MiraVista engaged CMS to revise a recently proposed automated audit (1) that would have recovered every DME claim that overlapped a patient’s hospice stay. CMS originally posted the proposed audit on August 7, 2018 with the following description: “All DME billed after the admit date of a beneficiary to hospice services and before the discharge date of a beneficiary from hospice services, will be denied as inclusive to hospice services unless there is a GW modifier present indicating DME is not related to the hospice diagnosis.”
The GW modifier, however, is unfamiliar to most DME suppliers because there is no guidance for using it in the DME claim setting.
CMS cited the following resources in support of the audit:
Only one of these resources, Chapter 11 of the Claims Processing Manual, mentions the GW modifier. Though it appears eight times throughout the 65-page document, every iteration limits the use to A/B MAC claim processing. Section 40.2, for example, states “For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim [sic] that are submitted without either the GV or GW modifier.” Notably absent from this directive is a reference to the DME MACs.
The DME MAC is mentioned once, but does not invoke the GW modifier; the manual states “A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner. Such claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.”
The DME MACs consistently review claims that overlap hospice admissions and deny when the DME claim diagnoses appear to be related to the terminal diagnosis.
After CMS approved the audit without modification, MiraVista raised the issue with Performant, the Region 5 RAC contractor, to prevent unnecessary recoupments and supplier appeals. After multiple productive conversations, the RAC contractor modified the audit description to decrease the importance of the GW modifier and increase the importance of the diagnosis codes for this audit:
09/24/2018 Revised Description Issue 0114: “All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services when the principal diagnosis of the Hospice claim is similar (same first three characters) to the DME claim and the GW modifier is not present on the DME claim giving indication that the DME is related to the Hospice patient’s terminal condition. Affected codes: See Appendix D of the downloadable Excel file.”
The audit description was modified again on October 1, 2018:
10/01/2018 Revised Description Issue 0114: “All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D of the downloadable Excel file.”
Due to the substantive edits made by Performant, DME suppliers should not expect mass recoupments. In the coming days, however, we expect the RAC to finalize the description of this audit and completely remove references to the GW modifier. MiraVista has not yet determined if the language regarding the comparison of principal diagnoses will change. As a general matter, however, the first three characters of an ICD-10 code relate to a very broad diagnosis category, or general type of injury or disease. The DME MACs presently leverage the first three characters of the ICD-10 code in their editing process. As a result, we expect the RAC to use similar logic, regardless of how it is spelled out in the description.
You can follow approved RAC audit issues and updates to Issue 0114, DME While in Hospice, on the Performant website at https://performantrac.com/audit-regions/region-5/.
SOURCE LINKS AND FOOTNOTES
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0112-DME-while-in-Hospice.html
https://performantrac.com/audit-regions/region-5/
(1) Automated reviews do not require medical documentation or supplier-involved claim development. The audit decision is based entirely on information that is included with the original claim.
The GW modifier, however, is unfamiliar to most DME suppliers because there is no guidance for using it in the DME claim setting.
CMS cited the following resources in support of the audit:
- 42 Code of Federal Regulations, Section 418.202 (f).
- CMS Pub. 100-2, Medicare Benefit Policy Manual, Chapter 9, Section 10.
- CMS Pub. 100-4, Medicare Claims Processing Manual, Chapter 20, Section 10.2.
- CMS Pub. 100-4, Medicare Claims Processing Manual, Chapter 11, Sections 10, 30.3, and 40.2.
Only one of these resources, Chapter 11 of the Claims Processing Manual, mentions the GW modifier. Though it appears eight times throughout the 65-page document, every iteration limits the use to A/B MAC claim processing. Section 40.2, for example, states “For beneficiaries enrolled in hospice, A/B MACs (B) shall deny any services on professional claim [sic] that are submitted without either the GV or GW modifier.” Notably absent from this directive is a reference to the DME MACs.
The DME MAC is mentioned once, but does not invoke the GW modifier; the manual states “A/B MACs (A) and (B) or DME MACs, shall deny claims for all other services related to the terminal illness furnished by individuals or entities other than the designated attending physician, who may be a nurse practitioner. Such claims include bills for any DME, supplies or independently practicing speech-language pathologists or physical therapists that are related to the terminal condition. These services are included in the hospice rate and paid through the institutional claim.”
The DME MACs consistently review claims that overlap hospice admissions and deny when the DME claim diagnoses appear to be related to the terminal diagnosis.
After CMS approved the audit without modification, MiraVista raised the issue with Performant, the Region 5 RAC contractor, to prevent unnecessary recoupments and supplier appeals. After multiple productive conversations, the RAC contractor modified the audit description to decrease the importance of the GW modifier and increase the importance of the diagnosis codes for this audit:
09/24/2018 Revised Description Issue 0114: “All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services when the principal diagnosis of the Hospice claim is similar (same first three characters) to the DME claim and the GW modifier is not present on the DME claim giving indication that the DME is related to the Hospice patient’s terminal condition. Affected codes: See Appendix D of the downloadable Excel file.”
The audit description was modified again on October 1, 2018:
10/01/2018 Revised Description Issue 0114: “All DME billed after the admit date of a patient to Hospice services and before the discharge date of a patient from Hospice services, will be denied as inclusive to Hospice services if after comparing principal diagnoses, the DME claim is related to the Hospice diagnosis. This review also excludes claims with the GW modifier. Affected codes: See Appendix D of the downloadable Excel file.”
Due to the substantive edits made by Performant, DME suppliers should not expect mass recoupments. In the coming days, however, we expect the RAC to finalize the description of this audit and completely remove references to the GW modifier. MiraVista has not yet determined if the language regarding the comparison of principal diagnoses will change. As a general matter, however, the first three characters of an ICD-10 code relate to a very broad diagnosis category, or general type of injury or disease. The DME MACs presently leverage the first three characters of the ICD-10 code in their editing process. As a result, we expect the RAC to use similar logic, regardless of how it is spelled out in the description.
You can follow approved RAC audit issues and updates to Issue 0114, DME While in Hospice, on the Performant website at https://performantrac.com/audit-regions/region-5/.
SOURCE LINKS AND FOOTNOTES
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Approved-RAC-Topics-Items/0112-DME-while-in-Hospice.html
https://performantrac.com/audit-regions/region-5/
(1) Automated reviews do not require medical documentation or supplier-involved claim development. The audit decision is based entirely on information that is included with the original claim.
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