With Round 2021 underway, many brace suppliers outside competition areas have been surprised to get competition-related denials, especially those that sell products to walk-in customers. I always hate to bear the bad news that the denials are legitimate when the beneficiary’s address is inside a CBA. Medicare makes payment decisions using the home address on file, not where the supplier sells the product. Fortunately, a simple pre-sale routine can protect suppliers from the same fate.
Prior to filling an order for knee and back braces included in the competitive bid program, all suppliers should:
Prior to filling an order for knee and back braces included in the competitive bid program, all suppliers should:
- Obtain the patient’s address on file with Medicare using one of the Medicare portals or the eligibility checking feature included in most billing software applications.
- Copy the five-digit zip code and paste it into the Find a CBA tool on the CBIC website.
On the other hand, if the CBIC tool results indicate the zip code is part of a CBA for the brace in question, suppliers must document circumstances that justify the customer seeking service outside of his or her home area.
Traveling Beneficiaries Seeking Service Outside Their Home Area
If the patient needs the brace before returning home, the supplier can add a KT modifier to the claim to signal the item is for a traveling beneficiary. With this modifier, Medicare will override the edits that normally require a contracted supplier to fill the order.
As a condition of using the KT modifier, Medicare requires non-contracted suppliers to accept assignment at the single payment amount (SPA) for the competition area where the beneficiary normally resides. Suppliers should look up the SPA for the HCPCS and beneficiary competition area to make an informed decision before the sale.
There is, of course, potential for misuse of the special exceptions afforded to traveling beneficiaries. Generally, Medicare expects contracted suppliers will service beneficiaries in competition areas. As such, MiraVista advises non-contracted suppliers to limit the use of the KT modifier to cases when patients are far from home or otherwise have an urgent need for a product. Contractors may look more closely at suppliers with unexpected billing patterns and, if contractors identify improper use of the KT modifier, suppliers can find themselves on the wrong side of the False Claims Act.
Following these protocols will prevent denials and ensure that suppliers make informed decisions about the orders they fill and the payment amounts they can expect.
SOURCE LINKS
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/DME_Travel_Bene_Factsheet_ICN904484.pdf
https://dmecompetitivebid.com/cbic/cbicr2021.nsf/DocsCat/H5O2KFK4HO
https://www.dmecompetitivebid.com/SPA
RSS Feed