CMS updated CMN forms to accommodate the new Medicare Beneficiary Identifier (MBI). The only notable difference, however, is a change to the policy number label from “HICN” to “Medicare ID.”

The update affects two DME Information Forms:

• Enteral/Parenteral
• External Infusion Pump

The update affects six CMN forms:

• Oxygen,
• Seat Lift Mechanisms,
• TENS,
• Pneumatic Compression Devices,
• Osteogenesis Stimulators, and
• The Continuation Form.

Updated forms contain a February 2017 (02/17) date for version control. Check with your software vendor to determine if the new forms are available in your system. Medicare will not require suppliers to revise previously completed CMNs but encourages early adoption for new setups.

If you have any questions, give us a shout.

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Source Links
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/2230703/cms-difs-and-cmns-updated

Suppliers delivering a Condition of Payment (COP) covered wheelchair base (HCPCS K0813-K0816, K0820-K0856, or K0861) on or after September 1, 2018, must request prior authorization before delivery. Authorization is a condition of payment, and all applicable claims without prior approval will deny.

Suppliers can submit prior authorization requests via mail, fax, or the DME MAC portals. Additionally, suppliers that pay for and utilize an esMD gateway through a certified HIH can upload requests through those channels.

CMS requires suppliers to secure an authorization even when Medicare is secondary to other insurance coverage.

Submission Requirements

CMS expects suppliers to include the following elements with their authorization request:

• MAC-approved Condition of Payment PA Coversheet
• 7-Element Order
• Face-to-Face (FTF) assessment
• Detailed Product Description (DPD)
• Specialty PT/OT Evaluation (if required)
• Any other relevant medical documentation

If an upgrade is involved, the FTF documentation and 7-element order must include the PMD base that is medically necessary for the beneficiary. Upgraded product information should appear on the Detailed Product Description with a note indicating when a supplier will deliver an upgraded item.

Accessories
​
The MACs will review same and similar history in the course of their review. They will not, however, review medical necessity for every accessory. Specific options and accessories that address patient limitations can be considered as part of the prior authorization request when evaluations support the need. The MACs often review integral accessories such as:

• Power seating combination tilt and recline (E1007).
• Head control interface (E2327, E2328, E2329, E2330).
• Sip-n-puff interface (E2325).
• Joystick, other than a standard proportional joystick (E2312, E2321, E2373).
• Multi-switch hand control interface (E2322).
• Seat cushions.

The MACs exempt from review non-integral accessories such as:

• Headrests (E0955).
• Lateral hip/trunk supports (E0956).
• Swing away hardware (E1028).
• Electronics (E2310, E2311).
• Leg rests (K0195, K0108, E1012).
• Batteries.

While the Advanced Determination of Medicare Coverage (ADMC) process historically issued individual approvals for accessories, suppliers cannot use ADMC to secure approval of accessories attached to COP eligible bases.

[Get answers to your questions, and keep your team’s billing expertise sharp. Join us on August 16, 2018, at 1:00 PM (ET) for (K)notes.]

Decisions

After completing its prior authorization review, the applicable MAC will provide a provisional decision to the supplier. Upon request, MACs will send a copy of the decision to the beneficiary, but not to the physician.

MACs will respond within 10 business days of an initial submission or within 20 business days for repeat submissions. In special circumstances where the beneficiary’s life or health is in serious jeopardy, suppliers can request an expedited response and receive an authorization decision within two business days.

The authorization decision is not a claim determination. As such, prior authorization decisions cannot be appealed; appeal rights only apply to submitted claims. There is no limit on the number of authorization submissions. If the authorization process is bypassed, the MACs may choose to suspend and develop claims, but they have the discretion to outright deny these claims.

Claims Submission

For all decisions, the MACs issue a letter containing a Unique Transaction Number (UTN) that must be recorded in Box 23 on the 1500 claim form. Electronic claims transmit the UTN in loop 2400 REF02 where REF01 = G1. Always attach the UTN to the base line item and not to accessories.

​If the applicable MAC renders a non-affirmative decision, the supplier may:

• Resubmit the authorization request, or
• Issue an ABN based on the medical necessity failures and file the claim with the non-affirmed UTN.

Claims filed with a non-affirmed UTN will deny, but the denials can be appealed.

Suppliers will have up to six months to deliver the PMD after the MACs issue the UTN.

Effective Date

DME MACs will accept PA review requests for the COP program on August 18, 2018. To remain eligible, suppliers must plan to schedule delivery of the PMDs on or after September 1, 2018. DME MACs will honor all PMD Demonstration and Advanced Determination of Medicare Coverage (ADMC) decisions rendered prior to September 1, 2018.

For more information, the DME MAC websites contain a wealth of PMD resources, and CMS posted an updated FAQ on June 1, 2018, related to the COP prior authorization program.

If you have any questions, give us a shout.

##

Source Links
https://www.gpo.gov/fdsys/pkg/FR-2018-06-05/pdf/2018-11953.pdf
https://med.noridianmedicare.com/web/jadme/article-detail/-/view/6547796/transition-of-eligible-pmd-hcpcs-codes-in-the-pmd-demonstration-to-the-required-prior-authorization
​

Hey there!

I know there is some confusion around the CMN requirements for Medicare oxygen volume adjustments, so I thought you might benefit from a brief summary of the MAC’s communications and a flow chart we designed to help you and your staff determine how to handle volume adjustment scenarios as they encounter them.

On April 26, the MACs partially reversed instructions from their February 15 communication regarding oxygen CMNs and volume adjustments. According to the new instruction, suppliers are not required to secure a revised CMN to justify high liter flows and comply with changes to when volume adjustments are paid.

To be clear, the MACs did not reverse the revised coverage criteria or calculation protocols for volume adjustments that took effect on April 1, 2018. However, this reversal means suppliers will not have to ask physicians to answer a different Question 5 than what is on the current, OMB approved, oxygen CMN.

Here’s what you need to do:

1. Query from the billing system active orders for high liter flow oxygen claims, designated with modifiers QE, QF or QG. If no existing orders meet the criterion, only new customers that qualify for volume adjustments must comply with CMS instructions.
2. Retrieve current O2 prescriptions for each applicable patient billing for a volume adjustment.
3. Based on the prescription, log these two values:
   1. Physician ordered LPM at rest
   2. Physician ordered LPM at night

 
Per CMS, exertion prescription orders no longer factor into volume adjustment consideration.

To keep it all straight, we posted a flow chart to help you bill consistently using the right calculations and modifiers.

If you have any questions, give us a shout.

Talk soon.

​Andrea

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Source Links
https://cgsmedicare.com/jb/pubs/news/2018/04/cope7420.html
https://med.noridianmedicare.com/web/jddme/policies/dmd-articles/billing-instruction-oxygen-cmn-question-5-revised
​

Hey there!


Medicare is making a pretty big change to oxygen billing on August 1.  Here is what’s up.


CMS is realizing that Oxygen CMNs are not reliable for certifying LCD coverage criteria. CMNs do not capture scenarios such as when:

• The physician hasn’t considered alternative treatments.
• Oxygen is being ordered for short term conditions like pneumonia.
• Sleep tests do not satisfy the minimum, five-minute requirement.
• Exertion tests do not include a test while on oxygen.

Absent direct medical record scrutiny, these scenarios are routinely paid under the current system.


That’s about to change…


CMS is adding a new requirement to the Oxygen LCD that will require a KX modifier to certify all coverage criteria are met. If a criterion is not met, suppliers should execute an ABN to explain why the records do not qualify and append a GA modifier. With the KX modifier logic in place, suppliers can expect accurate claim processing that is driven by the modifier. When the supplier knows a beneficiary does not qualify, they can omit the KX, replace it with a valid ABN modifier, and the claim should deny for patient responsibility.


As a reminder, ABNs and related modifiers are subject to contractor review. The above example (KX or GA) outlines the most common scenario and modifier protocol. The LCD, however, outlines other modifier combinations that include the use of GY (for cases where gas or liquid oxygen is ordered and delivered without a required 5 element order), and GZ (for cases where the criteria is not met, but an ABN was not properly executed). These variables determine appropriate supplier and patient responsibility.


If you have questions about proper liability and ABN execution, check out our on-demand course “The NBA of ABNs: Scoring Profitable Customer Experiences.”


The change is effective for claims with service dates on or after August 1, 2018. Suppliers must update all active oxygen orders to transmit the KX modifier on future claims. Failure to make necessary updates will result in cash flow disruptions. We at MiraVista, however, strongly discourage automatic application of this modifier through billing software pricing and fee schedules. Defaulting the KX modifier within your billing software will force non-compliant claims to transmit with an inappropriate modifier. Instead, establish prompts in your billing software that engage the intake staff to make a conscious decision. Always apply the KX modifier purposefully based on the individual merits of the case.


If you have any questions, give us a shout.


Talk soon.


Andrea

Source Links
​https://www.cgsmedicare.com/jc/pubs/news/2018/0518/cope7576.html