MiraVista: Medicare News Blog

Updated Quantity Language for Enteral Impacts Claims Payment

June 29th, 2015

Andrea Stark


A new enforcement of quantity details on Detailed Written Orders for enteral nutrition is manifesting in claim denials. CGS recently updated the language on the Enteral Documentation Checklist (as of January 27, 2015) that mentions a new description for quantity on the Detailed Written Order to be represented on a “per fill” basis. This is new terminology and a compliance expectation that CGS and other MACs are now beginning to enforce. We have not seen these quantity errors in prior claims because the medical reviewers were using discretion to calculate proper quantities using other elements on the Detailed Written Order. However, because there are so many variations and fluctuations with the prescription and how claims are billed, they are now requiring the orders to be more specific to avoid denial. The Provider Education departments are also increasing their discussion of this expectation. The MACs are interpreting this nuance to be a part of the quantity requirement of the LCD.


This enforcement has been hardest felt in Jurisdiction C, but other MACs are incorporating this into their education as well. To avoid future denials, providers are encouraged to secure updated orders for nutrition that comply with the details of a per fill quantity:


Quantity to be dispensed (Should correspond with the total amount of each item to be provided per refill. This information may be expressed as cans, bottles/bags, cases, or billing units [1 unit=100calories]).


Under this new guidance the contractors are expecting language to appear on Detailed Written Orders along the lines of:


  • 1200 calories per day X 30 days X 12 refills
  • 120 units at 100 calories X 30 days X 12 refills
  • If the patient is on a formula that consists of 300 calories per can, the suitable example might read, 4 cans per day X 30 days X 12 refills.


If you provide enteral nutrition we encourage you to connect directly with your POE (Provider Outreach & Education) department of your MAC to confirm their expectations as there may be slight nuances from DME MAC to DME MAC. As additional details become available on this topic, MiraVista will keep you informed.


OMHA Takes Next Step for Improving the Third Level of Appeals

June 25th, 2015

Angela Hayden


The Office of Medicare Hearings and Appeals (OMHA) has announced the contract award for the next phase of process improvement for the third level of Medicare appeals (Administrative Law Judge or ALJ).  On March 30, 2015, CACI Inc. was awarded the development contract for the Electronic Case Adjudication and Processing Environment (ECAPE) for OMHA.  This tool is an effort to streamline the procedures of the ALJs after an exponential increase of third level appeals overwhelmed the office and pushed case assignment wait times to nearly two years. This tool will allow the ALJs to process cases electronically, and will feature functionality for:


  • Case and workload management,
  • Exhibiting,
  • Scheduling,
  • Document generation,
  • Electronic filing of requests for hearing and supporting documents, and
  • Enhanced management information and business intelligence.


Overall, this tool improves the internal process of the ALJs by streamlining case management from start to finish. Creating this electronic system will increase ease of access for all departments within the ALJ and expedite the resolution process.  This tool is expected to be rolled out in release phases.


The first release will tackle case intake and create an application called the Appellant Public Portal (APP).  The first release is anticipated for early 2016. The Appellant Public Portal (APP) is a sub-component of ECAPE. APP will allow appellants to file requests for hearings, submit additional evidence, check appeal status, and view the appeal case file online.  There are two separate phases that exist within APP deployment.  Phase one of APP will allow a guest user (without registration) to file a request for hearing online, check the status of an appeal and upload the additional relevant evidence to support the case. Phase two of APP will allow users that frequently file appeals to register as a user to file requests for hearing online, upload evidence, check appeal status, view case files, access electronic correspondence, and establish and maintain an appellant profile to expedite repetitive tasks.


The second release of ECAPE is expected in early 2017 and will encompass functionality for the remaining parts of the adjudication process from assignment to case closure.


The third and final release of ECAPE is also scheduled to take place in 2017 to address any enhancements needed to APP as well as other functionality not addressed in the first two releases. This is a major undertaking for the contractor, converting the current labor intensive manual process into an electronic process and streamlining communication channels.  Integrating paper documents into an electronic storage and management solution is an extensive process, but is expected to pay dividends for work flow purposes. Ultimately, this new tool will deploy functionality to improve the ALJ appeal process for both appellants and ALJs. OMHA has indicated that additional details will be provided via their listserve as the development of ECAPE progresses.


CBIC Backtracks & Removes Ventilators from Round 1 2017

June 9th, 2015

Angela Hayden


In a listserve posted on June 4th, 2015, the CBIC announced the removal of Non-Invasive Pressure Support Ventilators from Round 1 2017.  The E0464 was introduced as a stand-alone product category for this particular round of bidding in April 2015. Bidding for this round has not yet begun, which allows the CBIC to process these kinds of changes.


CMS has recently released a number of educational bulletins and Joint DME MAC publications to inform suppliers that Ventilators are not appropriate for the treatment of OSA and those conditions covered in the Respiratory Assist Device (RAD) policy (Complex Sleep Apnea, Central Sleep Apnea, Hypoventilation Syndrome, etc).  Because of advancements in technology, some ventilators are able to operate in PAP or RAD modes, therefore suppliers are incorrectly utilizing these ventilators in place of a PAP or RAD device.


With the announcement, CMS also announced plans to consolidate current ventilator codes into two codes effective December 31, 2015.  As of December 31st, the following codes will be obsolete:


  • E0450 – Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
  • E0460 – Negative pressure ventilator, portable or stationary
  • E0461 – Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g.,mask)
  • E0463 – Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube).
  • E0464 – Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)


CMS will replace the above codes with two new codes that have yet to be assigned, but will be effective January 1, 2016:


  • Exxx1 – Home ventilator, any type, used with invasive interface (e.g., tracheostomy tube)
  • Exxx2 – Home ventilator, any type, used with non-invasive interface (e.g., mask, chest shell)


Exxx1 will be used in place of HCPCS E0450 and E0463, while Exxx2 will be used for HCPCS E0460, E0461, and E0464.  In terms of fee schedule, CMS will establish the fee schedule amounts for the new codes using the current fee schedule for E0450, which varies in allowable (depending on state) from $868.40 to $1,761.50.  CMS also noted in this bulletin that they “intend to closely monitor” the use of the newly established codes to ensure that items used for the treatment of OSA are not being billed under these codes.


CMS is accepting comments for consideration on these changes through 5pm on June 25, 2015 at codingcomments@cms.hhs.gov.  Suppliers that wish to submit a comment should make the subject line “Ventilator Comments”. See the official notice here.


New Bill Seeks Prior Authorization for Oxygen & Other High Cost DME

June 2nd, 2015

Angela Hayden


On May 19, 2015, HR 2437 was introduced by Tennessee Representative Marsha Blackburn.  This legislative piece seeks to require CMS to create and implement a prior authorization program (similar to that of the Power Mobility Device Demo) for high cost DMEPOS items, such as Oxygen which is specifically mentioned in the language of the bill.  The bill also has a provision to exempt claims that are approved for prior authorization from both pre-pay and post-pay audit.


Prior authorization has been an increasingly popular Medicare initiative for DMEPOS in the last few years. First with the live expansion of the PMD Prior Authorization demo into 12 new states and then with the introduction of a proposed rule to institute prior authorization for DMEPOS in general.  With HR 2437 we see a scaled down version of the proposal for DME prior authorization, which broadly discusses high cost DME, but specifically addresses Oxygen.


The bill requires the HHS Secretary to expedite emergency review of prior authorization requests to ensure same day delivery expectations can be met by suppliers for items such as Oxygen.


The regulation requires that stakeholder input be included in the development process and that priority be assigned to items that are subject to a high number of contractor audits (specifying Oxygen as a priority).


Overall the tone of the bill is positive and seeks to reduce the audit burden for suppliers providing high cost DME items through a prior authorization process.  To see the full text of the bill use this link: http://thomas.loc.gov/cgi-bin/query/z?c114:H.R.2437:.

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.


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