One of the many security benefits of the policy number migration to Medicare Beneficiary Identifiers (MBI) is the ability for Medicare to issue a new number anytime a beneficiary’s card is lost or compromised.  Unfortunately, if a customer receives a new number but does not provide it to their suppliers, those suppliers will get:

• “Invalid Member ID” when performing the eligibility check, or
• CO-16 denials with the MA27 and N382 remark codes.

No worries. Follow these steps to find the beneficiary’s new policy number:

1. Backdate the eligibility query with an earlier search date (when the MBI was known to be valid). A valid response will provide a term date for the defunct MBI.
2. Use the MBI Lookup Tool on the MAC Portal to obtain the active MBI. Enter the following beneficiary identifiers to return the active MBI:
   1. First name.
   2. Last name.
   3. Suffix (if applicable).
   4. Date of birth.
   5. Social Security number (SSN).

Wait! What? Social Security Numbers are Required to Lookup MBIs?

Another of the many security benefits of the MBI is the elimination of the need to obtain and store Social Security numbers. Under the premise of identity protection, CMS issued over 44 million MBIs to eradicate Social Security number-based policy numbers … only to continue to require suppliers to collect and maintain SSNs for MBI lookup purposes? MiraVista is seeking guidance from the MACs on possible alternatives to Social Security numbers for identification queries. But for now, suppliers cannot query a new MBI without having the customer’s SSN.

[Need a quick way to be the boss’s go-to billing expert and problem solver? Try (K)notes.]

MBI-Related Rejections

Suppliers still submitting claims with the old policy numbers are likely suffering an influx of claim rejections. Regardless of service date, Medicare claims submitted with a legacy HICN reject with the following codes:

• A7 (rejection for invalid information).
• 164 (entity’s contract/member number).
• IL (subscriber).

Denied and rejected claims require prompt intervention. Start by using the MAC web portals to obtain current MBIs:

• Jurisdictions A and D - https://www.noridianmedicareportal.com.
• Jurisdictions B and C -  https://mycgsportal.com/MyCGS/CGSAccount/Login

If you have any questions, give us a shout.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2019/11/cope14782.html
https://cgsmedicare.com/articles/cope14902.html
https://med.noridianmedicare.com/web/jddme/topics/ra/denial-resolution/ma27-n382-16

In the CY2020 End-Stage Renal Disease/Durable Medical Equipment Final Rule (the "Final Rule"), CMS harmonized three preceding rules addressing face-to-face visits (FTF), written orders prior to delivery (WOPD), and prior authorization (PA):

1. April 2006 Final Rule / Medicare Modernization Act of 2003 (MMA):
   1. Requires an FTF visit within 45 days of prescribing a power mobility device (PMD).
   2. Requires a 7-element written order prior to delivery.
   3. Covers 69 different PMD HCPCS.
2. November 2012 Final Rule / Affordable Care Act of 2010 (ACA):
   1. Requires an FTF visit within six months.
   2. Requires a 5-element written order prior to delivery.
   3. Covers 164 different HCPCS.
3. December 2015 Final Rule / Prior Authorization establishes:
   1. Master list of 135 eligible HCPCS for prior authorization.
   2. Required Prior Authorization List of 45 PMD and support surface HCPCS where authorization is mandatory as a condition of payment.

The new rules establish a singular master list of products eligible for inclusion on subordinate lists that require specific conditions of payment.

[Trouble keeping up with all of these billing changes?  No worries. With (K)notes, you can copy our homework.]

New Master List

In order to capture all of the regulatory requirements asserted by the preceding three rules, CMS changed the basis for adding items to the Master List. Additions now include:

1. Items that statutorily require an FTF visit, WOPD, or PA.
2. Items that:
   1. Have a fee schedule with an average purchase price of $500 or average rental price of $50 (both adjusted for inflation), or
   2. Account for at least 1.5% of Medicare expenditures for all DME items in a recent 12-month period and are:
      1. Flagged by the OIG or GAO after 2014 as potentially fraudulent or overutilized, or
      2. Identified as having a high improper payment rate in a CERT annual report issued in 2018 or later.
3. Items with:
   1. At least 1,000 claims and $1 million in payments during a recent 12-month period, and
   2. Aberrant billing patterns without explanatory factors such as a new LCD or newly approved technology, where:
      1. The percentage change in payment for the item from the current and preceding 12-month period is greater than the doubled percentage change for all DME payments in the same time frame, or
      2. Payments in the current 12-month period for the item exceed a 30% increase in payments for the same item in the preceding 12-month period.

New HCPCS

Using the new criteria, CMS added 212 new codes to the Master List. Additions include:

• 96 new orthoses.
• 46 new lower limb prostheses.
• 36 new wheelchair accessories.
• Six oxygen codes, including E1392 and K0738.
• One new catheter code, A4351.
• One new ventilator code, E0465.
• Test strips and two specialty meters.
• Custom breast prostheses.

Deleted HCPCS

CMS removed 101 HCPCS from the Master List that were formerly subject to ACA requirements including:

• Several wheelchair accessories.
• Lymphedema items.
• Group 1 support surfaces.
• Cervical traction units.
• Discontinued ventilator HCPCS.
• Oxygen contents.
• Standard glucose meters.
• TENS units.
• Seat lifts.
• Nebulizers.
• Several other low utilization products.

As a result of the change, suppliers need not secure a 5-element order before delivery of the deleted HCPCS. Instead, suppliers should secure a new standardized order prior to billing.

While medical necessity must be supported, CMS will not require an FTF visit within six months of the order for removed HCPCS.

New Required Lists

Inclusion on the Master List makes HCPCS eligible for (but not automatically subject to) FTF, WOPD, and PA. Only eligible codes on the Master List published to one of the following required lists are subjected to applicable conditions of payment:

1. Required Face-to-Face Encounter and Written Order Prior to Delivery List.
2. Required Prior Authorization List.

We predict CMS will push the same 45 codes currently subject to prior authorization to the new Required Prior Authorization List. Power mobility and support surface providers should experience no disruption or modification to the prior authorization process already in place.

We anticipate CMS might shake things up a bit with the Required Face-to-Face Encounter and Written Order Prior to Delivery List. We could end up with a mixed result where new codes migrate to WOPD and FTF for the first time, while others that have been subject to these same conditions under ACA fall off the list.

Notwithstanding, the Final Rule allows CMS to suspend any condition of payment for any item at any time. CMS can remove individual items or individual suppliers from either condition of payment. These permissions give the agency much more latitude in how it rolls out or scales back a condition of payment.

The Transition

​When CMS posts the two required lists, the effective date will be at least 60 days from the date of public notification. CMS has the authority to establish a later effective date, and may do so if the agency believes suppliers need more time to educate referral sources and implement internal procedures.

On January 2, 2020, the MACs posted a revised Standard Documentation Policy Article to introduce the new Standard Written Order (SWO) effective January 1, 2020. CMS will provide the MACs and other contractors with written directives via updates to the Program Integrity Manual and subregulatory guidance. The MACs will be busy updating LCDs, website materials, educational resources, and tutorials. 

Even after these changes are finalized, we always recommend suppliers secure orders and medical records prior to delivery for their own protection. Medical records are the only way to justify medical necessity in the event of an audit.

Why This Matters

Streamlining these disparate conditions of payment should reduce documentation burdens for suppliers across the board. Suppliers of power mobility products stand to benefit the most from a simplified order and FTF visits that remain viable for six months instead of 45 days. Under these guidelines, more customers will be served with fewer return office visits and fewer rounds of order corrections.

Despite the positives for mobility suppliers, it is impossible to determine the aggregate burden on suppliers. The dust hasn’t quite settled yet. A bigger Master List doesn’t necessarily mean that all products will require a WOPD and FTF visit, but until we know how many HCPCS will fall under this condition, we wait. 

SOURCE LINKS
https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf (Pages 60648, 60650, 60651, 60742 - 60777, 60788, 60789, 60800,60801, 60802, and 60807-60808)
42 CFR §410.38
April 2006 Final Rule
November 2012 Final Rule
December 2015 Final Rule
​

In the CY2020 End-Stage Renal Disease/Durable Medical Equipment Final Rule (the “Final Rule”), CMS instructs medical reviewers to consider the totality of the medical record if any of the required order elements are missing or flawed.  For example, if an order does not include an item description, reviewers can and should look beyond the face of the order to see if the description is identified in the medical records.

Perhaps more exciting, CMS is consolidating the myriad of order requirements into a svelte 6-element universal order.  That means no more separate order specifications for 5-element ACA orders, 7-element PMD orders, or detailed written orders for drugs or equipment and supplies!

There is more! To discover all of the DME-specific matters covered in the Final Rule, as well as other current reimbursement and industry developments, consider becoming a (K)notes subscriber.

SOURCE LINKS
https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf
https://www.cms.gov/newsroom/fact-sheets/cy2020-end-stage-renal-diseasedurable-medical-equipment-final-rule-cms-1713-f

Standardized claim forms, whether electronic or paper, are great for communicating lots of information efficiently.  But what if a billable transaction isn’t … you know … standard? 

Enter the narrative.

The narrative, otherwise known as the NTE 2400-line item note for electronic claims, allows suppliers to transmit special instructions to the applicable payer for each service or line item. With a limit of 80 characters, however, narratives make tweets look like epic novels.

Because space is limited, suppliers must be purposeful with every letter. To assist suppliers with crafting clear and concise narratives, CGS posted a list of over 90 common abbreviations to use when populating narratives. Noridian also has a shorter list of narrative abbreviations.

This article is the first in our series exploring the role of the narrative in common scenarios such as:

• O2 restarts.
• Breaks in service and need.
• Equipment replacement.
• Repairs.

But first, let’s consider a few general situations that require narratives to avoid denials.

More Than Four Modifiers

Claim forms have space for a maximum of four modifiers, but sometimes circumstances require more. Billers can use the narrative field to work around the four-modifier limitation, but they must first determine if an upgrade is part of the billable transaction:

• If no upgrade is involved, enter the first three applicable modifiers and then 99 in the final modifier spot.
• If an upgrade is involved, enter the first three applicable modifiers and then KB in the final modifier spot.

In both cases, enter all modifiers in the narrative field with no spaces, including the first three modifiers.

No Upgrade (99) Sample Narrative

Normally, a hospital bed rental in the first month requires three modifiers. If, however, the same bed replaces existing equipment after five years and the patient is a traveling beneficiary who normally resides in a competitive bid area, five modifiers are required.  Since the billable transaction is unrelated to an upgrade, the claim and narrative should read:

​Upgrade Overflow (KB) Sample Narrative

​If the same scenario above involved an upgrade instead of a replacement, the supplier would bill as follows:

Statutorily Non-Covered Items Billed With a GY Modifier

When beneficiaries use products for purposes that are not specifically discussed in the statute, the service is not covered. In such cases, the LCD calls for the use of the GY modifier.

Sometimes, otherwise eligible equipment is not covered for certain situations and uses. Suppliers must review the section “Non-Medical Necessity Coverage And Payment Rules” in the related policy article to understand when specific uses render the service not covered. Examples include:

• Commodes used as raised toilet seats over a functioning toilet.
• Wheelchairs used exclusively outside the home.
• Surgical dressings used for wound cleansing.
• Therapeutic shoes used for non-diabetics.
• Catheters used to manage urinary tract infections without incontinence.

When the use case is excluded by statute, suppliers must append the GY modifier to the claim and include a narrative identifying the equipment and explaining the circumstances that cause the item to be non-covered. By default, claims with a GY will deny for missing information if the supplier does not attach a narrative.

Statutorily Non-Covered Item Sample Narrative (31 characters)​

​Free Upgrades Billed With a GK Modifier

Free upgrades are scenarios where suppliers choose to provide an upgraded item without any additional charge to the beneficiary. Suppliers do this when it is more economical to purchase higher-level items in larger volumes and then use the premium item to meet the needs of substantially all beneficiaries. For example, some suppliers offer semi-electric beds in lieu of variable height beds or fixed height beds.

When suppliers provide the upgraded item at no additional charge to the beneficiary, the supplier must bill the lesser, medically necessary item with a GL modifier. Additionally, the narrative must document the make and model of the upgrade, HCPCS of the upgraded equipment, and the features that make it an upgrade. By default, the payer will deny claims that do not have a narrative to explain what item(s) the beneficiary actually received. 

​Free Upgrade Sample Narrative (56 characters)

Supplies Used With Patient-Owned Base Equipment

When beneficiaries change insurance, use donated equipment, or purchase items privately, the insurance has no record of the base equipment. By default, the payer will deny claims for accessories when they have no history of the base equipment. Suppliers must use the narrative to establish history.

The narrative should include the:

• Justification for the narrative.
• Designation of patient-owned base equipment.
• HCPCS and description of the base item.
• Approximate date of when the original equipment was delivered so the payer can calculate a reasonable useful lifetime for the base equipment.

Supplies Used With Patient Equipment Sample Narrative (38 characters)

Miscellaneous HCPCS

Payers mandate a narrative when suppliers bill for miscellaneous codes. In Medicare publications, miscellaneous codes are sometimes referred to as “not otherwise classified (NOC)” or “not otherwise specified.” Miscellaneous codes are effectively blank slates with no specific definition of their own, so payers need a narrative to determine what is being billed, why it is needed, and how to price it. By default, the payer will reject miscellaneous claims without a narrative.

The narrative must contain a description of the item, manufacturer, part/model number, HCPCS of the related base item, and a retail price. In the sample narrative below, the supplier is billing the miscellaneous HCPCS K0108 for knee supports attached to a power wheelchair at a rate of $300.

Miscellaneous HCPCS Sample Narrative (57 characters)​

In addition to the above elements, miscellaneous surgical dressing codes require details related to the pad size for wound covers and the number of ounces or grams in each tube/packet for wound fillers. These additional elements apply to miscellaneous HCPCS A4649, A6261, A6262, and A6512.

When off-the-shelf or custom molded shoes are substantially modified, the narrative for the miscellaneous modification must also provide a justification for the modification. This additional element applies to miscellaneous HCPCS A5507.

Narratives act as a supplier’s advocate at the time of claim processing. Use them to make a convincing argument.

​Next time, we’ll discuss narratives for restarting oxygen equipment, breaks in service, and breaks in need.