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New Proof of Delivery Requirement to be Incorporated in Future LCDs

Friday, February 20th, 2015

Andrea Stark


CMS released an update to the Standardized Documentation Language template in October of 2014.  This template is used to populate the Documentation section of the Local Coverage Determinations (LCDs).  The template was first implemented in February of 2012 to bring uniformity and consistency to the LCDs.


Most of the changes in the October update stem from previously posted clarifications and updates released by the DME MACs primarily related to the Face-to-Face rule.  By periodically incorporating the updates into the LCD they ensure that providers can rely more heavily and consistently on the one-stop shop known as the LCD and policy article.  However, there was a significant change to the documentation requirements for Proof of Delivery in instances where equipment is retained from a prior payer (the patient switches to Medicare for the first time).


CMS has always educated that at the time of transition, it is the supplier’s responsibility to evaluate the coverage criteria to determine the beneficiary meets Medicare guidelines.  It is also expected the supplier will secure an updated proof of delivery document and simultaneously determine that the equipment is in operational order and should last the patient five years from the date they enter the Medicare program.  In this update, however, CMS takes this assessment to a whole new level. Suppliers are now to be required to obtain an attestation statement from the beneficiary (or their designee) that stipulates the supplier has examined the equipment, it is in good working order, and meets Medicare requirements.


The directive stipulates, “For the purposes of reasonable useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare payments are made for the item (i.e., date of service)  serves as the start date of the reasonable useful lifetime and period of continuous use.  In these cases, the proof of delivery documentation serves as evidence that the beneficiary is already in possession of the item.”


These changes will be incorporated into future LCDs and policy article revisions, which we will likely see published over the course of the upcoming months.  To see the CGS notice including the full text of the updated language click here.

The Clock Is Ticking: Recompete Registration Ends Soon

Friday, February 13th, 2015

Andrea Stark


If you are a provider participating in the Round 2 or National Mail Order Recompete programs for Competitive Bidding contracts, and you have not yet registered, time is running out.  The Competitive Bidding Implementation Contractor (CBIC) will close the registration window on Tuesday, February 17, 2015. Suppliers that have not yet registered (and wish to participate in bidding) will need to have the Authorized Official for the business establish an account via the CMS IACS system by 9pm EST on February 17, 2015.  Registration in the IACS system is required to obtain a user ID and password for the electronic bidding system DBidS. If you miss the registration deadline, you will not be able to submit a bid. Registering for an account provides you with the most flexibility, but does not obligate you to formally submit a bid.  If you are undecided, it is best to secure your access immediately.

As a recap, the following product categories are up for bid in Round 2:


  • Enteral Nutrition, Equipment and Supplies
  • General Home Equipment and Related Supplies and Accessories
    • includes hospital beds and related accessories, group 1 and 2 support surfaces, commode chairs, patient lifts, and seat lifts
  • Nebulizers and Related Supplies
  • Negative Pressure Wound Therapy (NPWT) Pumps and Related Supplies and Accessories
  • Respiratory Equipment and Related Supplies and Accessories
    • includes oxygen, oxygen equipment, and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories
  • Standard Mobility Equipment and Related Accessories
    • includes walkers, standard power and manual wheelchairs, scooters, and related accessories
  • Transcutaneous Electrical Nerve Stimulation (TENS) Devices and Supplies


The National Mail Order contracts to supply mail order diabetic supplies are being recompeted on the same timeline. The covered documentation review deadline is February 23, 2015. Suppliers that wish to have their required documentation packets reviewed for missing documentation must have that in by February 23rd. The bid window, however, will remain open until March 25, 2015. See the latest edition of VistaNotes (Volume 6 Issue 6, available for purchase on our products page) for a condensed, but comprehensive, bidding guide for suppliers.


Why is National Bid Pricing Relevant to Your Business?

Thursday, February 5th, 2015

Angela Hayden


Competitive Bid pricing will expand to all suppliers on January 1, 2016. This mandate is a directive of the 2015 End Stage Renal Disease and Prospective Payment System final rule posted on November 6, 2014.


If you supply respiratory equipment, enteral nutrition, mobility equipment (from walkers to power chairs), infusion equipment, TENS units, support surfaces, commodes, patient lifts, seat lifts, NPWT, or hospital beds you are affected by this rule, and now is the time to prepare for how these changes will impact your business.


Per the ruling, fee schedule amounts for items and services that are subject to competitive bidding will be adjusted on a regional level. The US will be broken down into a total of eight regions where this logic will be applied, including rural areas. Pricing will be adjusted based on how your area is classified within your respective region (rural or non-rural), but one thing is for certain, reimbursement is slated to decrease across the board.


In our recently aired webcast on January 13th, we partnered with HME News to deliver a better understanding of this complex ruling. We provided our attendees with an example of what pricing might look like after the expansion from this rule. Using the pricing adjustment logic explained in the final rule and current Single Payment Amount (SPA) data, we were able to determine what the new Regional SPA might look like for suppliers in a hypothetical location (Bartlesville, OK) post roll out. The results showed a 47% reduction in the reimbursement rate for oxygen concentrators in that area.


A realistic calculation is an essential tool to prepare your business for these future changes.  Now is the time to examine your processes, re-negotiate contracts with your vendors, and/or reallocate staff resources to eliminate inefficiencies in your system. MiraVista can equip you with tools you need to progress through this process.


If you missed the event and would like to get the full details for how this ruling is to be implemented, the event is still available on-demand in digital format.


Additionally, we will be hosting the second part of this series on February 11th to discuss the bundled payment demonstration. The bundled payment provision will directly affect the way that CPAPs and Standard Power Wheelchairs are reimbursed in up to 12 demonstration areas and will set a precedent that will likely impact other products in the future.  Register for the bundle that includes coverage of Part 1 and Part 2 of this series here.


See the HME News write up of the January 13th webinar here.

RAD Policy Updates Reflect Major Changes for Suppliers

Thursday, January 29th, 2015

Andrea Stark



The Respiratory Assist Device LCD and Policy Article have been updated with new coverage criteria.  If you bill for this product you may have missed some of the significant and technical changes for this policy.  Changes took effect December 1, 2014. CMS made a number of modifications that impact the coverage criteria for RADs and documentation practices.


The first change appears in the coverage criteria section where CMS clarifies the definition of Central Sleep Apnea (CSA).  Central Sleep Apnea is defined by the following criteria:

  1. The sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; and
  2. A central apnea-central hypopnea index  (CAHI) is greater than or equal to 5 events per hour; and
  3. The presence of at least one of the following:
    • Sleepiness
    • Difficulty initiating or maintaining sleep, frequent awakenings, or non-restorative sleep
    • Awakening short of breath
    • Snoring
    • Witnessed apneas
    • There is no evidence of daytime or nocturnal hypoventilation


The definition of Complex Sleep Apnea (another diagnosis group referenced in the LCD) was also updated:

  1. With use of a positive airway pressure device without a backup rate (E0601 or E0470), the polysomnogram (PSG) shows a pattern of apneas and hypopneas that demonstrates the persistence or emergence of central apneas or central hypopneas upon exposure to CPAP (E0601) or a bi-level device without backup rate (E0470) device when titrated to the point where obstructive events have been effectively treated (obstructive AHI less than 5 per hour).
  2. After resolution of the obstructive events, the sum total of central apneas plus central hypopneas is greater than 50% of the total apneas and hypopneas; and
  3. After resolution of the obstructive events, a central apnea-central hypopnea index (CAHI) greater than or equal to 5 per hour.


In the update, the qualifying CAHI for Central Sleep Apneas is defined as the average number of episodes of central apneas and central hypopneas per hour of sleep without the use of a PAP (during a diagnostic study). For Complex Sleep Apnea the CAHI is determined during the use of a PAP device (during a titration study) after obstructive events have disappeared.


Additional language was included to qualify a patient with Severe COPD.  In the prior policy, it states that before initiating therapy, Obstructive Sleep Apnea and treatment with a CPAP must be considered and ruled out.  This statement is modified in the new policy to add a note indicating “Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea (OSA), CSA and/or Comp SA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation.”


Criteria for qualifying a patient with Hypoventilation Syndrome for an E0470 and E0471 have also been modified significantly to address the use of a Home Sleep Study to determine oxygen saturation.  The revision applies to the Hypoventilation diagnosis group, and the Coverage Guidance stipulates that not all types of HST are appropriate for CSA or Complex Sleep Apnea diagnosis groups). Under the prior policy, only a facility based PSG was allowed as a qualifying test for hypoventilation. The update adds a significant section on defining different types of sleep studies and defining which studies can be used to qualify a patient in specific diagnostic scenarios. This section also breaks down who may interpret the study (the same four parameters that exist in the PAP LCD: ABMS, ABSM, staff privileges at an accredited lab or residents waiting for their first exam in sleep medicine).


Throughout the policy, greater than and less than symbols are replaced with the written form.


It is important to consider these changes and how they will impact current protocols. In some cases these clarifications require additional scrutiny of the testing data and in others it opens the door to less restrictive requirements.  Currently, the E0470 (Respiratory Assist Device) is under prepayment review in Jurisdiction D; however, when the data supports examination, other contractors often follow suite and initiate reviews for these codes.



Date Stamp Rules Clarified by CMS

Friday, November 14th, 2014

Angela Hayden


CMS has released a clarification via a Joint DME MAC publication regarding the usage of date stamp protocols for compliance with the Affordable Care Act. Many suppliers have been struggling with denials stemming from improper date stamps. According to the Face-to-Face rule, implemented by the Affordable Care Act, “A date stamp or equivalent must be used to document receipt date.” This allows the auditor to verify that the DWO was in fact received prior to delivery per the requirements of the rule.


In this publication, CMS speaks to several “commonly accepted methods” of date stamping.  Those are: hard copy date stamps, hand-written dates, facsimile headers and electronic receipt dates.  The date stamp should include the word “received” and the month, day and year.


CMS goes on in the notice to caution providers utilizing facsimile headers to document receipt date.  Oftentimes, the headers can become distorted from multiple transmissions or can come across illegibly due to a poor connection. This makes it difficult for the auditor to determine the proper receipt date.  Another concern with facsimile dates is power outage or date reset – if the date resets and it is not caught timely it can invalidate orders down the road. When in doubt, utilize a physical date stamp to reduce risk.


Proper date stamping can make the difference between a payable claim and a denial.  Be sure that you have a date stamping protocol in place for all incoming documentation. See the update here: http://cgsmedicare.com/jc/pubs/news/2014/1014/cope27091.html

MiraVista Needs a Chief of Staff

Tuesday, September 16th, 2014


MiraVista LLC, a medical billing and consulting company, is searching for a chief of staff.


WTF is a Chief of Staff, you ask?


Wikipedia words it as eloquently as we can.  They describe a Chief of Staff, in part, as:


The coordinator of the supporting staff, adjutant, or primary aide-de-camp to an important individual, such as a president or a senior military officer.


Our Chief of Staff, working full time from our Columbia, South Carolina office, will have primary responsibility for the design, execution, and oversight of our internal administration.  Some of the matters our Chief of Staff would have handled last month include:

  • brainstorming with our managing member on the cost benefit of this position, the desired skills and characteristics of an ideal candidate, and the overall plan for recruitment and selection of this new position
  • reviewing resumes, conducting telephone interviews, and scheduling live interviews for candidates for accounts receivable associates
  • preparing employee agreements for new hires
  • coordinating our Columbia office expansion.  Tasks included:
    • reviewing lease provisions
    • scheduling construction to minimize impact on our work
    • working with our accountant on growth forecasts associated with the expansion
    • procuring equipment and setting up workstations
  • planning a trip for one of our officers to Seattle, WA that balances the costs of travel with the opportunity cost of being away from the office and general wear and tear on her poor soul
  • proofreading articles for publication in one of our educational publications, our blog, or national trade publication
  • preparation of invoices to our clients
  • working with our accountant on month end accounting reports, general bookkeeping, and weekly cash forecasts
  • assisting our IT manager with minor software updates, research, and
  • managing vendor relationships for office supplies and the like


To actively contribute to our work, we require:

  • Strong communication skills.  To contribute to our staff, you have to initiate discussion and participate in debate.  You cannot do that without strong communication skills.  Twitter only counts if you are truly compelling in 140 characters or less.
  • Decent desktop computer skills.  We use Microsoft Excel…heavily.  Most other applications we use pivot on the general knowledge necessary to get around Microsoft Office products and popular browser-based web tools.  There are no wildly specialized applications that we use, but you have to know your way around a computer.
  • Good research skills.  If you don’t know the answer to a question, you should be able to Google it…and get it…and then share it with us.
  • Hustle.  Period.


So why not just call our new position administrative assistant or office manager?  Mostly because administrative assistant focuses too much on doing tasks specifically assigned by someone else; office manager is too overused to mean essentially the same thing.  We need someone to handle the business of being MiraVista while we are focused on providing better results for our rapidly expanding list of clients.  The primary focus of this position is operational outcomes, not individual tasks.  Said another way, you will have to contribute to the decision making process, make decisions, and execute based on said decisions.


This position is important to our future growth strategy, so please…apply only if you have meaningful experience managing people and office operations.  This is not an entry level position for those in hopes of eventually working in medical billing, sales, or accounting.  We are not looking for a back up dancer that hopes to drop their single one day; we are looking for the band manager…metaphorically speaking, of course.


We are excited to meet you.  Send your resume and cover letter to resume@miravistallc.com.

Newest FTF Clarification Opens Doors for DME Suppliers

Monday, August 11th, 2014

Andrea Stark


A new FTF clarification that came through a joint DME MAC publication on August 7th gives providers a new flexibility concerning corrections to Detailed Written Orders (DWOs). The Policy Articles and prior education instructed that a DWO lacking all necessary components required under the FTF is incurable once the equipment has been delivered. Meaning once the equipment has gone out with a non-compliant DWO, the supplier can never receive payment on that equipment.


This latest clarification, however, defines new directives that permit modification and cure to the DWO in a new limited circumstance.  The clarification, posted to the NHIC website here http://www.medicarenhic.com/viewdoc.aspx?id=2760 reads:


“Medicare policy stipulates that a WOPD that is missing an element is not “curable” by a provider (i.e., a provider cannot make corrections to a WOPD) except as outlined below.


I.            If errors in the WOPD are found prior to delivery, the supplier has two options:


A.            The WOPD may be properly amended following the guidance in the Program Integrity Manual (Internet-Only Manual, Publ. 100-08), Chapter 3, Section; or,


B.            A new WOPD may be created and sent to the physician for signature and date.


II.            If errors in the WOPD are found after delivery of the item, the supplier has two options:


A.            If the error is discovered prior to claim submission, the original supplier may recover the delivered item(s), obtain a compliant, complete WOPD and then may re-deliver the item(s) to the beneficiary; or,


B.            If the error is discovered after submitting a claim, the original supplier can recover their items and a new supplier must complete the transaction after complying with all requirements.”


This newest development opens the door for suppliers struggling with errors in the DWO found after delivery. The clarification allows suppliers the opportunity to collect a new compliant DWO after delivery but before billing and still remain compliant with FTF requirements.  In this instance, the supplier would be required to pick-up the equipment issued under the non-compliant order, obtain the new DWO with all necessary components to comply with the FTF rule and then redeliver the equipment, and allow the new claim to bill for reimbursement.


This is a major shift from prior education that opens reimbursement opportunities in the event of proactively identified DWO errors.


CMS has not yet issued information on when the second phase of the FTF rule will be rolled out regarding collection of the FTF notes prior to delivery that will also require NPs, PAs and CNSs to secure a physician co-signature on their notes. Stay tuned to the MiraVista blog for updates on this and other important topics impacting reimbursement.



CMS Announces Next Steps for Competitive Bidding

Monday, July 21st, 2014

Angela Hayden


The gavel has come down on next steps for the Competitive Bidding program as CMS has issued notice for a Recompete of both Round 2 and National Mail Order contracts. The original Round 2 and NMO contracts are in effect until June 30, 2016. Speculation has been circulating concerning what CMS’ next steps for the program would be since the issuance of a request for comment on a nationwide competitive bidding program in February 2014.  While the most recent announcement shifts focus toward the Recompete process, we fully expect the Nationwide Competitive Bidding effort to move forward in the days ahead via a separate notification process.


While most aspects of the program will remain the same for the Round 2 Recompete (R2RC), there were some minor, notable tweaks. For example, Round 2 encompassed a total of 91 Metropolitan Service Areas (MSAs) with 100 Competitive Bid Areas (CBAs) to sub divide the larger MSAs. However, for the Recompete there will be 90 MSAs and 117 CBAs; 16 of the MSAs in R2RC are divided into multiple CBAs to break up the expansive metropolitan areas and to avoid multiple-state bid areas. Additionally, any zip code changes that have taken place since Round 2 implementation have been translated into the R2RC zones.


As for products, the R2RC has been updated to reflect much of what we saw with the R1RC. Many categories have now been grouped rather than broken out for individual bid.  Under the R2RC Oxygen, CPAP, RADs and their related supplies and accessories have been grouped together into the Respiratory Equipment and Related Supplies and Accessories category.  Nebulizers which were grouped into the respiratory category for R1RC, have now been broken out into their own bid category for the R2RC.


Hospital beds and Group 1 and 2 support surfaces have been grouped together under the General Home Equipment and Related Supplies and Accessories category, which now includes three new products (commode chairs, patient lifts and seat lifts).  Under Round 1 Recompete TENS units were grouped into this General product category, however, for the Round 2 Recompete TENS devices and supplies will be included in an independent category for bid.


Walkers, which were previously a stand-alone product category, have now been pushed into the Standard Mobility Equipment and Related Accessories category. This category now encompasses walkers, standard power and manual wheelchairs, scooters, and related accessories. The product category we do not see up for bid in this round which was included with the R1RC is External Infusion Pumps; CMS has indicated that this product will not be bid in the R2RC. See below for a full R2RC product list:


  • Enteral Nutrition, Equipment and Supplies
  • General Home Equipment and Related Supplies and Accessories (hospital beds and related accessories, group 1 and 2 support surfaces, commode chairs, patient lifts, and seat lifts)
  • Nebulizers and Related Supplies
  • NPWT Pumps, Related Supplies and Accessories
  • Respiratory Equipment and Related Supplies and Accessories (oxygen, oxygen equipment and supplies; CPAP devices; RADs; and related supplies and accessories)
  • Standard Mobility Equipment and Related Accessories (walkers, standard power and manual wheelchairs, scooters, and all related accessories)
  • TENS Devices and Supplies

The National Mail Order program will also be subject to Recompete at the same time as Round 2 with no notable changes to that program.


With the announcement, CMS also issued important dates for all suppliers to consider. The bidding schedule will be announced this Fall. During this time, suppliers that wish to participate in the bidding program will begin the registration process to obtain a User ID and password.  The actual bidding for the Recompete will not begin until winter of 2015; therefore suppliers will have roughly a year to prepare for the formal bidding process. Those who are currently contracted under Round 2 will be eligible to participate in the Recompete as long as all requirements are met for bidding. This is a new opportunity for suppliers that were not awarded a contract under Round 2 to participate in the newest round for contracting.


In order to be eligible to participate in the bidding process suppliers must have an accurate record with the Provider Enrollment, Chain and Ownership System and the National Supplier Clearinghouse. All participating bidders must be licensed for the product that they wish to supply in the state in which they are bidding in prior to submitting a bid. Additionally, all locations the supplier intends to offer product from must be accredited by a CMS approved accrediting organization for the items that they provide in a product category.  All other standard bidding rules will apply – more information on those rules can be found on the CBIC website at www.dmecompetitivebid.com.


Prior Authorization for General DME: Good or Bad?

Friday, June 27th, 2014

Angela Hayden


A proposed rule was published on May 28th, 2014, seeking comment on a prior authorization program for certain DMEPOS items. In the proposal, CMS collected a Master List of 139 HCPCS that have been determined to have frequent,   unnecessary utilization. The list includes a variety of products such as hospital beds, RADs, Power Wheelchairs, Manual Wheelchairs, CPAPs, Support Surfaces and Lower Limb Prostheses.  The proposal suggests that a certain portion of the HCPCS within the Master List would be carved out and that list (referred to in the proposal as the Required Prior Authorization List) would contain those HCPCS subject to the Prior Authorization requirement. Not all items within the Master List would be rolled out at once; instead CMS seeks to slowly infuse those HCPCS to the master list over time.


Once the final list of HCPCS subject to the rule is determined, the list would be released with a 60 day notice for providers to get prepared for implementation. If the proposal is finalized, the program would be rolled out on both a national and local level depending on the scale of unnecessary utilization uncovered during data analysis of each area.  Also within the notice is a provision for CMS to use its discretion, at any time, to pause or suspend the program without creating a separate rule.


Should the rule become final, suppliers would be required to submit a request for Prior Authorization when billing for any of the selected HCPCS.  The request would need to be submitted to the DME MAC and would have to include documentation to support that the item complies with all coverage, coding and payment rules. The DME MAC would then have 10 days from receipt of all applicable information to render its decision.  In the instances where an expedited decision is necessary to preserve the life or health of the beneficiary, the proposal has included a provision for the DME MAC to render a decision within two business days of the receipt of all required documentation. Any claim submitted for one of the affected HCPCS without a valid prior authorization number would automatically be denied.


An interesting section of the proposal speaks to the applicability of this proposal to Competitive Bidding Areas: “We note that this proposal would apply in competitive bidding areas because CMS conditions of payment apply under the Medicare DMEPOS Competitive Bidding Program.”  This means that contracted suppliers would not be exempt from this protocol should the final rule come into action.


The proposal goes on to indicate that because of the existing PMD Demonstration Program, PMDs would be excluded from the initial rulemaking  – but this could be revisited once the original Demonstration has ended. The current PMD Prior Authorization Demonstration is active in seven states and not slated to expire until August 31, 2015.  A proposal to expand that program into 12 additional states is already in the works as of April 4, 2014.  The comment period for that proposal closed on April 18, 2014, with all comments in favor of an expansion.


For PARs that are denied or non-affirmed, the supplier would not be limited (based on this proposal) by a specific number of times that a request can be submitted for re-examination. The DME MAC would have 20 days to review the resubmission before rendering a decision.


The comment period for this proposal is open until 5pm Eastern Time on July 28, 2014.  Suppliers that wish to submit comment can do so using this link: http://www.regulations.gov/#!submitComment;D=CMS-2014-0070-0001

Update on FTF Directives for Multiple Physicians

Tuesday, May 13th, 2014

Andrea Stark


MiraVista has it on good authority that a clarification from CMS is imminent regarding scenarios where multiple physicians participate in the order process and whether this will be allowed under the FTF directives.  While we can only speculate on what the directive will actually contain, we are optimistic that the change will be a welcomed one by providers.


Currently, CMS has directed the DME MACs that only the physician that documents the FTF can be the one that orders the equipment.  However, the industry has presented CMS with numerous examples of instances where multiple practitioners can be involved.  One such example is a patient visiting a primary care physician with signs of obstructive sleep apnea.  After evaluation, the patient is referred to a sleep lab where the interpreting physician orders the CPAP and suggests an appropriate pressure setting.  Other scenarios are complicated in a hospital setting where multiple physicians evaluate the patient during rounds and the physician coordinating the discharge may or may not be the one that documented the prior evaluation(s).  Each of these two scenarios present suppliers with a predicament in the context of existing guidance.


MiraVista will continue to monitor for this development and will provide an update to our subscribers when the final direction is made available.


Still confused about Face-to-Face requirements? 

You are not alone.


The rules and requirements have continued to unravel since the publication of the Face-to-Face rule and many providers are still scratching their heads about implementation in the real world. Join our webcast “Face-to-Face in the Real World: How to Comply in Its Current Form” on June 3, 2014 at 3pm ET as Andrea Stark partners with HME News to discuss the Face-to-Face rule as it currently exists for DME providers and what to anticipate as we move forward.  Register on our webinars/seminars page.


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