Region D Questions to CMS

June 26th, 2013 Teleconference

  1. There have been several questions asked recently about billing Enteral for denial in a CB area by a non contracted CB supplier.We asked this question back in the spring of 2011 and I have copied below.

However, providers have been receiving different responses from the CBIC .

Can we ask for confirmation on this question & answer below from a claim processing standpoint? Meaning, if we have ABN for Enteral and bill with the GA modifieror GY modifier– we would expect to get the PR denial regardless of being a contracted or non-contracted Enteral supplier.

IV PEN Spring 2011 Region D Q&A

Leader: Deanne Birch

Assistant: Rosalie Weber

EC Liaison: Sheila Roberson

23. The following question was asked and answered by Elaine Hensley (CBIC). We would like to ask if Noridian agrees with the answer that an ABN would be appropriate, and the supplier would get a PR denial.

Q:A supplier is providing Enteral therapy to a beneficiary in a competitive bid area, but supplier is not contracted. The Enteral therapy does not meet the coverage criteria under the Enteral benefit, so the supplier is billing Medicare for denial to move the claim to the patients secondary payor that will cover the Enteral therapy.

A: Elaine stated thatthe system logic would 1) look at the product category first, and then 2) look at the supplier contracted status.

Under the above situation, the supplier is non-contracted to provide the product category, and would need to obtain an ABN and bill with the GA modifier in order to get a PR denial.

The IV/PEN would like to confirm that the DMEMAC would in fact process the claim with a PR denial given the GA modifier? Non-contracted suppliers should follow the CBICs instructions.

If the reason for denial was due to the Enteral Therapy being ordered for less than 90 days, therefore is statutorily non-covered, we would normally append a GY modifier and could give a voluntary ABN. Would we still get the PR denial under the above circumstances if in a CB area and a non contracted supplier? Yes. Suppliers outside of a CBA would use the GY modifier for temporary conditions, but within a CBA you must follow the CBICs instructions first, which will give you the same end result, a PR denial.

  1. Since so many Suppliers bill multiple MAC’s and on occasion the MAC’s have a difference in interpretations of the Policy how can Suppliers able to get this reconciled? Please see example below”

NGS Jurisdiction B council in January 2013:

24. If an audit/ADR is received for an oxygen patient who was restarted after 5 years, what documentation is required to be submitted?

Answer: If a claim for the rental of the replacement equipment (following RUL) is selected for review, the reviewer may request a copy of the dispensing order, the detailed written order and/or CMN, qualifying test results supporting information on CMN (new testing is not required for replacement of equipment), documentation of continuing use and documentation of continuing need. When responding to a request for documentation, the supplier should carefully review the ADR letter to determine the documentation being requested by the reviewer. The supplier must submit all documentation requested for review.

CGS Jurisdiction C has emphatically told us we always need a new dispensing order.

Q&A from Noridian Jurisdiction D:

Appeals Ask the Contractor Teleconference Q&A – April 3, 2013

Q: Does a 5 year oxygen restart require a dispensing order?

A: It is not necessary to have a new dispensing order for oxygen Reasonable Useful Lifetime (RUL). It is up to the beneficiary to elect replacement at the end of the five year period. A new initial Certificate of Medical Necessity (CMN) is needed and proof of continued medical need would be required.

  1. Question regarding MOA (method of administration) vs. ROA (route of administration) on DWO

We have just recently started to see denials for not stating both the MOA and the ROA on the DWO for Enteral. We generally list the MOA as being pump, gravity, or bolus on the DWO which correlates with the MOA on the DIF. The patient’s medical record supports the Enteral is via tube feeds, and is also acknowledged on the DIF as well. The LCD states we would append the modifier BO if Enteral is for oral administration.

Can Noridian please clarify what is expected for a valid Enteral DWO? We are finding conflicting information from recent enteral webinars by Region C and Region D, and in comparison to the PIM. Please see all references below:

Region C recent webinar states:

The detailed written order should contain:

  • Beneficiary’s name
  • Description or name of the nutrient to be administered
  • Administration instructions {method (syringe, gravity or pump), rate and/or frequency, amount}
  • Number of refills
  • The treating physician’s signature
  • The date the treating physician signed the order
  • The start date of the order, if different than the signature date
  • If the order is for a rented item or if the coverage criteria in a policy specify a length of need, the order must include the length of need

Region D recent webinar states:

Additional Detailed Order Elements

  • Accessories or supplies
  • Quantity used
  • Frequency of change or use

•Formula

•Calories per day

  • method and route of administration, duration of infusion

DETAILED WRITTEN ORDERS (PIM 5.2.3)

For items provided on a periodic basis, including drugs, the written order must include:

  1. Item(s) to be dispensed
  • Dosage or concentration, if applicable
  • Route of Administration
  • Frequency of use
  • Duration of infusion, if applicable
  • Quantity to be dispensed
  • Number of refills.

Below is example of how we have interpreted the above PIM requirements to be compliant. Note that both MOA and ROA are not required, so we have completed as noted below in red.

Item to be dispensed(would be formula, pump, and supply kits -We do add the feeding tube type in case of replacement & we bill for it)

Dosage or concentration, when applicable (would be the no of calories or cans/day or cc per hour over # /hours.)

Route of administration (would be gravity, pump, or bolus syringe - we have the verbal order for feeding tube type and it is on the DIF via tube)

Frequency of use (generally daily)

Duration of infusion, when applicable(again would be cc/hour over **/hours…or # cans/ bolus X **/day etc. etc.)

Quantity to be dispensed(it noted above with the dose and concentration, etc.)

Number of refills(would be duration of therapy ordered, i.e. 90 days6 months, lifetime, etc.)

Physician signature and signature date

We would like to see consistent direction among the various DMEMAC’s.

  1. There have been several times over the past 18 months where the MAC’s have made errors in processing of pre-pay audits and claims were denied that should not have been. Because of this Suppliers often have to appeal an incorrect denial often times up to the ALJ level. Other suppliers are able to try and track down someone at the MAC who recognizes the training/interpretation error , and will have the claims reprocessed. The Supplier will have to provide a spreadsheet of the accounts that were denied in error and the MAC will reprocess them off of the spreadsheet.

When an error is found why can’t a global fix be done to capture all claims that denied in error? In most situations the only ones that are corrected are those for the Supplier that asked the question. This does not seem fair to the entire supplier community.

  1. Why doesn’t the Supplier get interest since the MAC made a processing error?