In a joint DME MAC article on public health emergency (PHE) protocols published a while back, contractors instructed suppliers to bypass the:

• Certificate of Medical Necessity (CMN) attachment for select oxygen claims.
• DME MAC Information Form (DIF) attachment for select external infusion pump claims.

MiraVista does not interpret this exception to apply to every oxygen or infusion claim. Suppliers should only bypass attachment requirements during the PHE when the circumstances render the forms inapplicable.

The DME MAC article on PHE protocols contemplates the impact of document deficiencies that arise from setups during the PHE. Under the relaxed guidelines, it is probable that questions on these forms do not apply or otherwise disqualify a beneficiary under normal circumstances. To avoid claim processing complications, the DME MACs decided to forego the attachments entirely for affected claims.

When suppliers qualify oxygen or external infusion pump patients using relaxed baseline criteria and known deficiencies exist, suppliers should release the claims without a CMN or DIF form attachment. These claims should also contain an appropriately applied CR modifier and a COVID-19 narrative.

SOURCE LINKS
https://cgsmedicare.com/jc/pubs/news/2020/05/cope17333.html

As schools prepare to reopen across the country, practitioners and suppliers must prepare for an influx of patients infected with COVID-19.  Many of those patients may not have health insurance that covers treatment. Fortunately, the Health Resources & Services Administration (HRSA) COVID-19 Uninsured Program provides reimbursement, subject to available funding, for the treatment of uninsured patients with COVID-19 or related complications. Here is how it works.

Supplier Registration

Interested suppliers must complete the registration process before submitting eligible claims for reimbursement. UnitedHealth Group (United), the same organization that dispersed Provider Relief funds on behalf of HHS, administers the uninsured benefit. United uses their Optum portal to process claims, so suppliers that do not already have an Optum ID must sign up for one. 

Suppliers must agree to:

• Research and confirm:
  • Patients do not have insurance coverage (including individual, employer-sponsored, Medicare, or Medicaid coverages), and
  • No other payer will reimburse for COVID-19 care.
• Accept claim reimbursement (at Medicare rates) as payment in full.
• Not balance bill customers.
• The program terms and conditions.

Suppliers are also required to acknowledge claims are subject to audit.

Creating a Patient Roster

Prior to submitting claims, suppliers must login to the Optum portal and add each uninsured patient to a roster with basic demographics. Suppliers can manually key each patient one-at-a-time or upload patients in batches using a template CSV file. Template fields include the following:

• Billing TIN Number*
• Patient First Name*
• Patient Middle Initial
• Patient Last Name*
• Patient Date of Birth (MM/DD/YYYY)*
• ID Type (SSN, State ID, No ID)*
• ID Number
• Patient Gender (M/F)
• Patient Account Number
• Patient Street Line 1
• Patient Street Line 2
• Patient City
• Patient State*
• Patient Zip Code
• Service Type (Professional, Institutional Outpatient, Institutional Inpatient)*
• Date of Service (MM/DD/YYYY)
• Date of Admission (MM/DD/YYYY)
• Date of Discharge (MM/DD/YYYY)

Suppliers should register only those beneficiaries that have a diagnosis of COVID-19 and receive treatment for a COVID-19 complication on or after February 4, 2020. To populate the roster, suppliers must collect the following:

• Social Security number.
• State of residence, or a state issued ID/driver's license.

The CSV template requires suppliers to enter the service date, but suppliers should leave the fields for the date of admission and discharge blank, as those only apply to institutional claims. Suppliers must also certify that none of the patients on the roster have insurance coverage at the time of service.

Submitting Claims

Within 24 hours of receiving a new roster, United will assign a temporary member ID to each patient that suppliers can use to submit electronic claims for reimbursement. Suppliers must submit all claims electronically through approved clearinghouses using payer ID 95964.
HRSA published a 40-page document explaining various claim processing edits and rejection reasons. Otherwise, the program should reimburse approved claims within seven to 10 days of receipt.

The COVID-19 Uninsured Program Portal User Guide and frequently asked questions document provide additional information about the program. Suppliers can also call 866-569-3522 Monday through Friday between 8:00 AM and 8:00 PM (in the caller's local time zone) for technical and payment support. 

SOURCE LINKS
https://coviduninsuredclaim.linkhealth.com/
https://coviduninsuredclaim.linkhealth.com/static/HRSA%20COVID-19%20Uninsured%20Program_Clearinghouse%20Partners.pdf
https://www.kff.org/policy-watch/limitations-of-the-program-for-uninsured-covid-19-patients-raise-concerns/

With the recent extension of the public health emergency (PHE) and CMS’s announcement to restart audit activity, suppliers continue to struggle with the vague distinctions between baseline medical necessity and permissible deficiencies during the PHE under the relaxed documentation standards. Last week we discussed specifics related to oxygen setups; this week we zero in on PAP and RAD.

PAP

The baseline for PAP therapy starts with evidence of sleep-disordered breathing. Practitioners should document a physical exam that measures neck circumference and body mass index (BMI). The medical record should also reference patient symptoms indicative of obstructive sleep apnea (OSA), such as:

• Snoring.
• Daytime sleepiness.
• Witnessed apneas.
• Choking or gasping during sleep.
• Morning headaches.
• Hygiene inventory indicators (e.g. Epworth Sleepiness Scale).

Ideally, a sleep study will confirm the extent of the OSA, but practitioners will probably use home sleep tests more frequently during the pandemic.

For continued use beyond the trial period, suppliers must document timely compliance using downloads from the machine and coordinate telehealth visits with the practitioner to document objective and subjective evidence of improvement. 

Potentially Permissible Deficiencies for PAP Setups

Under the relaxed guidelines, patients will not necessarily have a traditional sleep study or documented apnea hypopnea index.

RAD

The baseline for RAD therapy generally starts with symptoms characteristic of sleep-associated hypoventilation, such as:

• Daytime hypersomnolence.
• Excessive fatigue.
• Morning headaches.
• Cognitive dysfunction.
• Dyspnea.

During the PHE, the medical records should document significant patient symptoms that warrant equipment intervention to mitigate health risks. We also suggest the practitioner first consider PAP therapy.

If routinely required testing is not feasible during the PHE, we advise suppliers to ensure the medical record documents an estimation on how and when the practitioner will coordinate further testing.

For continued use beyond the trial period, the medical record must document:

• Compliant usage of the equipment using downloads from the machine.
• Subjective evidence of improvement (via telehealth visits when in-person encounters are not feasible). 

Potentially Permissible Deficiencies for RAD Setups

Under the relaxed guidelines, patients will not necessarily have lab-performed test results to confirm a suspected diagnosis per the LCD requirements. Practitioners may not be able to perform many of the routine tests required in the LCD that measure arterial blood gas, forced vital capacity, forced expired volume, or carbon dioxide retention.

Suppliers must monitor patients carefully and discontinue billing if the underlying condition improves.  If the condition endures, suppliers must obtain objective evidence using baseline medical necessity requirements before the PHE ends.

Last week’s extension of the COVID-19 public health emergency (PHE) continues the relaxed clinical enforcement items CMS outlined in a series of interim final rules (IFR) earlier this year. And while suppliers quickly adapted to provide care in a socially-distanced world, many remain uneasy on how to document patients’ medical need using the relaxed standards.

Existing documentation does not distinguish between baseline medical necessity and permissible deficiencies. We at MiraVista have done our best, based on our experience interpreting CMS guidance and policy, to mold the rudimentary guidelines into more tangible concepts and concrete examples. CMS and the DME MACs continue to issue guidance, and future clarifications may alter our conclusions.

After wrestling with the authoritative publications and various exchanges with Medicare, we boiled it down to this:

Medicare will reimburse services during the public health emergency when medical records meet the spirit of longstanding policies, even if the records do not meet every detail.

CMS is not waiving long standing policy to allow every patient to access services regardless of need. Instead, the CMS instructions temporarily relax some of the formal documentation requirements. The medical records still must demonstrate a baseline medical need for the equipment or supplies as a condition of Medicare payment.

For those that attended our last (K)notes event in June, we covered an array of respiratory products.  Here, we revisit oxygen as an example.

Oxygen Baseline

The baseline for oxygen therapy starts with documented hypoxia-related symptoms that might improve with oxygen therapy. Ideally, an objective SAT or ABG test result is available.

Physicians who cannot see patients in person should obtain objective evidence of hypoxia using:

• Telehealth,
• Remote monitoring technology, or
• Overnight oximetry.

If objective evidence is not immediately available, the record must document subjective evidence of hypoxia. Examples might include combinations of:

• Confusion.
• Shortness of breath or increased respiratory rate.
• Sweating.
• Wheezing.
• Anxiety or restlessness.
• Bluing fingernails or lips.
• Flaring nostrils.

Suppliers must ensure continued medical necessity, and they must stop billing when the underlying condition improves.

Potentially Permissible Deficiencies for Oxygen Setups

Under the relaxed guidelines, medical records may contain permissible deficiencies where the notes do not contain evidence of:

• Oximetry test results taken while the beneficiary is in a chronic stable state,
• Long-term chronic conditions, or
• Evidence of alternative treatments. 

Nonetheless, suppliers should monitor these patients carefully and:

• Discontinue billing if the underlying condition improves, or
• For sustained conditions, obtain objective evidence as soon as it is accessible (before the PHE ends).

SOURCE LINKS
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-23June2020.aspx
https://cgsmedicare.com/jc/pubs/news/2020/05/cope17333.html
https://www.govinfo.gov/content/pkg/FR-2020-04-06/pdf/2020-06990.pdf
https://www.govinfo.gov/content/pkg/FR-2020-05-08/pdf/2020-09608.pdf