July 16, 2010
Ask-the-Contractor Teleconference (ACT) Q&A – June 8, 2010 – Revised
Note: Questions 39 through 45 have been added to this document.
The DME MAC Jurisdiction A quarterly ACT call was conducted June 8, 2010 as a teleconference/webinar. A presentation of general updates and hot topics was provided followed by an open Q&A chat session. As participants submitted questions via the webinar chat mechanism staff responded by sharing both the question and the answer with the entire audience. In addition, many questions were also obtained during the registration process which enabled staff to provide verbal responses to everyone during the call.
Note: Individual claim specific questions are not included below. As advised during the call, please contact Customer Service to address these types of questions.
Q1: What is the use of the KR modifier?
A1: Suppliers are entitled to bill and receive a full month of reimbursement for capped rental items that are provided to qualifying beneficiaries; however, suppliers have the option of billing for a partial month of service and receiving reimbursement on a prorated basis by using the KR modifier.
Q2: Are diabetic shoes covered under the Part B benefit for a patient in a skilled nursing facility (SNF)?
A2: Yes, but only if the Medicare beneficiary has exhausted his or her allowed days of inpatient coverage under Part A. If the patient is at a SNF being covered under Medicare Part A, the facility is responsible for the cost of the shoes.
Q3: Can the signature date on a Certificate of Medical Necessity (CMNs) or physician order be stamped or is a handwritten signature date required?
A3: The signature date must be handwritten. Signature and date stamps are not acceptable.
Q4: Is it acceptable for a doctor to put his initials over a stamped date to affirm that the date is correct?
A4: No. Date stamps are not acceptable under any circumstance.
Q5: When billing for items that a patient does not qualify for but are typically covered in other circumstances we do not get a patient responsibility (PR) denial when using the GY modifier. Why would this occur?
A5: The GY is not appropriate to use in that situation. The DME MACs use the presence of a KX, GA, GZ or GY modifier to indicate whether the coverage criteria are or are not met. System edits are in place that will reject a claim line if the supplier does not include one of these modifiers if instructions are included to do so in the particular Local Coverage Determination (LCD). Refer to the LCD to determine the appropriate modifier use. The Documentation Section outlines the use of these additional modifiers to indicate that an item is statutorily noncovered or not medically necessary and whether or not a waiver of liability statement (i.e., Advance Beneficiary Notice of Noncoverage or ABN) is on file for an expected medical necessity denial.
Q6: The Oxygen and Oxygen Equipment LCD has a statement related to the testing and visit requirements that indicates if the patient is transitioning from a Medicare HMO to fee for service (FFS) Medicare then a new test result is not required within 30 days of the Initial CMN and the most recent available test can be used. Is there a similar policy in place regarding sleep study testing for a PAP device?
A6: Yes. Refer to the LCD for PAP Devices for information related to beneficiaries who received a PAP device prior to enrollment in FFS Medicare.
Q7: We have a patient whose doctor prescribed a rollator (wheeled walker) and their diagnosis is atrial fibrillation. Is that a covered diagnosis for this item?
A7: Coverage of any type of mobility assistive equipment (MAE) is not based solely on a diagnosis. MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. Determination of the presence of a mobility deficit will use the algorithmic process outlined in the Clinical Criteria for MAE Coverage. For additional coverage information, refer to the LCD for Walkers located on the DME MAC A Web site.
Q8: Where can I find the Medicare enrollment application for PECOS?
A8: Information on Medicare enrollment is located in the Medicare Provider and Supplier Enrollment section of the CMS Web site at: http://www.cms.gov/MedicareProviderSupEnroll/01_Overview.asp
Q9: Can you clarify the new rule related to the timely filing of Medicare claims?
A9: Claims for services furnished on or after January 01, 2010, must be filed within one calendar year after the date of service. In addition, claims for services furnished before January 01, 2010, must be filed no later than December 31, 2010. The following rules apply to claims with dates of service prior to January 01, 2010. Claims with dates of service before October 01, 2009, must follow the pre-PPACA timely filing rules. Claims with dates of service October 01, 2009, through December 31, 2009, must be submitted by December 31, 2010. Refer to the Timely Filing Requirements for Medicare Fee-For-Service Claims article for additional details.
Q10: If equipment is broken beyond repair, (i.e. fell down a flight of stairs and it cannot be repaired) can it be replaced?
A10: Yes. Medicare will consider coverage for replacement equipment in situations where the equipment was broken beyond repair. For additional details, refer to the article titled Billing Reminder: Submitting Claims for DME Replacement Items Broken Beyond Repair which is available on the DME MAC A Web site.
Q11: If a patient previously rented a CPAP machine under a Medicare HMO and they are now transitioning to fee for service (FFS) or traditional Medicare, must they meet all current Medicare policy requirements?
A11: Per the LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, beneficiaries who received a CPAP device prior to enrollment in FFS Medicare and are now seeking Medicare coverage of either a replacement PAP device and/or accessories, both of the following coverage requirements must be met:
Sleep Test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare, that meets the FFS Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks a replacement PAP device and/or accessories; and,
Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating physician who documents in the beneficiary’s medical record that:
The beneficiary has a diagnosis of obstructive sleep apnea; and,
The beneficiary continues to use the PAP device.
If either criteria 1 or 2 above are not met, the claim will be denied as not medically necessary. The supplier may hold claims, pending confirmation that the above requirements are met, and then submit claims with the KX modifier beginning with the date of the beneficiary’s enrollment in FFS Medicare. Refer to the Positive Airway Pressure Devices for Treatment of Obstructive Sleep Apnea LCD for additional details.
Q12: When Change Request (CR) 6698 was re-issued on April 26, 2010 the fact that the signature log must be a part of the patient’s medical record was removed. Is it correct that the signature log does not have to be placed in the medical record?
A12: The revised CR is correct and this requirement was removed. Please reference MM6698 for the most current information on signature requirements.
Q13: How long does a supplier have to deliver a CPAP device after the sleep study is completed?
A13: Currently, there is no set time limit for a CPAP delivery, but it should occur within a reasonable amount of time for the patient’s medical situation.
Q14: When billing Vancomycin for a denial, why would you use the GX modifier opposed to the GA modifier?
A14: Since Vancomycin is a drug that is statutorily excluded from coverage, the GX modifier would indicate a voluntary ABN was provided and can be used in addition to the GY modifier. The GA modifier should not be used for voluntary ABNs and should not be used in combination with a GY modifier. Suppliers should reference the HCPCS Modifiers list for a complete listing of modifiers.
Q15: We currently bill non-covered items (Vancomycin via pump) with a GA modifier. Should we be billing the Vancomycin and supplies with GYGX and the pump with GA?
A15: Vancomycin is a statutorily excluded drug and should be billed with a GY modifier to indicate noncoverage. A GX may also be used in combination with the GY if a voluntary ABN was issued for the Vancomycin. The pump and supplies would be billed with a GA modifier (assuming a properly issued ABN was signed) as they are not statutorily excluded. Suppliers should reference the HCPCS Modifiers list for a complete listing of modifiers.
Q16: Can you please provide us with an example of when the GX modifier would be used?
A16: This informational modifier is used to report when a voluntary ABN was issued for a service. Providers may use the GX modifier to provide beneficiaries with voluntary notice of liability regarding services excluded from Medicare coverage by statute. See the responses to questions 14 and 15 above for an example.
Q17: What should I do if a patient is using a family member’s CPAP and wants to get the supplies covered through Medicare?
A17: The date they obtained the CPAP would be considered the date of purchase. However, medical necessity information would have to be established and would have to meet the coverage and documentation requirements in the Positive Airway Pressure (PAP) LCD.
Q18: Can you review the oxygen documentation requirements for CERT? Are providers required to have documentation on file that patient is continuously using oxygen, and how often are we required to get an update?
A18: Refer to the Oxygen and Oxygen Equipment LCD (L11468) and related Policy article and DME MAC A Supplier Manual (Chapter 10 – Durable Medical Equipment) for additional information regarding coverage and documentation requirements. Suppliers are also encouraged to visit the DME MAC Web site on a regular basis to remain current with the latest information regarding the LCDs for Jurisdiction A. In addition the following educational articles are relevant to payment of oxygen equipment claims: March 2010 CERT Errors and Documentation Reminder – Order Requirements.
Q19: Do we need to get an update every 3 months from the physician in regards to continued oxygen use?
A19: Not every 3 months. For patients initially meeting the group I or group II criteria, the patient must be seen and re-evaluated by the treating physician within 90 days prior to the date of any Recertification. For additional information, refer to the LCD for Oxygen and Oxygen Equipment.
Q20: Why would Medicare pay on an O&P claim for an L1832 when the claim was billed with a qualifying diagnosis code but the GZ modifier was on the claim?
A20: The GZ modifier will not necessarily cause a claim to automatically deny. The claim would still be looked at on its own merits. If it required a KX and was billed with a GZ instead, the claim would deny.
Q21: Do I have to attach signature log when I send redetermination.
A21: If the order or any documentation does not meet the requirements as being legible, it would be in your best interest to submit the signature log with your redetermination.
Q22: The attestation statement indicated under signature guidelines is referring to a physician attestation for medical records correct? An attestation for a prescription refill can be provided by either a pharmacy or a patient correct?
A22: It would be required for the prescription as well if the physician’s name is not printed on the document.
Q23: We have one particular doctor who is out on leave. Other doctors have split up her case load and are signing physician orders on her behalf. Is this wrong based on what was just said regarding signatures?
A23: You must use the NPI of the person who signed the order.
Q24: If medical records are typed on letterhead, does the provider need to sign the notes? Without the signature, are they still valid medical records?
A24: Yes, even though there is a letterhead present on the medical records, the physician’s signature is still required. Since the letterhead is present, the signature does not need to be legible. If the signature was missing, this would invalidate the medical records. Additional information and examples regarding signature requirements are located in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.4.1.1
Q25: Is a provider generated form acceptable for the therapeutic shoe exam?
A25: It can be used; however, anything on the form must be supported by information in the patient’s medical record. For additional information regarding documentation refer to the Medicare Program Integrity Manual, Publication 100-08, Chapter 5, Section 5.7
Q26: Will providers start receiving denials on their claims if the doctor is not enrolled in PECOS system 07/01/2010?
A26: We are seeking CMS clarification regarding this issue. Once clarification is received, we will publish the information to our Web site. Please be sure you are registered to receive DME MAC A ListServe notification in order to receive important announcements.
Q27: Can we get a copy of the PECOS letter that is going out to the doctors?
A27: Yes. The letter is included in CR6842.
Q28: If a CMN is submitted with the physician’s name and address printed in Section A but the signature on the CMN is illegible is this considered a valid signature?
A28: If the signature is not legible you will need to get a signature card, attestation, etc., to verify the physician’s signature. Additional information regarding signature requirements is available in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.4.1.1
Q29: What documentation and paperwork is the supplier required to have in order to dispense a CPAP or BIPAP machine?
A29: Refer to the LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea or the LCD for Respiratory Assist Devices to review the appropriate documentation requirements. Additional references such as FAQs, educational articles, bulletins, etc. are available in the Medical Review section of the DME MAC A Web site.
Q30: Is a new prescription required for repairs on a CPAP machine that was previously billed by another supplier?
A30: No. Repairs do not require new orders. However, the supplier must have access to the documentation supporting the medical need for the CPAP including the initial order.
Q31: Are “signature cards” required if the order has an illegible signature but their name is pre-printed on the order?
A31: No. A signature card is not necessary if the physician’s name is pre-printed on the order. The only time a signature card may be required is if there is no pre-printed name or letterhead on the document in question. Additional information regarding signature requirements is available in the Medicare Program Integrity Manual, Publication 100-08, Chapter 3, Section 3.4.1.1
Q32: Does the clinical documentation from the physician need to be on file before billing Medicare?
A32: No. The clinical documentation does not need to be on file but we strongly encourage you to obtain the documentation for your records in the event of an audit.
Note: There are exceptions for certain items that may require supplier receipt of clinical documentation prior to dispensing an item. Refer to the specific LCD for additional information.
Q33: When an Enteral Nutrition DIF is changing from qualifying to non-qualifying should the non-qualifying DIF be “Revised” or “New Initial”?
A33: This would be a revision to the qualifying DIF as long as the HCPCS remain the same.
Q34: How do you bill repairs and replacements?
A34: Please refer to the following articles for additional information regarding Repairs and Replacements: Submitting Claims for DME Replacement Items Broken Beyond Repair, Repairs and Replacement for Beneficiary Owned Equipment, Frequently Asked Questions (FAQs).
Q35: If there are more current test dates and results for an oxygen recertification or revision should these be submitted rather than the initial results?
A35: Yes. Per the LCD, “For patients initially meeting Group I criteria, the most recent qualifying blood gas study prior to the thirteenth month of therapy must be reported on the Recertification CMN.”
For Revision CMNs, the most recent testing must be submitted for situations 7 and 8 in the Revision Certification section of the LCD. Please refer to the following link for additional information; Oxygen and Oxygen Equipment LCD.
Q36: When using a shipping service (i.e., USPS, FedEx, etc.) what is the date of service on the claim?
A36: The date of service is the shipping date.
Q37: If a patient is non-compliant with their CPAP device, do we need Rx to pick up the machine?
A37: There are no Medicare regulations regarding this issue; however, there may be state laws in place which prohibit you from picking up the equipment. We suggest you review your state laws regarding this issue.
Q38: When we get an order for a service that contains many supplies is the phrase “and all related supplies” acceptable?
A38: No. The order must include all items and accessories being ordered. Additional information is available in the DME MAC A Supplier Manual Chapter 10 – Written Orders.
Q39: A patient received a K0001 and is unable to sit straight up without pillows and cushions. The physician has now ordered a Tilt-in-Space, E1161. Can we get this new item covered?
A39: It is recommended that you request an Advanced Determination of Medicare Coverage (ADMC) for the E1161 prior to dispensing the item. Upon receipt of the ADMC request, the DME MAC will review the information in order to determine if there is sufficient medical documentation that supports whether the item is reasonable and necessary. In addition, a review of the beneficiary’s claims history shall be conducted in order to determine whether any other reason exists to cause the claim to be denied, e.g., whether the same or similar equipment has already been provided. For additional information on the ADMC process, refer to Chapter 10 of the DME MAC A Supplier Manual.
Q40: Does a patient need to make an appointment with the physician every 3 months to be evaluated for continued need?
A40: Currently, there is no set requirement for a physician visit every three months; however, rental items such as oxygen, nebulizers, CPAP, wheelchairs, and hospital beds and recurring supplies such as glucose test strips, urological supplies, and ostomy supplies must be periodically justified in the medical record in order for Medicare to continue reimbursement for these items. In these instances, the physician or their staff should regularly review the use of medical equipment and supplies by their patients. For additional information, refer to the Dear Physician Letter – Durable Medical Equipment – Documentation of Continued Medical Necessity.
Q41: Can a physician sign an order for a resident who originally placed the order? Do we bill with the residents or the physician’s NPI?
A41: The physician or the resident may write and sign the detailed written order. The NPI identified on the claim must match whoever signed the order. The patient’s medical record should clearly document the circumstances surrounding why the physician who signed the order is not the same person who initially placed the order.
Q42: I have a copy of the physician’s records as proof of medical necessity. Does the physician need to sign his/her name to the dictated notes?
A42: Yes. A signature and date is required in order to authenticate the dictated notes.
Q43: Can a GY and GA modifier be billed on a custom wheelchair?
A43: The GY and GA modifiers should not be used in combination on the same claim line. Use of the GY modifier for a wheelchair applies only in situations where the wheelchair would be statutorily excluded. For example, wheelchairs used exclusively outside the home are considered statutorily excluded and should be submitted with the GY modifier. The GA modifier is used in situations where the wheelchair is expected to be denied for medical necessity and the supplier has properly obtained an Advance Beneficiary Notice of Noncoverage (ABN). Refer to the LCD for Manual Wheelchair Bases or the LCD for Power Mobility Devices for the appropriate use of these modifiers.
Q44: Do we need to establish medical necessity for a beneficiary owned base piece of equipment that was purchased privately if this item now needs repairs?
A44: Yes. Medical necessity documentation for the beneficiary owned base piece of equipment must be kept on file in order for Medicare to determine if the repair is suitable. This information may be requested in the event of an audit.
Q45: In the event that Medicare should start rejecting claims July 06, 2010 due to PECOS editing and a physician enrolls in PECOS after this date, will the enrollment be retroactive? What happens if we accept an order prior to the physician’s enrollment date?
A45: CMS is not making any enrollments retroactive; however, if a claim should reject due to the PECOS editing the claim can be resubmitted. Rejections will be based on the date the claim is processed, not the date of the physician’s enrollment.