Just a quick reminder the covered document review deadline (CDRD) for Round 2021 is Monday, August 19, 2019. CBIC will review financial documents uploaded to Connexion before the CDRD and, within 90 days, provide suppliers an opportunity to submit any missing documents required for bid submission.

Though suppliers may upload financial documents (and corrections) through the close of the bid window on September 18, 2019, documents uploaded after the CDRD are not eligible for the review process.

CBIC Will Not Review for Acceptability

Under the covered document review process, CBIC is only looking for missing documents. Suppliers should not rely on the process to identify documents that are incomplete or unacceptable. That means CBIC could find there are no missing documents in the covered document review but later reject those same covered documents for errors. Rejected documents will cause suppliers to receive zeros for applicable financial scoring ratios.

Submitted documents cannot be changed or modified after the bid window closes on September 18, 2019.

Source Links
https://dmecompetitivebid.com/cbic/cbic2021.nsf/DocsCat/Fact%20Sheets~AJKNDLARRR?open

On May 16, 2019, the MACs published instructions that prohibits payment for PAP equipment and supplies between an unsuccessful initial trial and a clinical re-evaluation that documents therapeutic benefit.

What Does This Mean?

Every PAP failure means lost Medicare revenue until the supplier can fully document compliance. According to the bulletin, after the initial trial, suppliers can only bill for service dates that follow a compliant re-evaluation.

In these circumstances, suppliers must complete the following five steps to resume payment:

1. Secure face-to-face clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy.
2. Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.
3. Document in-home use of a PAP device for 31-90 days.
4. Document adherence through use of the PAP ≥4 hours per night on 70% of nights during a consecutive thirty (30) day period within the 90 day repeat trial.
5. Secure a face-to-face clinical re-evaluation with the treating practitioner to document improved symptoms of obstructive sleep apnea and objective evidence of adherence.

Claims with dates of service beyond the initial trial and before the date the physician completes the final clinical re-evaluation remain unpayable. During any interim period, the supplier should execute an ABN and collect from the beneficiary.

Does This Clarification Affect the RAD Policy?

No. The clarification only applies to beneficiaries with obstructive sleep apnea under the PAP policy. The Respiratory Assist Device (RAD) LCD addresses other medical conditions like central sleep apnea, severe COPD, and complex sleep apnea. The RAD LCD is not governed by the same national coverage determination that spurred this clarification.

Is There Anything We Can Do?

We are actively developing our understanding of the surrounding facts to inform our next move. MiraVista is searching for a viable alternative to the MAC’s interpretation. A few ideas we are exploring include:
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• Can we convince CMS that patients benefit from therapeutic intervention, even if they have yet to achieve “adherence” (possibly using a titration study that documents reduction in apneas and hypopneas)?
• If CMS will not waiver and the NCD language is problematic, should the industry pursue an NCD reconsideration?

In the interim, suppliers should immediately educate staff to cease billing Medicare with a KX modifier for rentals and accessories during repeat trial periods. 

SOURCE LINKS
https://cgsmedicare.com/jb/pubs/news/2019/05/cope12486.html

Recent updates to the myCGS portal now permit users to access TPE audit correspondence and introduces secure messaging features.  That's useful, but we think it could be a sign of bigger things to come.

TPE Audit Correspondence

Version 5.3 added features that provide users access to Additional Documentation Request (ADR) communications. The MACs generate ADRs, or development letters, to request information from suppliers on Targeted Probe and Educate (TPE) audited claims. From myCGS, suppliers can:

• Find all open and closed ADR cases.
• Check the status of ADR cases.
• View the details of ADR claims.
• View a copy of the most current ADR letter.
• Submit responses to the ADR.
• View a summary of any education.

myCGS Accepts Five File Types for Upload

When suppliers submit responses to ADRs through the portal, myCGS allows them to upload five different file types: DOC, DOCX, PDF, RTF, and TIFF. As of June 15, 2019, CGS has an active alert regarding portal messaging on file types. Contrary to portal instructions, CGS does not accept ZIP or TXT files. The alerts page instructs users to ignore the portal instructions and only upload documents in one of the five supported file types.

Secure Messaging

Version 5.4 added a secure messaging feature to the portal allowing suppliers to receive notifications from, and respond to, CGS regarding curable errors.

Suppliers can only respond to messages from CGS, they cannot initiate independent inquiries. Approved users will receive an email notification when a new message is pending in the portal. Upon login, approved users will also see an inbox alert with the number of unread messages.

​When CGS receives documentation from suppliers for TPE audits, the nurse reviewers may identify missing elements or documents. Suppliers are afforded an opportunity to fix these “curable errors.” CGS will message suppliers in the portal and allow five days for a response. If the supplier does not respond, the claim will automatically deny after 10 days.

CGS automatically grants access to the secure messaging feature to designated approvers. Designated approvers can grant access to additional end users as needed.

​At MiraVista, we believe these recent feature additions provide a foundation to eventually support prior authorization requests and appeal submissions in future updates.

SOURCE LINKS
https://cgsmedicare.com/jb/pubs/news/2019/02/cope11380.html
https://cgsmedicare.com/jb/pubs/news/2019/06/cope12792.html
https://cgsmedicare.com/jb/mycgs/alerts.html

Last August, CMS issued Change Request 10345 and made substantial changes to Chapter 5 of the Program Integrity Manual related to order requirements. Among other things, the change request seemingly established a single “date of the order” for detailed written orders. The summary of changes states, in part:
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“Previously, detailed written orders were required to have a start date. Now, the order is required to contain the date that the order was written.”

Why, then, would a supplier receive a denial in a recent TPE audit for a missing start date?

Despite guidance in the change request, MACs only honor a single date for detailed written orders generated by the physician. The MACs are firm in their position: orders initiated by anyone other than the physician always require two dates: a contact date and a date of the order.

The MAC interpretation is inconsistent with our reading of the CMS guidance. MiraVista believes CMS removed start dates to simplify the order process and reduce unnecessary errors and appeal escalations.

The change request makes a clear distinction between verbal and written orders:

"For 'Date of the order', use the dispensing order date, i.e., the date the supplier was contacted by the prescribing physician (for verbal orders) or the date entered by the prescribing physician (for written dispensing orders)."

We believe the highlighted instruction requires two dates only in the context of verbal orders where product is delivered before a physician signature is affixed on a compliant order. For example, a nurse reviewer would need two dates to validate a date of service that falls in between the initial contact date from the physician and the official signature date.

In light of the MAC’s position in these recent audits, suppliers may continue to use a separate start/contact date on future orders. While this extra element should not be required, it will not cause harm. Until the MACs follow the CMS guidance, the extra element may reduce the hassle of operating in an unnecessarily gray area.

MiraVista is currently seeking guidance from CMS officials.

SOURCE LINKS
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018Downloads/R812PI.pdf