In CMS-1713-F, the final rule that replaced detailed written orders (DWOs) with standard written orders (SWOs), CMS eliminated the requirement to document frequency. Despite the change, DME MACs and auditing contractors continued to invalidate non-specific orders with “PRN” or “as-needed” instructions, relying on old habits and outdated language in the Program Integrity Manual (PIM).

To promote consistency with the revised SWO requirements, CMS updated section 5.11 of the Program Integrity Manual (PIM) and removed conflicting language that stated “PRN” and “as-needed” were not acceptable frequencies for SWOs. The revised PIM language now reads:

“If replacement supplies are needed for the therapeutic use of purchased DMEPOS, the treating practitioner must specify on the standard written order, or on the CMN, the type of supplies needed, in such a manner that the supplier may calculate the necessary disbursement and assess the continued need for refill with the beneficiary. DME MACs, UPICs, and other contractors evaluate supply utilization information as part of their medical necessity and coverage determinations for DMEPOS.” 

On the surface, it appears CMS relaxed an antiquated policy. However, the agency stopped well-short of sanctioning non-specific frequencies. The change request states that, alone, the words “PRN” or “as needed” do not provide sufficient information to allow calculation of quantity, which remains a required SWO element. CMS goes on to instruct auditors that medical documentation outside the SWO must objectively support quantities ordered by a doctor and filled by a supplier. As such, suppliers should remain guarded when it comes to non-specific order quantities. 

After establishing a baseline, CMS instructs auditing contractors to refrain from a too-literal application of policy when it comes to quantity calculations. Even if the doctor does not spell everything out word-for-word, CMS expects contractors to use other readily available variables, like dosing amounts and potential frequency, to calculate quantity.

CMS also instructs contractors to assume the beneficiary will use the medication at the maximum amount prescribed so long as it does not exceed limits in the local coverage determination. For example, if an order states “Albuterol 0.83%/3ml vial every 6-hours PRN,” suppliers and auditors can determine the beneficiary should receive 120-unit dose vials. So long as coverage requirements are met, auditing contractors should infer this order supports the maximum potential quantity of 120 vials.

Upon receipt of a PRN order, suppliers should review the records and ensure a reasonable person can fill in the quantity blanks with available information in the record. Doing so should spare suppliers from premature SWO rejection and frivolous quantity denials.

SOURCE LINKS
https://www.cms.gov/files/document/r10492pi.pdf
https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf

Though the Provider Relief Fund (PRF) Reporting Portal officially opened as scheduled on January 15, 2021, PRF recipients can do little more than register on the site. The current version does not permit users to submit any information related to the use of funds.

The Department of Health and Human Services (HHS) and its partner agencies are updating reporting elements in accordance with the Coronavirus Response and Relief Supplemental Appropriations Act passed on December 27, 2020. The agencies did not specify when the reporting features will be available, but suppliers that received more than $10,000 from the PRF should register now to receive email notifications and updates.

HHS estimates users will spend approximately 20 minutes completing the registration path. The portal will, however, time out after 15 minutes of inactivity, and frustrated users will lose all in-progress data. To avoid setbacks, registrants should compile the following required information for each non-consolidated reporting entity before starting the process:

• Tax Identification Number (TIN).
• Business name and address of the reporting entity (as listed on Form W-9).
• Name, phone number, and email of the responsible submitter.
• TIN for each subsidiary, if reporting on behalf of subsidiaries.

Registrants must further verify their identity with the following details of the PRF payment:
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• TIN of entity that received the payment.
• Payment amount.
• Mode of payment (check or direct deposit ACH).
• Check number or ACH settlement date.

For those that received more than one disbursement, the specifics for any single payment will work.

Portal registration is an important first step. Once the portal is fully functional, recipients will likely have 30 days to report eligible expenses incurred through December 31, 2020. If reported eligible expenses and losses do not exhaust PRF receipts by June 30, 2021, suppliers will have to return unused funds.

SOURCE LINKS
https://www.hhs.gov/about/news/2021/01/15/hhs-announces-provider-relief-fund-reporting-update.html
https://prfreporting.hrsa.gov/s/

Medicare suppliers are often frustrated with frequent same or similar denials for brace claims. In part, physicians commonly prescribe new braces to patients recovering from surgery or other injuries without first asking about braces the patient may already have at home. But while the nature of the ordering process may increase the risk, there are two supplier intake deficiencies primarily to blame for these persistent denials:

1. Skipping same or similar checks.
2. Checking for history in the wrong place.

Of course, no process is effective if skipped altogether, so intake personnel must complete same or similar checks before every setup or delivery. Nonetheless, a common mistake can foil even diligent brace suppliers and lead to incorrect results and denied claims …using the incorrect search method.

DME MAC portals provide two methods for same or similar searches:

1. CMN data searches.
2. Claim data searches.

Traditional same or similar searches query the electronic CMN documents Medicare creates to track monthly payments and one-time purchase transactions for traditional DME billed with E and K codes. Medicare does not, however, create CMN documents for the L codes for braces, so suppliers need to search patient claim data for evidence of a paid claim for L codes.

Suppliers often use the wrong search method because the DME MAC portals do not make a clear distinction between the two available options. Individuals using the incorrect method are often none the wiser because choosing incorrectly produces no error. The system simply returns no results, leaving the user with a false sense of security.

Here’s how suppliers can get to the right source to check claim data for evidence of a past brace.
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Jurisdictions B and C (MyCGS):

• Go to the Claim History menu.
• Go to the Claim Preparation tab.
• Select the second tab for Claim History.
• Enter “L” instead of a specific HCPCS.

Jurisdictions A and D (Noridian Medicare Portal):

• Click the Same or Similar menu on the home page.
• Select option 2 (search for all paid dates of service for a range of HCPCS).
• Enter “L0001” to “L9999.”

By following these steps, the system will return every paid brace from the last five years.

What should suppliers do when they find a brace in history?

Ask the patient what happened to their last brace. Depending on the answer, suppliers have three options:

1. Provide a new brace if Medicare covers an early replacement.
2. Execute an ABN to transfer payment responsibility to the patient.
3. Refuse the order.

For the first scenario, Medicare will pay for an early replacement if the supplier can produce documentation supporting:

• The beneficiary lost or damaged the previous brace.
• A change in condition renders the previous brace inappropriate.

For the second scenario, assuming Medicare will not cover an early replacement, the supplier can execute an ABN to inform the patient Medicare will probably deny the current claim due to the previous brace. Once the patient signs the ABN, suppliers can collect payment at the time of delivery.

Using the correct eligibility tools is a simple way to eliminate many of the denials that clog reports, consume billing resources, and disrupt revenue.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2020/08/cope18619.html
https://med.noridianmedicare.com/web/jadme/topics/same-or-similar 
https://med.noridianmedicare.com/web/portalguide/inquiry-guide/same-or-similar
https://cgsmedicare.com/jc/pubs/news/2020/01/cope15520.html

CMS recently finalized payment rules for a new Medicare home infusion therapy (HIT) benefit, created by the 21st Century Cures Act (2016), covering professional services provided to patients that receive certain medications at home via an infusion pump. Covered services include training and education, patient assessments and evaluations, medication management, and remote monitoring by clinical professionals (e.g. nurse, pharmacist). 

Unfortunately, the 2021 Home Health Rule (CMS-1730-F) lays out a complex procedure requiring suppliers to bill the professional services component separately to an A/B MAC after the DME MAC pays for related medications and supplies.

Part B Enrollment as a Qualified HIT Supplier

Because CMS tasked Part B carriers ­­— not DME MACs ­­— with processing professional services, interested suppliers must pursue accreditation as a qualified HIT supplier and enroll as such with the A/B MAC.

Bill A/B MACs for Professional Services

CMS created six G-codes for the professional services component of the new benefit.

Claims for G-codes only pay when the system finds a DME MAC payment for an eligible J-code medication within 30 days of the G-code’s service date. If the A/B MAC cannot locate a paid corresponding drug claim, it will deny the claim for professional services as CO-16 with an N657 remark code. N657 simply states “this should be billed with the appropriate code for these services.”

Dually-enrolled suppliers have visibility into both sides of the transaction, and as such, may fare better than their standalone counterparts. The combination supplier can ensure the DME claims process ahead of professional services and, at the very least, confirm DME payment before submitting Part B claims blindly. Nonetheless, the administrative burden is significant.

Bill DME MACs for Equipment, Medications, and Supplies

Infusion suppliers should continue billing E-codes, J-codes, and A-codes to the DME MAC for the pump, meds, and supplies, respectively. To maintain coordinated processing between the two MACs, suppliers should pay extra attention to denial and stopped/held revenue reports to quickly resolve any DME processing matters that may disrupt billing for professional services.

SOURCE LINKS
https://www.cms.gov/files/document/mm11880.pdf
https://www.cms.gov/files/document/mm11954.pdf
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf 
https://www.nahc.org/wp-content/uploads/2020/12/HIT-Fact-Sheet-final.pdf
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