Region C Council Q & A, November 17, 2004
To: Region C Council Members From: Palmetto GBA DMERC Supplier Education Date: November 17, 2004 Location: Wingate Hotel – Columbia, SC
Rehab
1) If a supplier has to make a part for a piece of equipment such as a custom foot box or custom mount for a specialty client, how is it supposed to be billed? There are many suppliers who actually build multiple items for beneficiaries who cannot be accommodated with an off the shelf or even a custom mold. What are the requirements for a supplier who builds such items?
If a supplier is making additions or modifications to a prefabricated item, in house or by sending measurements to the manufacturer, the item should be billed with the same HCPCS code as the prefabricated item. If the supplier is creating a custom fabricated item, i.e., the item has been individually manufactured for one patient as a molded-to-patient model, CAD-CAM or handmade to such precise measurements to ensure the item is unique for that individual, and the device cannot be used by any person other than the one for whom it was created, a supplier may submit documentation detailing the manufacturing technique and materials used in construction of the device, pictures of the products used, and samples of the product to the SADMERC for a HCPCS code determination prior to billing the DMERC. Suppliers may also bill for custom fabricated items using a miscellaneous code and include all of the supporting documentation with the claim. (Please note that SADMERC will keep any sample items submitted for review.)
Rehab cushion and back codes
Date of service driven? We need to get some clarification on the DMERC advisories that were published relating to the new codes for wheelchair cushions and backs.
These codes are effective for dates of service on or after October 1, 2004. However, adjustable seat cushions were removed from both the skin protection seat cushion codes (HCPCS codes K0652, K0653) and the combination skin protection and positioning seat cushion codes (HCPCS codes K0656, K0657). These cushions should be coded using HCPCS code K0108 (wheelchair component or accessory, not otherwise specified) until such time as an acceptable code description and test requirements can be determined. For more information, please refer to the article entitled, ‘Wheelchair Seating-Coding and Pricing Changes’ that was posted to the Palmetto GBA Web site on October 29, 2004.
2) Example #1: If an item was “furnished” as an E0192 (or any previous code) between July 1 and Sept 30th but not billed till after October 1, 2004, is the item date of service driven and billed using the previous code?
Yes, the supplier should use the code that was applicable when the item was dispensed.
3) Example #2: If an item was ordered by a PT/OT or physician prior to October 1, 2004 but not provided until after October 1, 2004 and the new allowables are so low that the supplier cannot even recover his cost, can he/she (a) substitute a different item within the same code without the PT/OT input (this is just an example) or (b) will the patient have to go back for another evaluation?
It depends on what was actually ordered by the physician. If the physician’s order was specific as to the brand, etc., then a substitution would not be allowed. However, if the item ordered is more generic, it could be substituted as long as it met the medical need of the beneficiary and the physician approves the change.
4) Are the DMERCS allowed to do individual consideration if there is a posted allowable?
No, we must pay claims based on the posted allowable.
Miscellaneous
5) See attached references to change request 3030 which affects the proof of delivery requirements with an effective date of May 10, 2004. According to region C references and web educational sessions, providers are still being told that the date of utilization is the date of service. Can region C please review the attached information and reiterate in the response which requirement is correct.
For initial shipments of items that are delivered directly to the patient, the date of service will be the date of delivery. For items shipped to the patient, the date of service will be the ship date.
For refills of items delivered directly to the patient, the date of service will be the date of delivery. For items shipped to the patient, the date of service will be the ship date. The supplier may ship/deliver the supplies up to five days prior to the end of the usage period if the patient has indicated their supply is nearly exhausted. The supplier may contact the patient up to 7 days prior to the shipping/delivery date to determine this.
The DMERCs will process claims when there is a date overlap. This overlap may not be any greater than five days. Please refer to a clarification article regarding this issue that was posted on the Palmetto GBA Web site on October 20, 2004.
4.26 – Supplier Proof of Delivery Documentation Requirements
(Rev. 71, 04-09-04)
Suppliers are required to maintain proof of delivery documentation in their files. Documentation must be maintained in the supplier’s files for 7 years.
Proof of delivery is required in order to verify that the beneficiary received the DMEPOS. Proof of delivery is one of the supplier standards as noted in 42 CFR, 424.57(12). Proof of delivery documentation must be made available to the DMERC upon request. For any services, which do not have proof of delivery from the supplier, such claimed items and services shall be denied and overpayments recovered. Suppliers who consistently do not provide documentation to support their services may be referred to the OIG for investigation and/or imposition of sanctions.
4.26.1 – Proof of Delivery and Delivery Methods
(Rev. 71, 04-09-04)
For the purpose of the delivery methods noted below, designee is defined as:
“Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary.”
Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier (i.e., spouse, neighbor, etc.). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.
Suppliers may deliver directly to the beneficiary or the designee. An example of proof of delivery to a beneficiary is having a signed delivery slip, and it is recommended that the delivery slip include: 1) The patient’s name; 2) The quantity delivered; 3) A detailed description of the item being delivered; 4) The brand name; and 5) The serial number. 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.
Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a form of proof of delivery. The descriptive information concerning the DMEPOS item (i.e., the patient’s name, the quantity, detailed description, brand name, and serial number) as well as the required signatures from either the beneficiary or the beneficiary’s designee should be included on this invoice as well.
For DMEPOS products that are supplied as refills to the original order, suppliers must contact the beneficiary prior to dispensing the refill. This shall be done to ensure that the refilled item is necessary and to confirm any changes/modifications to the order. Contact with the beneficiary or designee regarding refills should take place no sooner than approximately 7 days prior to the delivery/shipping date. For subsequent deliveries of refills, the supplier should deliver the DMEPOS product no sooner than approximately 5 days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. DMERCs shall allow for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply.
For those patients that are residents of a nursing facility, upon request from the DMERC, suppliers should obtain copies of the necessary documentation from the nursing facility to document proof of delivery or usage by the beneficiary (e.g., nurse’s notes).
4.26.2 – Exceptions
(Rev. 71, 04-09-04)
Exceptions to the preceding statements concerning the date(s) of service on the claim occur when the items are provided in anticipation of discharge from a hospital or nursing facility. A supplier may deliver a DMEPOS item to a patient in a hospital or nursing facility for the purpose of fitting or training the patient in the proper use of the item. This may be done up to 2 days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and shall use the Place of Service (POS) as 12 (Patient’s Home). The item must be for subsequent use in the patient’s home. No billing may be made for the item on those days the patient was receiving training or fitting in the hospital or nursing facility.
A supplier may not bill for drugs or other DMEPOS items used by the patient prior to the patient’s discharge from the hospital or a Medicare Part A nursing facility stay. Billing the DMERC for surgical dressings, urological supplies, or ostomy supplies that are provided in the hospital or during a Medicare Part A nursing facility stay is not allowed. These items are payable to the facility under Part A of Medicare. This prohibition applies even if the item is worn home by the patient from the hospital or nursing facility. Any attempt by the supplier and/or facility to substitute an item that is payable to the supplier for an item that, under statute, should be provided by the facility, may be considered to be fraudulent. These statements apply to durable medical equipment delivered to a patient in hospitals, skilled nursing facilities (Place of Service = 31), or nursing facilities providing skilled services (Place of Service = 32).
A supplier may deliver a DMEPOS item to a patient’s home in anticipation of a discharge from a hospital or nursing facility. The supplier may arrange for actual delivery of the item approximately 2 days prior to the patient’s anticipated discharge to their home. The supplier shall bill the date of service on the claim as the date of discharge and should use the Place of Service (POS) as 12 (Patient’s Home). CMS Manual System Department of Health & Human Services (DHHS) Pub. 100-08 Medicare Program Integrity Centers for Medicare & Medicaid Services (CMS) Transmittal 71 Date: APRIL 9, 2004
CHANGE REQUEST 3030
I. SUMMARY OF CHANGES: The Program Integrity Manual (PIM) chapters on medical review (MR) and benefit integrity (BI) were revised to apply to Program Safeguard Contractors (PSCs) as well as Medicare contractors that have not transitioned their MR and BI work to a PSC. Acronyms such as PRO, HCFA, and SVRS were changed to QIO, CMS, and statistical sampling for overpayment estimation respectively. This revision incorporates Change Request 2342, which was not communicated and replaces the current PIM in its entirety except for Chapter 10.
NEW/REVISED MATERIAL – EFFECTIVE DATE: MAY 10, 2004. *IMPLEMENTATION DATE: MAY 10, 2004.
Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. Any other material was previously published and remains unchanged.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual not updated.) (R = REVISED, N = NEW, D = DELETED – (Only One Per Row.)
R/N/D CHAPTER/SECTION/SUBSECTION/TITLE R Chapter 1 R Chapter 2 R Chapter 3 R Chapter 4 R Chapter 5 R Chapter 6 R Chapter 7 D Chapter 8 R Chapter 9 R Chapter 11 R Chapter 12 R Chapter 13 R Exhibits
*III. FUNDING: These instructions shall be implemented within your current operating budget.
IV. ATTACHMENTS:
X Business Requirements X Manual Instruction Confidential Requirements One-Time Notification Recurring Update Notification
*Medicare contractors only
Respiratory:
Dr. Hoover has indicated the following:
6) When a physician in the same practice signs a CMN for a patient with whom he is involved in the care Dr H says it is OK even if Section A states a different DR name. There is no need to have section A ratified. The question is which doctor do you report on the claim?
The treating physician must be listed in Section A of the CMN, and must be the same physician who signs section D. This instruction is printed on the back of the CMN form. Enter the unique physician identification number (UPIN) of the treating physician who ordered the equipment on the CMS-1500 claim form.
7) Is it ok for a different doctor to sign the CMN versus what is listed in section A? If so, then which MD goes on the claim?
No, the treating physician listed in Section A must sign Section D.
8) Has Region C DMERC received clarification or instruction from CMS on the questions posed in the July 2004 Region C Council Q/A, questions 8 & 9 regarding Letco Pulse Ox-System testing allowance?
We still have not received clarification from CMS regarding this issue. Until clarification is received, our education remains the same. The supplier should in no way be involved in the testing of oxygen patients. Suppliers may wish to contact a healthcare attorney until clarification is received from CMS.
9) What is the definition of a “mobile sleep lab” for CPAP and RAD testing purposes? If a sleep lab company, which does not have a Medicare provider number, sets up testing equipment on a patient in a hospital and bills the hospital directly, is that considered a “mobile sleep lab”? The hospital will then bill Medicare for the sleep study/lab services with the patient’s other charges.
A mobile sleep lab travels to different sites to perform polysomnogram tests. The CPAP and RAD medical policies say that a polysomnogram performed in a mobile facility is not an acceptable source of documentation for coverage of a CPAP device or RAD. The above-mentioned relationship between the hospital and mobile sleep lab is not acceptable. The hospital cannot bill for services provided by an independent mobile facility. In order to be considered for coverage, the mobile lab would have to be enrolled as an independent diagnostic testing facility (IDTF) and would bill Medicare directly for their services.
Region C DMERC published in the Autumn 2001 DMERC Advisory entitled “Oximetry Testing” page 65, that article provided that Home Health Agencies (HHA) could provide testing to qualify patients for home oxygen. The Spring 2004 DMERC Advisory page 10, states a clarification of HHAs testing to qualify patients for home oxygen. The NCD provides for 3 sources.
A – The attending physician when performed under his her direct supervision, B – A qualified provider, C – A supplier of Laboratory services
The DMERC article states that the NCD provides for 2 sources for performance of a qualifying blood gas test, but lists the three sources above. The article goes on to state that in order for a Home Health Agency (HHA) to be qualified to test, the HHA must be licensed as an independent laboratory.
CMS provides licensure of Home Health Agencies to be licensed as Clinical Laboratories under the “Clinical Laboratory Improvement Amendments, CLIA Program. As of August 2004 CMS CLIA Update has 8,308 HHAs listed as laboratories by type of facility.
Questions:
10) Does the DMERC recognize CMS allowance that a Home Health Agency holding a CLIA license is a qualified licensed lab?
CMS guidelines advise that the HHA be qualified as an independent lab in order to be a qualified testing entity for oximetry testing. The NCD does not include information regarding having a CLIA license as authorization to perform this test. Unless the HHA qualifies as an independent laboratory as outlined in CMS Manual System, Pub. 100-4, Medicare Claims Processing Manual, Chapter 16, § 10.1 and CMS Manual System, Pub. 100-2, Medicare Benefit Policy Manual, Chapter 15, § 80, the agency (and its employees) would not meet the NCD requirement as a provider of blood gas testing for the purposes of Medicare oxygen coverage. Certificates of Medical Necessity (CMNs) indicating qualifying testing performed by HHA or an HHA employee will be denied because Medicare oxygen coverage requirements are not met.
11) Oxygen CMN question #4 indicates HHA as the testing entity. If the CLIA # is indicated in question #4 or in the HA0 record will the DMERC process the CMN to pay?
See answer to question 10.
12) CMNs obtained prior to the Spring 2004 article that have HHA indicated in question #4, without CLIA info should continue to pay based on previous DMERC instruction of Autumn 2001. Yes ___ No ___
Yes.
13) Subject: CPAP billing with a humidifier
E0561 + E0562 per SADMERC Manf. coding but the humidifier is actually a part of the C-PAP provided.
Can the water chambers (A7046) be billed as accessory replacements on a rental CPAP?
The Humidifier is in the inexpensive routinely purchased category. The CPAP itself is a capped rental
Yes, the water chambers can be reimbursed as a replacement as needed.
DME
(Question #14 and #15 are being re-asked from previous Q&A)
14) The response to Question #6 on the April, 2003, Q & A (a follow-up from question #11 of the December Q & A) still does not give direction to suppliers who have patients/caregivers of patients who want to purchase the current rental equipment when the patient is admitted to an SNF. It reads:
6) Please clarify the answer to Question 11 from the December 10, 2003 Q & A. The question: 11) A patient is being admitted to a SNF and currently has a wheelchair. We explain to the beneficiary that it is the responsibility of the SNF to provide any equipment needed by the patient. The beneficiary wants to keep the wheelchair and wants to purchase it. How can this be accomplished? Durable medical equipment cannot be reimbursed for patients in a SNF. The SNF is responsible for providing the beneficiary with a wheelchair. We understand and explain to the patient/responsible party that DME cannot be reimbursed for patients in a SNF. The patient also understands that Medicare will not pay for continued use of our wheelchair and that the SNF is responsible for supplying a wheelchair. With full understanding of the above, the patient still wants to keep the wheelchair that Medicare has been renting through the DME company and wants to purchase it. How can this be accomplished? A. Can the supplier: 1) complete an ABN stating that Medicare is likely to deny because Medicare does not pay for the wheelchair through a DME provider when the patient is in a SNF AND that Medicare does not pay for the outright purchase; 2) have patient sign the ABN and an agreement that the supplier is not taking assignment.; 3) collect from the patient and bill Medicare non-assigned for the used wheelchair with a GA modifier and the skilled nursing facility as the POS? An ABN cannot be used in this situation because it does not fall under any of the outlined uses of an ABN: + lack of medical necessity + prohibited, unsolicited telephone contacts + no supplier number + denial of an Advanced Determination of Medicare Coverage (ADMC) request B. Since a SNF is not a valid place of service for a DME supplier (for wheelchair), can the DME supplier sell the chair to the patient, send a non-assigned claim to Medicare and anticipate a “PR” denial for non-covered (no ABN necessary)? If a supplier bills a non-assigned claim while the patient is in a SNF, the supplier will receive a CO-denial regardless the assignment on the claim. DME in a SNF does not fall within the DMERC jurisdiction. For services and supplies furnished to a SNF resident covered under the Part A benefit, SNFs are not able to unbundle services to an outside provider of services or supplies that can then submit a separate bill directly to the Medicare carrier. Instead, the SNF must furnish the services or supplies either directly or under an arrangement with an outside provider. The SNF, rather than the provider of the service or supplies, bills Medicare Part A. As a result, the outside provider of the service or supplies must look to the SNF, rather than the beneficiary or the Medicare carrier, for payment. Once the DMEPOS item is billed to the fiscal intermediary, a PR denial may then be applied to the adjudicated claim. Medicare law is silent regarding specific terms of a SNF’s payment to the outside provider or supplier and currently does not authorize the Medicare program to impose any requirements in this regard. Therefore, the issue of the outside provider or supplier’s payment by the SNF is a private, contractual matter that must be resolved through direct negotiations between the parties. For more information regarding this issue, please refer to Change Request 1764 (Transmittal AB-03-041 dated April 4, 2003 and AB-01-159 dated November 1, 2001.)Again, all parties (supplier, SNF, beneficiary, caregiver) understand that Medicare provides the benefit of a wheelchair as provided by the SNF. The patient has either not reached the rent/purchase option point of the capped rental period OR the patient chose the rental option (this is not an issue for those patients who chose purchase and reached the 13th month). The patient does not want to use the wheelchair that the SNF is willing to provide.
Several suppliers recalled previous instructions from the DMERC stating that this would result in a “PR“denial. Dana stated that she would research and clarify.
Upon researching this issue, feedback was provided to the council advising that if a supplier submits a claim while the patient is in a SNF, the supplier will receive a CO-denial regardless the assignment on the claim. Copies of the above-mentioned Change Requests have been included for your reference.
15) Please clarify the answer to Question #7 in the April Q & A (this was a clarification from Question #12 from the December Q & A). It currently reads:
7) Please clarify the answer to Question 12 from the December 10, 2003 Q & A. It reads: 12) A patient has had a standard wheelchair for a period of time and then, due to a worsening condition, requires an electric wheelchair or scooter. The provider who provided the wheelchair gets a denial for same/similar and contacts the patient to pick-up the wheelchair. The patient wants to purchase it. How can this be accomplished? A standard wheelchair must be rented for a minimum of ten months, at which time the beneficiary has the option to continue renting or to purchase the equipment. The wheelchair cannot be purchased in the first month.Just to elaborate:
A common complaint that we receive from patients who use an electric wheelchair/scooter in the home is that they are unable to arrange transport of the equipment when they need to go away from home thus creating a need for a lighter-weight alternative (standard wheelchair, companion chair, etc.). It is understood that Medicare limits their coverage to items used within the home. The patient uses the electric wheelchair/scooter in the home, but wants to purchase a manual wheelchair to be used as a back-up. Since Medicare does not pay for “back-up” equipment or “like/same-similar” equipment, can the provider a) explain to the patient that Medicare will likely deny because they do not pay for equipment that is same/similar to equipment already in use and they do not pay for back-up equipment, b) obtain a signed ABN stating the above, c) pick-up the rental manual chair, d) deliver a used chair as a purchase (ABN as noted above A medical criterion for a power wheelchair includes the inability to operate a manual wheelchair due to a neurological or muscular condition. Therefore, it would not be suitable for the patient described in this scenario to have a manual wheelchair. An ABN is not appropriate in this situation.This answer differs from the answer that was on the Q & A as distributed at the April meeting. The answer on the document distributed was:
“A medical criterion for a power wheelchair includes the inability to operate a manual wheelchair due to a neurological or muscular condition. Therefore, it would not be suitable for the patient described in this scenario to have a manual wheelchair. In the above scenario, a manual wheelchair would not be covered and an ABN could be obtained.”
Please clarify!
3) We continue to have questions regarding the ability of a Medicare beneficiary to choose to purchase an item for which Medicare only makes payment on a rental basis. As in the above examples, a wheelchair is a prime example. There are cases where a supplier explains the rental provisions of Medicare, the beneficiary opts to purchase, the supplier obtains an ABN explaining that Medicare does not pay for an outright purchase, adds the GA modifier to the claim and submits the claim to Medicare. Instead of receiving a “PR” denial, the supplier receives a “CO108” stating that the claim was denied because the rental/purchase guidelines were not met.
I am attaching a 1993 letter from Kathleen A. Buto whose title is listed as “Director, Bureau of Policy Development.” The letter is on DHHS letterhead. It is stated in the letter, “The purchase transactions that you cite effectively exclude the items from Medicare coverage. The supplier may collect its usual charges from the beneficiary for each item in question. The supplier may also, if it wishes, ask the beneficiary to sign a statement at the time the item is purchased, acknowledging that the supplier has informed him that, under the circumstances described, the supplier believes the item will not be covered by Medicare.” The letter goes on to state, “The submission of a claim in the situations you have described would have no adverse consequences for the supplier. The claim would be denied and the supplier would not have to refund the payments it has received for the noncovered item.”
Has there been any change in policy to invalidate this document? If so, please provide documentation of the change in policy.
A supplier needs to obtain a signed statement that indicates the beneficiary has agreed to purchase the item and that s/he does not wish to have the claim filed to Medicare. This statement is a private business transaction between the supplier, beneficiary, and the supplier’s attorney.
16) A patient receives a three-month diabetic order (i.e. 3/18/04- 6/17/04). The patient receives six boxes (50/bx) strips and 3 boxes (100/box) lancets. During this time, patient is admitted to facility or hospital stay (i.e. 4/10 – 4/15). We then receive an OA109 denial. How do we need to resubmit this claim to get paid?
The supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the “from” (anniversary) date for all subsequent claims. However, when the “from” date on a DMEPOS claim falls within an inpatient stay and the beneficiary returns home within the same calendar month, the supplier must submit a new claim on the date of discharge from the institutional provider and the date of discharge will become the “from” (anniversary) date for all subsequent claims.