MiraVista: Medicare News Blog

ICD-10 is Back Again: Are you Ready?

May 26th, 2015

Angela Hayden


The transition to the ICD-10 diagnosis coding set is officially scheduled for October 1, 2015. Despite previous delays in deployment, the Department of Health and Human Services has not given any reason to expect any further deferments. That means we are just a few months away from ICD-10.


The transition from the ICD-9 diagnosis code set to ICD-10 will be a major undertaking for DME suppliers and should not be taken lightly. If you have not considered how ICD-10 will impact your business, now is the time. The ICD-10 code set is significantly more robust than the current ICD-9 which means that many ICD-9 codes will not crosswalk directly to a single ICD-10 code. Where there is a one-to-many link, claims will require manual intervention to be assigned the appropriate ICD-10 code for processing.


Communicating with your billing software vendor is an integral part of a successful transition. Your vendor may have tips or tools that can assist you with the migration of your claims from one code set to the other. As you communicate with your software vendor here are a few key questions to consider:


  • Will claims be cross-walked automatically by the vendor or will they require manual intervention by your staff?
  • Will there be a protocol for scrubbing claims prior to submission to ensure that codes have been transitioned appropriately? If so, what will this process look like and what will be required of your staff to move these claims forward?
  • Has the vendor participated successfully in the ICD-10 front-end and/or the end-to-end testing offered by CMS?


Keep in mind that CMS has implemented a hard cut off for the use of ICD-9 codes. This means that claims submitted with dates of service on and after October 1st containing ICD-9 codes will be returned as unprocessable.  Claims that are not proactively identified and transitioned will stall revenue.



Overwhelmed with the transition? We can help with that. 


MiraVista has put together a tool that will not only help you identify your most vulnerable codes, but it will also map them to the ICD-10 equivalent(s)…within minutes.  Our programming team has created a tool, utilizing the General Equivalency Mappings, which will plug in exported active rental data from your billing software and provide you with:


  • A list of your most popular ICD-9 codes so that you can educate your staff and referral sources.
  • A classification for each code determining whether it is a one-to-one or one-to-many match.
  • A mapping from each ICD-9 code to the ICD-10 equivalent(s).
  • A list of the order numbers appended to each diagnosis code so that you can quickly identify which patients require intervention.


For more information on this service please contact us at icd10@miravistallc.com.


CMS Releases Additional Guidance on National CB & Bundled Payments

May 14th, 2015

Andrea Stark


CMS has released an updated FAQ regarding the National Competitive Bidding (NCB) pricing expansion and the bundled payment demonstration.  In this updated FAQ, they published the 1993 fee schedule rates that will be the basis for the maximum bid limit for the Continuous Positive Airway Pressure Device bundled payment demonstration.


In the final rule, it was announced that CMS will test a bundled, continuous payment model for CPAP Devices and Standard Manual Wheelchairs. Before any bid program can begin, CMS must establish a maximum bid limit that suppliers cannot bid above.  This is typically set at the current fee schedule for a product in a given Competitive Bid Area (CBA). For Standard Manual Wheelchairs, CMS established that the bid limit will be based on the total payment amounts per month in the selected CBA for the base equipment, repair, maintenance, service and accessories used, divided by the total (unduplicated) number of beneficiaries receiving those items and services.  For CPAP, however, there is precedent as CMS has paid CPAP on a continuous bundled payment methodology in the past. Therefore, in the final rule CMS announced that the maximum bid limit for CPAP will be based on the maximum allowable from the 1993 fee schedule for CPAP.  That fee schedule amount was not initially released with the final rule; however, after corresponding with the CBIC representatives MiraVista discovered that the 1993 rates were then pushed in the updated FAQs.


Our starting point on the fee schedule is the national ceiling for CPAPs back when they were in the frequent and substantially serviced category and paid as a continuous rental with all accessories, labor and maintenance included in the reimbursement rate. The ceiling back in 1993 was listed at $122.25. With all the adjustments for increases and decreases for all years in between 1993 and 2015, we end up with a current ceiling of $137.08. However, individual state fee schedules vary, and if a beneficiary lived in NY, the fee schedule in 2015 would be $116.73. CMS could choose to set the national ceiling as the max bid rate, or use individual state fee schedules. Opting to use the individual state fee schedule would lower the max bid amount (meaning, to secure a contract, supplier would have to bid below the established maximum). Therefore, at the national rate supplier would bid a max rate below $137.08, but if state fees are used, NY bidders would not bid any higher than $116.73. The bid amount must cover the provision of  the base equipment, all accessories, supplies, repairs, maintenance and service on a monthly basis for as long as medically necessary.


We put together a hypothetical reimbursement scenario for an E0601 with a nasal mask provided in a non-CBA in New York. In this scenario the supplier is replacing supplies at the frequency outlined in the PAP LCD. This scenario assumes the supplier is reimbursed for the setup of the PAP, accessories and supplies and continues to replenish supplies until the 5 year RUL. On average, in this scenario, the supplier would be reimbursed a total of $6,171.87 over a five year period. This breaks down to $102.86 a month. Keep in mind that this does not include any repairs or replacement parts. If we were to contract at the maximum allowable for the bundled payment program at $137.08, over the same five year period the supplier would be reimbursed a total of $8,224.80. That breaks down to a $34.94 increase in total monthly reimbursement.


The above is a hypothetical breakdown designed to get you thinking about how this ruling will impact you as a supplier.  While we do not yet have the designated demo areas, CMS has indicated that there will be no more than 12 CBAs in total for the new demonstrations. We have been told they will not overlap. There are three demos in all: the standard manual wheelchair bundled payment demo, CPAP bundled payment demo and the modified repair requirements for standard power wheelchairs paid on a capped rental basis.  These demonstrations typically last 2-3 years before expanding.


Keep in mind that all pricing is subject to change in 2016 as CMS rolls out National Competitive Bidding pricing to all areas rural and the like.


This is one of the many ways that MiraVista uses data analytics to make complex information translate into actionable intelligence. Learn more about how you can use simple data mining techniques to empower your business in our upcoming webinar “AR on the Rise? Mine Your Data & Leverage Online Tools” on May 21st at 2:00pm. See the details and register on our website at http://www.miravistallc.com/recent_services.php.


“Doc Fix” Repeals A Portion of the Face-to-Face Rule

May 12th, 2015

Andrea Stark


The final “doc fix” bill, HR 2 “The Medicare Access and CHIP Re-authorization Act of 2015” was signed into law on April 16, 2015.  This legislation was designed primarily to address the physician fee schedule and previously mandated cuts, but law makers took the opportunity to include several important changes affecting the DME industry. One of the most notable was the removal of the restriction on who can conduct a Face-to-Face (FTF) encounter for DMEPOS equipment.


In the final FTF rule for DME; NPs, PAs and CNSs were required to have a physician sign off on all face-to-face encounters for DME.  This caused quite the commotion as NPs, PAs and CNSs have always been able to independently prescribe DME and conduct visits. In some states and rural areas, NPs operate their own practices without an attending physician.  Therefore getting a physician sign off significantly increased the administrative burden of FTF implementation.  In large part, due to this requirement, CMS opted to delay enforcement of a part of the FTF rule.


In the “doc fix” bill section 1834(a)(11)(B)(ii) of the Social Security Act was amended to remove the restriction and expand the parameters to make NPs, PAs and CNSs  eligible to complete and document the face-to-face encounter for DMEPOS equipment. For suppliers, this change will likely expedite the enforcement of Phase II of the FTF Rule.


Currently, the implementation of the FTF rule has been broken down into two phases:

  • Phase I- Requires a face-to-face visit take place within the 6 months preceding the date of the detailed written order, and that the supplier secure a compliant, Detailed Written Order Prior to Delivery (DWOPD).  The DWO must be date stamped by the supplier prior to delivery of any item subject to the ruling.
  • Phase II – Requires suppliers to obtain executed copies of the FTF visit (performed within 6 months of the date on the DWOPD).  The FTF notes must be signed and dated by the physician and then date stamped by the supplier prior to delivery of the DMEPOS item subject to the ruling.

While the original FTF rule became effective in November 2012, enforcement was initially delayed.  CMS then came back and announced enforcement of Phase I of the ruling for dates of service on and after January 1, 2014.  Since then, enforcement of Phase II has been delayed without any indication of when it would be implemented.  However, this new provision in the “doc fix” bill eliminates the last foreseeable barrier to implementing the second phase.


With the roadway cleared, we speculate that CMS will begin Phase II enforcement soon. The new law specifically addresses implementation in Title V. Sec. 504 (b). In this section, the law states that the Secretary of Health and Human Services may implement the amendments [the inclusion of NPs, PAs and CNSs] by program instruction or otherwise.  This means that the final rule for the FTF does not need to be amended in order to move forward with implementation. We expect CMS to initiate an announcement in the weeks ahead.


Many suppliers are already complying with this rule, collecting medical necessity documentation from the face-to-face encounter before the product is delivered.  But many are not ensuring that the record is fully authenticated upon collection.  This will be a requirement upon enforcement of Phase II.  If you are not already complying with both phases of the Face-to-Face, we strongly recommend moving forward. Keep in mind that many items that are subject to the FTF rule are also currently under pre-payment review in several jurisdictions (CPAP for example). Once Phase II is enforced, if you have delivered your equipment AND billed your claim without compliant documents in hand, Medicare will refuse all future payment to that NPI.  While there are provisions that allow correction of errors identified in the DWOPD and FTF documentation when identified prior to claim submission, once the claim is submitted the errors are incurable and the beneficiary must seek service through a different provider.


Also, as a reminder, be sure to include a valid date stamp on your documentation.  Auditors will rely on the date of receipt to validate that your documentation was in hand prior to delivery.


If you need more information on the phases of FTF and how your business will be impacted, check out our on-demand recording “Face-to-Face in the Real World: How to Comply In Its Current Form” on our products page.


Claims Processing Logic Modified: Be on the Lookout for Recoupments

May 6th, 2015

Andrea Stark


CMS has had a longstanding policy to deny claims for DME while patients are in a SNF. But oftentimes, DME rentals get billed before the SNF data is in place to deny the claim and this causes routine erroneous payments. Quite often the MACs would initiate special project recoupments for DME claims that erroneously paid while the patient was in a SNF. However, recently CMS created Common Working File (CWF) edits to more consistently identify and recover these erroneous payments. An education article announcing the change was issued via CR 8172, but that directive spoke only to O&P. A new CR 8844 completes the cycle by addressing DME consideration along with a carve out to permit the “from” DOS to equal a date of discharge (as long as there is no evidence the patient was admitted to a difference inpatient setting on the same day). This edit will be effective on April 1, 2015, and will “trigger recoupment for DME items while the beneficiary was in a hospital inpatient stay.”


The logic has a carve out for status codes that indicate the patient is supposed to be transferred to a facility, but there is no evidence that they have been transferred by means of a billable claim from the SNF. This exception applies to patient status code of 03 (Discharged/Transferred to a Skilled Nursing Facility [SNF] with Medicare Certification in Anticipation of Skilled Care) and 83 (Discharged/Transferred to a Skilled Nursing Facility [SNF] with Medicare Certification with a Planned Acute Care Hospital Inpatient Readmission) where the Skilled Nursing Facility claim is not on file. The edit will also not apply if the “from” date on the DME claim is the same as the discharge date and the patient status code indicates they are discharged to a location where DME is payable:


  • 01 – discharged to home or self-care,
  • 06 – discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care,
  • 50 – discharged/transferred to Hospice- home,
  • 81 – discharged to home or self-care with a planned acute care hospital inpatient readmission, or
  • 86 – discharged/transferred to home under care of an organized home health service organization with a planned acute care hospital inpatient readmission.


Coordinate with your billing staff to ensure that they are on the lookout for these recoupments.  Claims denied for DME when a beneficiary is in an inpatient stay will including the following remittance codes:


  • Remark code PR96 -  Non-covered Charge(s)
  • Remark code M18 – Certain Services may be approved for home use. Neither a hospital nor a Skilled Nursing Facility (SNF) is considered to be a patient’s home.


New Electronic Signatures for CEDI Enrollment

May 1st, 2015

Angela Hayden


The Common Electronic Data Interchange (CEDI) contractor has announced that beginning June 29, 2015, suppliers will be able to sign enrollment forms electronically.  In order to submit DME claims electronically (837 files) to Medicare or to receive electronic remittance advices (835 files) a supplier must be enrolled with CEDI.  Currently, in order to enroll with CEDI either as a new submitter or to add a location, the forms must be downloaded, printed, completed, signed and faxed back to CEDI within 10 days of completion before it can be processed.  Starting June 29th, suppliers will be able to complete the form online via the CEDI website and submit it electronically to begin processing right away. This will expedite the enrollment process for suppliers and provide a streamlined system for CEDI.


CEDI will continue to verify enrollment forms, rejecting any forms that contain errors or missing information. Suppliers will still be able to check the status of their submission online using the Enrollment Status Tool.


As a reminder, all submissions prior to June 29th will need to be printed, signed and faxed back within 10 days for proper processing.  Suppliers should allow 10 business days from the date of submission for enrollment processing.


CBIC Announces Next Bid for Round 1 Areas in 2017

April 22nd, 2015

Angela Hayden


The Competitive Bidding Independent Contractor (CBIC) announced the next bidding competition for Round 1 areas in 2017.   This next round is to begin once the current Round 1 Recompete contracts expire on December 31, 2016.  Round 1 2017 will take place in the same nine Metropolitan Service Areas (MSAs) as the Round 1 Recompete; however, due to changes in the program and zip code updates the nine MSAs now break down into 13 Competitive Bidding Areas.  Those CBAs are:


  • Charlotte-Concord-Gastonia, NC
  • Chester, Lancaster & York Counties, SC
  • Cincinnati, OH
  • Cleveland-Elyria, OH
  • Covington-Florence-Newport, KY
  • Dallas-Fort Worth-Arlington, TX
  • Dearborn-Franklin-Ohio & Union Counties, IN
  • Kansas City, MO
  • Kansas City-Overland Park-Ottawa, KS
  • Miami-Fort Lauderdale-West Palm Beach, FL
  • Orlando-Kissimmee-Sanford, FL
  • Pittsburg, PA
  • Riverside-Bernardino-Ontario, CA


Product categories have also been shuffled in this next competition.  The major changes include:


  • The addition of Non-Invasive Ventilator HCPCS E0464 as a stand-alone product category.
  • TENS units were removed from the General Home Equipment category and established as their own separate bidding category.
  • Nebulizers and related supplies and accessories were also broken out from the Respiratory category to stand alone as their own bidding category.


The break out of these products as stand-alone product categories, provides flexibility for suppliers that supply only those products and not the remaining items in the General and Respiratory categories. To view the full list of HCPCS to be bid under this competition click here.


CMS has also established specific rules regarding the Ventilator category as this product will only be bid in a total of eight CBAs:


  1. Charlotte-Concord-Gastonia, NC
  2. Chester, Lancaster & York counties, SC
  3. Dallas-Fort Worth-Arlington, TX
  4. Kansas City-Overland Park-Ottawa, KS
  5. Kansas City, MO
  6. Miami-Fort Lauderdale-West Palm Beach, FL
  7. Orlando-Kissimmee-Sanford, FL
  8. Riverside-San Bernardino-Ontario, CA


Therefore bidding will not take place for the E0464 in: Cincinnati, OH; Cleveland-Elyria, OH; Covington-Florence-Newport, KY; Dearborn-Franklin-Ohio & Union Counties, IN and Pittsburg, PA.


This next round was announced April 21, 2015, and bidding is projected to begin this fall.


Billing Medicare for Temporary “Loaner” Equipment

April 15th, 2015

Angela Hayden


When repairing patient owned equipment, in the event that a repair takes longer than one day to complete, there may be instances when a supplier will need to provide temporary replacement equipment (i.e. loaner equipment). Suppliers commonly struggle with how to bill for this “loaner” or “temporary replacement” equipment while performing repairs.  With HCPCS K0462 (temporary replacement equipment) one unit of service is equal to one month of rental.  The date of service billed for the loaner equipment must be the date that it is delivered to the patient and must be billed on the same claim as the repairs. Keep in mind that when billing for loaner equipment you must include the following information in the NTE (narrative) segment of the claim:


  • Information regarding the patient-owned equipment in the form of a HCPCS code or brand name, model name/number,
  • Date of original purchase/delivery of the beneficiary owned equipment,
  • A description of the replacement/loaner equipment with the manufacturer brand name and model name or number, and
  • A statement of why the replacement/loaner equipment is needed (e.g. repairs to beneficiary owned equipment).


These requirements were mapped out in February 2013 (see that notice here).


Remember that when providing loaner equipment, suppliers may only bill for one month, regardless of how long the patient has the loaner equipment. Additionally, the allowable paid by the DME MAC for that loaner equipment will be based on the lesser of the allowable for either the item/HCPCS the patient owns or the loaner equipment being provided.


For additional guidance on billing for repairs and loaner equipment, register to attend our upcoming educational session entitled “The Ins and Outs of Billing for Repairs”, on May 7, 2015.


Bid Protests for National RAC Currently “Dismissed”

April 9th, 2015

Andrea Stark


In December of 2014, suppliers were alerted that the new national RAC contract for DMEPOS, Home Health and Hospice had been awarded to Connolly, LLC (currently serving as the Jurisdiction C RAC).  However, a protest to dispute the contract was filed with the Government Accountability Office (GAO) by the current Jurisdiction A RAC, Performant Recovery Inc. This protest essentially stalled CMS from proceeding with next steps until a decision was reached by the GAO.


While CMS has not directly addressed the status of these bid protests, a search of the GAO bid protest docket shows a total of two bid protests filed by Performant Recovery Inc. The first, B-410999.1 was filed on January 6, 2015 and the second B-410999.2 was filed on February 17, 2015.  Both cases have been decided as of February 23, 2015 and are listed with an outcome of dismissed. According to the GAO website, a status of dismissed means that the GAO determined the protest had a technical or procedural flaw (such as lack of timeliness or jurisdiction) or because the agency has taken corrective action that addresses the protest. This status classification likely means that CMS will move forward with the award to Connolly.  The other possible statuses are:


  • Withdrawn – the protest was removed by the protester
  • Denied – the GAO found no merit in the protest, or
  • Sustained – the GAO agrees with the argument of the protest.


It is unclear why the protests were dismissed specifically. The GAO website provides little to no information regarding a routine dismissal of a protest. As it stands, we do not have definitive information on next steps. However, we speculate that the contract will proceed with Connolly unless Performant Recovery takes the opportunity to submit another bid protest, if the timeliness of a protest is made viable through the dismissal process. MiraVista will continue to keep you posted as this develops.


(See: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html & http://www.gao.gov/docket/B-410999.2 & http://www.gao.gov/docket/B-410999.1)



Electronic Bid Window Extended for Round 2 & National Mail Order Recompete

March 26th, 2015

Andrea Stark


Due to some technical difficulties experienced in the electronic bid system, the CBIC extended the window to submit electronic bids to March 26, 2015 at 8:59 PM Eastern (this evening).


Keep in mind they did not extend the window for delivery of hardcopy documentation which still had be received by the CBIC no later than midnight on March 25th.  If your packet was not received by that deadline, it will not be accepted and your bid will be disqualified, even if it is postmarked before the deadline.


For bidders that submitted documentation in time for the Covered Documentation Review process, a notification will be sent by May 21, 2015 either confirming that your packet is complete or to notify you which financial documents were missing from your packet. Bidders will not receive email correspondence regarding receipt of the packet unless it was submitted by the Covered Documentation Review deadline of February 23, 2015.

Executing ABNs: When a Patient Refuses to Sign

March 18th, 2015

Andrea Stark


Executing compliant Advanced Beneficiary Notices (ABNs) can be tricky. ABNs are particularly troublesome when you encounter a beneficiary that refuses to sign and accept financial responsibility. In these cases you should generally refuse service to the patient. But what if that is not a viable option? Perhaps the health of the patient would be put in jeopardy if you refuse service or what if the patient already has the equipment and now refuses to sign? In these cases, it may be possible to execute an ABN even if the patient refuses to sign, as long as certain requirements are met.


In order to effectively execute an ABN in instances when the patient refuses to sign, ALL of the following conditions must be met (no exceptions):


  • You must accept assignment on the claim.
  • Your ABN must include the specific reason(s) the claim is expected to deny.
  • The patient must have demanded the service, but still refused to sign the ABN or be held financially liable.
  • The patient’s refusal to sign must be witnessed by the notifier (you) and a second party (this can be over the telephone where the second party is called to witness the refusal while you are on-site).

These requirements are outlined by CMS in Chapter 30 of the Claims Processing Manual (; Section discusses Beneficiary Refusal, Section 50.13.2 Discusses the Refund Requirements applicable to DME providers, and Section 150 further details the implementation of the Refund Requirements on DME claims.


If, and only if, the above requirements have been met are you able to proceed. Be sure to include an annotation on the ABN stating that the patient refused to sign or take financial liability, but still demanded service. This should be signed by both the notifier (you) and the second witness. The notation can be included above the empty patient signature line or in the margins of the ABN. When filing your claim, utilize the GA modifier to indicate that the ABN was presented to the patient. If executed properly, Medicare will hold the patient financially liable for the claim.


We recommend that you send a copy of the notice to the beneficiary along with a notice that they will continue to accrue monthly liability on the equipment up until the date the equipment is returned.  They may return the equipment at any time to avoid future monthly payments.  The customer remains responsible for any monthly payments accrued while the equipment remained in their possession.



güvenlik kamerası


panel çit