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which prohibited aliens who are not “qualified aliens” from receiving Federal benefits, including Medicare benefits. Suppliers will need to look to the patient for payment in these circumstances and not Medicare.
HME
Leader: Lelia Wilkerson
Assistant: Gloria Schulte
EC Liaison: Mary Stoner
No questions submitted.
IV PEN
Leader: Rosalie Weber
Assistant: Jeff Schwindt
EC Liaison: Dave Hosman
3. We are asking for clarification on POD, Method 2 from the Standard Documentation Language copied below in that is now states we must provide * Date Delivered, and * Evidence of delivery.
Method 2—Delivery via Shipping or Delivery Service Directly to a Beneficiary
If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable proof of delivery would include both the supplier's own detailed shipping invoice and the delivery service's tracking information. The supplier's record must be linked to the delivery service record by some clear method like the delivery service's package identification number or supplier's invoice number for the package sent to the beneficiary. The POD record must include:
· Beneficiary's name
· Delivery address
· Delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records.
· Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)
· Quantity delivered
· Date delivered
· Evidence of delivery
However, the most recent update to the PIM Chapter 4.26.1 (copied below) clearly states for delivery method 2 that the date delivered is not a requirement, but should be provided when possible.
Recent audits are recouping for Method 2 for not having the date of delivery. It would seem that if a supplier has the suppliers own detailed delivery ticket, the shipping service proof of ship to the beneficiary which contains the beneficiary name, address, items shipped, and confirmed date shipped with tracking number that would meet the guidance below.
4.26.1 - Proof of Delivery and Delivery Methods (Rev. 389, Issued: 09-30-11, Effective: 10-31-11, Implementation: 10-31-11)
The date of signature on the delivery slip must be the date that the DMEPOS item was received by the beneficiary or designee. In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply shall be the date of service on the claim.
If the supplier utilizes a shipping service or mail order, an example of proof of delivery would include the service’s tracking slip, and the supplier’s own shipping invoice. If possible, the supplier’s records should also include the delivery service’s package identification number for that package sent to the beneficiary. The shipping service’s tracking slip should reference each individual package, the delivery address, the corresponding package identification number given by the shipping service, and if possible, the date delivered. If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the date of service on the claim.
Response: The Standard Documentation Language goes beyond PIM 4.26.1 to make it absolutely clear that both the date delivered and “evidence of delivery” are required. Having the delivery service tracking slip/record which shows the date delivered meets the “evidence of delivery” requirement. If a claim denies with evidence of delivery, NAS recommends appeal.
4. Records outside of the 7 year requirement
It seems that with the increase in audits for TPN and Enteral patients we are being penalized and payment denied if we cannot provide the initial qualifying documentation for our long term TPN/ENT patients that may have initiated treatment far beyond the 7 year record retention requirement. While we may have the “continued need” documentation on file and/ or a renewed prescription signed and dated, in situations where the initial qualifying records are no longer available, does the supplier have any legal recourse?
Response: If the beneficiary originally qualified for TPN while Medicare eligible, NAS will not look for medical records greater than 7 years old. If the beneficiary recently became Medicare eligible, NAS must have medical records to support initial coverage criteria. If those records are over 7 years old and not available, coverage criteria cannot be verified and new documentation is therefore necessary.
5. Request clarification regarding Request for Refill documentation requirement for the following “kit” codes.
A4221 - Supplies for maintenance of drug infusion catheter, per week (list drugs separately)
A4222 - Infusion supplies for external drug infusion pump, per cassette or bag (list drugs separately)
B4220 - Parental nutrition supply kit; premix, per day
B4222 - Parental nutrition supply kit; home mix, per day
B4224 - Parental nutrition administration kit, per day
B4034 - Enteral feeding supply kit; syringe fed, per day, includes but not limited to feeding/ flush syringe, administration set tubing, dressings, tape
B4035 - Enteral feeding supply kit; pump fed, per day, includes but not limited to feeding/ flush syringe, administration set tubing, dressings, tape
B4036 - Enteral feeding supply kit; gravity fed, per day, includes but not limited to feeding/ flush syringe, administration set tubing, dressings, tape
NHIC FAQ 8.31.12 Q2: Some DME items like infusion pumps and enteral and parenteral nutrition pumps also have non-consumable items as supplies. What items are considered to be durable or non-consumable supplies?
A: Supplies used with RAD and PAP devices and mastectomy bras were the initial supply items identified as non-consumable or durable and not requiring routine, scheduled replacement. Some items such as external infusion pumps or enteral and parenteral nutrition pumps have supplies provided in all-inclusive supply kit allowances. These supply kit allowances are considered payable as noted in the applicable local coverage determinations (LCDs) to cover all costs of supplies necessary for effective use of the base product.
This question has also been asked to the 4 DMEMACs in regard to request for refill and supply/administration kits. We understood from all 4 DMEMAC’s that we do not have to ask for individual items remaining that are included in a daily kit. However, we are hearing from the home infusion industry there is an increase in denials for request for refill lacking documentation of the supplies the beneficiary has remaining. It would seem that since the “kits” are provided and billed for each day of administration of the primary product, drug, dose, etc. that verifying the amount or number of doses/TPN bags/Enteral formula will be needed justifies the accompanying administration supplies.
Since the kit is billed for each day of administration or daily allowance (one unit of service may be billed for any one day of administration), If providers document (1) How many bags of ___ or doses of ___ the beneficiary has remaining prior to next scheduled delivery, and (2) documenting they need the necessary supplies to administer those bags/doses…for example “will you need the usual supplies to administer your bags/doses of ____?.” Will this be considered as acceptable in audit situation?
How can we impact or educate the auditing contractors that we do not need to list out each individual item remaining? Since there is no definition of how much of each item in expected to be included in the “admin/ supply kit” and the “kit” is all inclusive of the items needed to administer the primary drug/nutrition, the provider must document that the patient needs the “kit”. It should be obvious that the drug, TPN, or Enteral Formula cannot be delivered by itself – there must be tubing, syringes, cassettes, bags, extension sets, and many other ancillary supplies necessary to get the “product” to the “SITE” that enters the patient’s body. When the auditor deems we have not met the requirement to document the supplies remaining, they are recouping the entire therapy….not just the supply kits.
This is becoming an undue burden for suppliers to have to go through the appeals process for these denial situations regarding documentation for “kit” supplies needed to administer the product/ drug/ Enteral and TPN therapy.
To illustrate the vast number of items necessary to administer infusion therapies we are providing an example what is included in what is perhaps the most simple of the kits, A4221.
The supplies necessary to maintain infusion catheters, A4221, can vary based on the type of IV access the patient has (Central Line, Midline, PICC line, Peripheral). Supplies commonly provided to patient for infusion catheter maintenance include, but are not limited to the following...
· Central line dressing trays that typically include the following items...
•1 face mask
•2 gloves
•1 towel
•1 alcohol swab stick
•1 tape measure
•1 gauze pad 2 x 2 inches
•1 gauze pad 4 x 4 inches
•1 dressing, non-adhering
•1 sponge, IV 2 x 2 inches
•1 roll medical tape
•1 transparent dressing
•1 patient label,
In addition to the dressing trays the patient will also need…
§ Bio-patches (or other brand of dressing)*
§ needleless connectors*
§ extension sets
§ alcohol wipes
§ catheter securement device
§ Flushes saline and heparin.
* The type of needless connector and dressing provided may vary based on where the patient is receiving primary care (site specific protocols).
The supplies necessary for external infusion pumps (A4222) can also vary greatly. Most external infusion pumps have dedicated sets, meaning the drug container utilized (bags or cassette) are pump specific and come in variety of sizes (50ml, 100ml, 250ml. etc.) In addition to the cassette or bag the patient may also need administration sets, extension sets, needless connectors, catheter maintenance supplies (see list above). If chemotherapy drugs are being provided the patient will also need a chemo skill kit and special chemo sharps container to manage hazardous waste.
We would be happy to provide additional examples if you would find it helpful.
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.
MED SUPPLIES
Leader: Gilbert Hererra
Assistant:
EC Liaison: Sheila Roberson
6. On 08/01/2012 the Tracheostomy Care Supplies LCD was updated with new policy quantity limits. Was there a comment period for these changes? If so, how and when was the provider community informed of the comment period?
Response: Maximum allowable quantities were based on the same codes used in the ostomy LCD and the clinical literature demonstrating the time frames recommended for changes in the home setting.
O & P
Leader: JR Brant
Assistant: Janet Malinowski
EC Liaison: Leslie Rigg
No questions submitted.
REHAB
Leader: Rick Graver
Assistant: Paula Koenig
EC Liaison: Leslie Rigg
7. In our example, we have a K0108 miscellaneous part which is a bolt that holds a motor onto a frame of a motorized wheelchair. The item is separate from the motor, is not considered part of the motor, and has a separate part number and cost from the manufacturer. In this example the bolt is the part that is broken and the chair is not safe to drive because the motor is falling off the frame of the chair. Would the bolt be considered for coverage if all the information regarding K0108 is provided and is compliant?
Response: Yes, the bolt can be considered for coverage in this circumstance. The narrative should explain the only part replaced was a broken bolt.
8. Can NAS help the providers with some guidance when we work with teaching facilities, group practices and
other instances wherein multiple doctors might see the patient? Specifically where there may be multiple doctors spread across the chart notes, prescription, eval reports, and DPD, what is the best way to document the proper physician?
Response: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, added section 1834(a)(1)(E)(iv) which provides that payment may not be made for a motorized or power wheelchair unless the practitioner who has conducted the face-to-face examination him or herself writes the 7-element order. It is a statutory requirement that all items of the 7-element order be entered specifically by and only by the practitioner who has conducted the face-to-face requirements. This information is found in the PMD Policy Article. Recommend sharing it with your referring physicians. One physician is responsible for the completion of the FTF examination, 7-element order and signing the detailed product description.