CMS issued its first formal instructions related to major oxygen policy changes published last year. Dated February 10, Change Request 12607 (CR) directs the DME MACs to synchronize their claim processing rules with the revised Home Use of Oxygen NCD before June 14, 2022.
That is good news, but …
While the change request confirms that NCD changes to expand coverage are retroactive, it provides no practical guidance to suppliers operating between the NCD’s September 2021 effective date and the contractors’ June implementation deadline.
That is good news, but …
While the change request confirms that NCD changes to expand coverage are retroactive, it provides no practical guidance to suppliers operating between the NCD’s September 2021 effective date and the contractors’ June implementation deadline.
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Oxygen CMN Use Will Cause Covered Claims to Incorrectly Deny
Where prior rules limited Medicare’s oxygen coverage to patients with chronic (long-term) hypoxemia, the revised NCD expands oxygen coverage to include patients with cluster headaches and a variety of short-term needs and acute conditions. However, new coverage rules conflict directly with existing claims processing logic and guidance used by the DME MACs. If the DME MACs continue to require the oxygen CMN - CMS Form 484 - as part of this transitional claim processing logic, many claims that meet the new NCD standards will deny.
Worse still, the CR places the responsibility for the conflicting rules squarely on suppliers. While the CR requires DME MACs to adjust claims processed incorrectly, it does not require them to proactively search their files for erroneous denials. That means suppliers will need to appeal unjust denials – which they will likely win – at their own expense in time and money.
CMS seems to double down on leaving the oxygen CMN in place, at least for the time being. The CR contains the following statement:
“Medical documentation requirements are not contained within the revised NCDs. The absence of medical documentation in these revised NCDs does not otherwise remove or modify Medicare requirements of the CMN form 484 itself or other medical documentation requirements under other existing authorities.”
The oxygen NCD, however, did contain medical documentation requirements before September. That’s why CMS included the following in its decision memo revising the oxygen policy:
“As part of CMS effort to reduce provider burden, we are removing the oxygen CMN requirement from the NCD.”
Both of the above statements cannot be true. Clearly, the NCD removes the oxygen CMN requirement. The real issue, however, is the continued requirement of an oxygen CMN form will cause erroneous denials for covered patient services.
As I wrote back in January, NCDs win out in any conflict with lower levels of authoritative guidance. I know this differs with recent DME MAC education and the “wait-and-see” approach suggested by other industry players, but a pathway for current claims is necessary to provide oxygen to patients included in the expanded coverage.
Resolving the Short-Term Conflict
There are a number of stop-gap measures the DME MACs could implement to remedy the issue until it is able to update its own guidance and claims processing logic:
The administrative CMN option is an ideal choice because it:
In the Meantime …
In “How to Restart Oxygen Rentals Without a CMN,” and again in the December edition of (K)notes, I laid out justification for using the CR modifier to bill qualifying claims during the transitional period (I also discussed scenarios the NCD does not adequately cover, and where, as a result, I recommend holding claims until DME MAC guidance is published). While Change Request 12607 offers little guidance to suppliers looking to properly service newly-covered patients, it is only the first in what I understand to be a series of CMS directives and clarifications.
SOURCE LINKS
www.cms.gov/files/document/r11263cp.pdf
Where prior rules limited Medicare’s oxygen coverage to patients with chronic (long-term) hypoxemia, the revised NCD expands oxygen coverage to include patients with cluster headaches and a variety of short-term needs and acute conditions. However, new coverage rules conflict directly with existing claims processing logic and guidance used by the DME MACs. If the DME MACs continue to require the oxygen CMN - CMS Form 484 - as part of this transitional claim processing logic, many claims that meet the new NCD standards will deny.
Worse still, the CR places the responsibility for the conflicting rules squarely on suppliers. While the CR requires DME MACs to adjust claims processed incorrectly, it does not require them to proactively search their files for erroneous denials. That means suppliers will need to appeal unjust denials – which they will likely win – at their own expense in time and money.
CMS seems to double down on leaving the oxygen CMN in place, at least for the time being. The CR contains the following statement:
“Medical documentation requirements are not contained within the revised NCDs. The absence of medical documentation in these revised NCDs does not otherwise remove or modify Medicare requirements of the CMN form 484 itself or other medical documentation requirements under other existing authorities.”
The oxygen NCD, however, did contain medical documentation requirements before September. That’s why CMS included the following in its decision memo revising the oxygen policy:
“As part of CMS effort to reduce provider burden, we are removing the oxygen CMN requirement from the NCD.”
Both of the above statements cannot be true. Clearly, the NCD removes the oxygen CMN requirement. The real issue, however, is the continued requirement of an oxygen CMN form will cause erroneous denials for covered patient services.
As I wrote back in January, NCDs win out in any conflict with lower levels of authoritative guidance. I know this differs with recent DME MAC education and the “wait-and-see” approach suggested by other industry players, but a pathway for current claims is necessary to provide oxygen to patients included in the expanded coverage.
Resolving the Short-Term Conflict
There are a number of stop-gap measures the DME MACs could implement to remedy the issue until it is able to update its own guidance and claims processing logic:
- Provide a pathway for suppliers to administratively complete the CMN in a manner that clearly identifies it as something other than a medical record prepared by the referring physician.
- Automatically add a “dummy” CMN to all oxygen claims to effectively bypass the obsolete processing logic.
The administrative CMN option is an ideal choice because it:
- Does not create a significant burden for the DME MACs.
- Substantially reduces logistical hardships for suppliers and referring providers.
- Offers immediate access to beneficiaries with conditions newly covered in the revised NCD.
In the Meantime …
In “How to Restart Oxygen Rentals Without a CMN,” and again in the December edition of (K)notes, I laid out justification for using the CR modifier to bill qualifying claims during the transitional period (I also discussed scenarios the NCD does not adequately cover, and where, as a result, I recommend holding claims until DME MAC guidance is published). While Change Request 12607 offers little guidance to suppliers looking to properly service newly-covered patients, it is only the first in what I understand to be a series of CMS directives and clarifications.
SOURCE LINKS
www.cms.gov/files/document/r11263cp.pdf
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