EDITION 17 | SUMMER 2020 · met, and that claims payment will be made correctly, if the external infusion pump is still in the capped rental period, drug(s) administered with the

EDI TION 17 | SUMMER 2020

This newsletter should be shared with all health care practitioners and managerial members of the provider/supplier staff. Newsletters

issued after 2014 are available at no cost from our website.

© 2020 Copyright, CGS Administrators, LLC

EDITION 17 ∙ SUMMER 2020 2© 2020 Copyright, CGS Administrators, LLC. Back to Table of Contents

Table of Contents

News from the InsideCGS Medicare, Any Time, Any Place. A Refreshed Version of Our App is Here! – CGS Publication ....................................5

The Claim Denial Resolution Tool and Why It’s Helpful – CGS Publication ..................................................................6

Utilize the Advanced Modifier Engine (AME) for all your Modifier Needs! – CGS Publication .........................................6

Take Advantage of the MBI Converter Tool Before Calling Customer Service or IVR! – CGS Publication .........................6

myCGSMake Simple Claim Corrections in myCGS! – CGS Publication ...................................................................7

Medicare Minute: myCGS – CGS Publication .........................7

Redeterminations and Reopenings Form Submission Now Available in myCGS! – CGS Publication .................................8

COVID-19Extension of Payment for Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (MM11784) ...............................................................................9

Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19) (SE20011 Revised) ..................................................................9

New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE) (SE20016 Revised) ................................................................10

Required Prior Authorization Suspended for the Duration of the COVID-19 Pandemic....................................................11

Billing of Part B Drugs and Enteral Nutrition to DME MACs During COVID-19 Pandemic – Dispensing Amounts – Revised – Joint DME MAC Publication ..................................12

Correct Use of the KX Modifier During the COVID-19 PHE – Joint DME MAC Publication ................................................13

CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) – COVID-19 Public Health Emergency – Revised – Joint DME MAC Publication ................................................15

Use of CR modifier and “COVID-19” narrative on Specified Claims Due to the COVID-19 PHE – Joint DME MAC Publication ................................................18

Coverage & BillingL3960 – Coding Verification Review Requirement – Joint DME MAC & PDAC Publication .................................19

Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section (MM11778) .................20

New Medicare Beneficiary Identifier (MBI) Get It, Use It (SE18006 Revised) ................................................................20

Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type (SE20001) ......21

Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare (SE20009) ...................................21

Supplier Education on Use of Upgrades for Multi-Function Ventilators (SE20012) ............................................................22

Positive Airway Pressure (PAP) Devices: Replacement – Revised March 2020 ...........................................................23

Positive Airway Pressure (PAP) Devices: Initial Qualification – Revised March 2020 ......................................25

Glucose Monitors – Revised March 2020 ..............................27

Documentation Requirements for Power Wheelchairs and Power Operated Vehicles – Revised March 2020 .................29

Medical PolicyLCD and Policy Article Revisions Summary for March 5, 2020 ........................................................................31

LCD and Policy Article Revisions Summary for March 12, 2020 ......................................................................34

LCD and Policy Article Revisions Summary for March 19, 2020 ......................................................................38

LCD and Policy Article Revisions Summary for April 2, 2020 ..........................................................................39

LCD and Policy Article Revisions Summary for April 16, 2020.........................................................................41

Policy Article Revisions Summary for April 30, 2020 ............42

Nebulizers Final LCD (L33370) and Response to Comments (RTC) Article Published – Joint DME MAC Publication ................................................43

External Infusion Pumps Final LCD (L33794) and Response to Comments (RTC) Article Published – Joint DME MAC Publication ................................................43

Frequently Asked Questions – Final Rule CMS-1713-F – Standard Written Orders – Joint DME MAC Publication ....44

Miscellaneous Claim Status Category and Claim Status Codes Update (MM11467 Revised) ...............................................................48

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update (MM11489 Revised) .......48

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE (MM11490 Revised) ....................................................49

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update (MM11638 Revised) .......50


Table of Contents continued...

Claim Status Category Codes and Claim Status Codes Update (MM11699) ................................................................50

Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update (MM11708) .....................51

Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE (MM11709) ..................................................................51

New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services (MM11750) ........................52

Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit Component (MM11754) .............................................................................52

Section 4.26.2 in Chapter 4 of Publication (Pub.) 100-08 .....53

Fees & PricingApril 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM11701) .....................................................................54

April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule (MM11702) ...................................54

July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files (MM11745) .....................................................................55

HCPCS UpdatesThe July 2020 HCPCS Updates – New, Revised, and Discontinued HCPCS Codes – CGS Publication ..................55

Competitive PricingQuarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2020 (MM11718) ...........................................................56

MLN Connects®MLN Connects® for May 21, 2020 .........................................57

COVID-19: Payment for Lab Tests, Safely Reopening Nursing Homes, Lab & Ambulance Claims ............................58

COVID-19: Nursing Home Deadline, Telephone E&M Visits, Hospital Time Studies, and Calls ...............................58

MLN Connects® for May 14, 2020 ........................................59

COVID-19: Additional Waivers, Price Transparency, and CMS Letter to Nursing Homes ..............................................59

COVID-19: Nursing Home Reporting, Updated Telehealth Video, Pharmacies & Other Suppliers Can Enroll as Labs, IRF Flexibilities ......................................................................60

MLN Connects® for May 7, 2020 ...........................................60

COVID-19: Second Round of Sweeping Changes, RHC & FQHC Flexibilities, EMTALA .................................................61

MLN Connects® for April 30, 2020 .......................................61

COVID-19: CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program ............62

MLN Connects® for April 23, 2020 ........................................62

COVID-19: Nursing Home Transparency, Recommendations for Areas with Low Incidence of Disease ..................................................................................63

COVID-19: RHC & FQHC Flexibilities, Increased Payment for Lab Tests, Hospital Waivers, Call Audio and Transcript ..63

MLN Connects® for April 16, 2020 ........................................64

COVID-19: Reprocessing Hospital Claims, Essential Diagnostic Services, Non-Invasive Ventilators ......................64

COVID-19: Infection Control, Maximizing Workforce, Updated Q&A, CS Modifier for Cost-Sharing, Payment Adjustment Suspended ..........................................................65

MLN Connects® for April 9, 2020 ..........................................65

COVID-19: Telehealth Video, Coinsurance and Deductible Waived, ASC Attestations, Ambulance Modifiers, Lessons From Front Lines, MLN Call Today ........................................66

COVID-19: Telehealth Billing Correction, Nursing Home Recommendations, Billing for Multi-Function Ventilators, New ICD-10-CM Diagnosis Code ..........................................66

MLN Connects® for April 2, 2020 ..........................................67

COVID-19: Regulatory Changes, Telehealth Billing, and Specimen Collection Codes ..................................................68

COVID-19: Financial Relief, Nursing Home Telehealth, Quality Reporting, Clinical Laboratories, Hospital Data Sharing ..................................................................................68

COVID-19: Enrollment Relief, Open Payments, Beneficiary Notices ...................................................................................69

MLN Connects® for March 26, 2020 .....................................69

COVID-19: Relief for Quality Reporting Programs and Provider Enrollment ...............................................................70

COVID-19: Telehealth and Non-Essential Procedures ..........70


COVID-19: President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak ........71

COVID-19: FFS Response and Nursing Home Visitor Guidance ...............................................................................71

COVID-19: Test Pricing, Diagnostic Lab Tests, Pricing & Codes, and EHB Coverage ....................................................72

The CMS articles in this edition of the Insider are current as of May 26, 2020


The Medicare Learning Network® on the CMS Website Knowledge � Resources � Training

� Publications & Multimedia

� Events & Training

� News & Updates

� Continuing Education

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNGenInfo/index


COVID-19 Response: CMS Issues FAQs to Assist Medicare Providers ................................................................73

CMS Develops Additional Code for Coronavirus Lab Tests ..73

MLN Connects® for March 5, 2020 .......................................73

CMS Announces Actions to Address Spread of Coronavirus ...........................................................................74

MLN Connects® for February 27, 2020 .................................74

DME MAC Jurisdiction B Contact Information ....................................................76




NEWS FROM THE INSIDE

CGS Medicare, Any Time, Any Place. A Refreshed Version of Our App is Here!

- CGS Publication

Link to current version on the CGS website: https://cgsmedicare.com/jb/pubs/news/2020/04/cope16758.html

Our app has gotten a full makeover for 2020! We have launched a brand new version of our previous mobile app “CGS Go Mobile” with a completely new style and name. The features have also been revamped. Simply called CGS Medicare, here’s what the refreshed app offers:

� LCDs/Policy Articles

� CGS Wizard

� DMEPOS Fee Schedule

� Physician Letters

� Drug/Pharmacy Fees

We can’t wait for you to take advantage of the free CGS Medicare app, so you can bring our most helpful features with you, wherever you go. The app is available in the App Store and Google Play Store, just search CGS Medicare to download!

For more information about the CGS Medicare App, visit our website: https://cgsmedicare.com/jb/onlinetools/cgsmedicare.html.

https://cgsmedicare.com/jb/pubs/news/2020/04/cope16758.html

https://cgsmedicare.com/jb/onlinetools/cgsmedicare.html

https://cgsmedicare.com/jb/onlinetools/cgsmedicare.html


The Claim Denial Resolution Tool and Why It’s Helpful

- CGS Publication

Have you had a claim deny? If so, it’s likely you need to quickly take steps to get it resolved. That is why we added the Claim Denial Resolution Tool to cgsmedicare.com. This self service tool allows you to get the answers quickly and efficiently, and takes the place of our previous ANSI Denial Guide which was time consuming and cumbersome to scroll through.

As a supplier, all you have to do is enter your ANSI Reason Code and ANSI Remark Code, if applicable, from your Remittance Advice. You can then click submit and see your precise remittance message and reason for denial. You will also see the possible causes and resolution to the denial.

Once you use the Claim Denial Resolution tool, you’ll be one step closer to getting your denial resolved. You can find the tool under the Online Tools & Calculators Tab on www.cgsmedicare.com/jb/index.html.

Utilize the Advanced Modifier Engine (AME) for all your Modifier Needs!

- CGS Publication

We encourage you to utilize AME for all your modifier needs, as we will soon be retiring the Repair Modifiers Tool which incorporates the same features.

AME recommends the modifiers to use on claim lines depending on your specifications, and in the correct order. With AME, modifiers can be specified by DMEPOS Category, HCPCS, Scenario and Sub-Scenario.

Take Advantage of the MBI Converter Tool Before Calling Customer Service or IVR!

- CGS Publication


Both Customer Service and the Interactive Voice Response (IVR) system ask suppliers to enter the patient’s name and MBI during the initial beneficiary validation process. Our MBI Converter Tool (https://cgsmedicare.com/medicare_dynamic/jb/ivr_mbi_converters/ivr_mbi_converters.aspx) makes this simple by giving the correct codes you should enter for each specific MBI.

Keep in mind that entering this information beforehand allows the representative to have it in front of them before your call even begins. This way, they can get your call and questions answered as quickly as possible. The MBI Converter Tool and IVR Beneficiary Name to Number Converter are located on the Tools & Calculators page of our website: https://cgsmedicare.com/jb/index.html.

https://www.cgsmedicare.com/jb/index.html



https://cgsmedicare.com/medicare_dynamic/jb/ivr_mbi_converters/ivr_mbi_converters.aspx

https://cgsmedicare.com/medicare_dynamic/jb/ivr_mbi_converters/ivr_mbi_converters.aspx

https://cgsmedicare.com/jb/index.html

https://cgsmedicare.com/jb/index.html


myCGS

Make Simple Claim Corrections in myCGS!

- CGS Publication


With Claim Correction, you can easily initiate an adjustment in real time via myCGS. There is no longer a need to call telephone reopenings to request a simple claim correction. Plus, you can easily check the status of your adjustment within myCGS after you have submitted your request.

There are two ways to correct a claim on myCGS. If you notice an error (i.e. wrong number of services or date of service) on your claim while viewing claim status, you can begin the correction on that same page in real time. Just click “Claim Correction”. Alternatively, you can go to the Reprocessing tab and choose Claim Correction from the drop down menu. From there, you can enter your criteria to initiate the same adjustments.

Here’s what can be corrected via Claim Correction:

� Place of Service

� Date of Service (From and To)

� Number of Services

� Submitted Amount

� Diagnosis Codes

� HCPCS Code and Modifiers

For full instructions on how to complete a claim correction in myCGS refer to the myCGS User Manual (https://www.cgsmedicare.com/jb/mycgs/pdf/mycgs_user_manual.pdf).

Medicare Minute: myCGS

- CGS Publication

In a new special edition of Medicare Minute, Dr. Robert Hoover explains the benefits of myCGS and all that it offers.

myCGS offers a wide range of functionality and support, such as: Beneficiary Eligibility, Claim Status and the MBI Lookup Tool. It also allows you to Search Same or similar, View ADR cases and letters, and brand new to myCGS is Redeterminations and Reopenings Form submission!

Medicare Minute Video: https://cgsmedicare.com/jb/education/video/vid_mycgs.html

https://cgsmedicare.com/jc/pubs/news/2020/01/cope15551.html

https://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_user_manual.pdf

https://cgsmedicare.com/jb/education/video/vid_mycgs.html


Redeterminations and Reopenings Form Submission Now Available in myCGS!

- CGS Publication


We’ve heard your feedback, and are now thrilled to offer Redetermination and Reopening form submission in myCGS.

RedeterminationsWith the Redeterminations menu, you can either see the current status of your redetermination, or submit a new redetermination request form. To search for a Redetermination status, you will enter either the Document Control Number (DCN) or Claim Control Number (CCN), along with the MBI of the beneficiary.

myCGS will display the following information:

� Date of Receipt

� Status

� Date of Decision

� CCN

� DCN

� Any applicable documents

ReopeningsThe Reopenings menu will offer you three options; Status, Form Submission, and Claim Correction. The Reopening Status will display the same information as Redetermination status (above).

We introduced Claim Correction recently, which allows you to make specific claim corrections in the portal. If Claim Correction is not a viable option for you, you can now submit a Reopening request instead. These requests can be accessed from the Claim Status screen in the Claims menu, or the Reopenings Form Submission Screen in the Reprocessing Menu.

A few things to keep in mind:

� A claim must already have been processed by CGS to be eligible for Reopenings.

� By default, End Users must be granted access by a Designated Approver to submit a Reopenings form.

The Redeterminations and Reopenings features can be found under the Reprocessing tab in myCGS (https://mycgsportal.com/mycgs/). For full instructions on how to use them, refer to the myCGS User Manual (https://cgsmedicare.com/jb/mycgs/pdf/mycgs_user_manual.pdf). We hope these new features enhance your myCGS experience!


https://mycgsportal.com/mycgs/

https://cgsmedicare.com/jb/mycgs/pdf/mycgs_user_manual.pdf


COVID-19

Extension of Payment for Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)MLN Matters® Number: MM11784Related CR Release Date: May 8, 2020 Related CR Transmittal Number: R10116OTN

Related Change Request (CR) Number: 11784Effective Date: October 1, 2020Implementation Date: October 5, 2020

This article informs you of the implementation of the new April 2020 DMEPOS fee schedule amounts based on changes mandated by Section 3712 (b) of the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Make sure your staffs are aware of these changes.

Read more…

View the entire article on the CMS website at https://www.cms.gov/files/document/MM11784.pdf

Medicare Fee-for-Service (FFS) Response to the Public Health Emergency on the Coronavirus (COVID-19)MLN Matters® Number: SE20011 RevisedArticle Release Date: April 10, 2020 Related CR Transmittal Number: N/A

Related Change Request (CR) Number: N/AEffective Date: N/AImplementation Date: N/A

Note: We revised this article on April 10, 2020, to:

� Link to all the blanket waivers related to COVID-19 � Provide place of service coding guidance for telehealth claims � Link to the Telehealth Video for COVID-19 � Add information on the waiver of coinsurance and deductibles for certain testing and related services � Add information on the expanded use of ambulance origin/destination modifiers � Provide new specimen collection codes for clinical diagnostic laboratories billing � Add guidance regarding delivering notices to beneficiaries.

All other information is the same.

The Secretary of the Department of Health & Human Services declared a public health emergency (PHE) in the entire United States on January 31, 2020. On March 13, 2020 Secretary Azar authorized waivers and modifications under Section 1135 of the Social Security Act (the Act), retroactive to March 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) is issuing blanket waivers consistent with those issued for past PHE declarations. Read more…

View the entire article on the CMS website at https://www.cms.gov/files/document/SE20011.pdf

https://www.cms.gov/files/document/MM11784.pdf


https://www.cms.gov/files/document/SE20011.pdf



New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)MLN Matters® Number: SE20016 RevisedArticle Release Date: April 30, 2020 Related CR Transmittal Number: N/A


Note: We revised this article on April 30, 2020, to provide:

� Additional claims submission and processing instructions

� Information on cost-sharing related to COVID-19 testing

� Additional information on telehealth flexibilities

� Information on provider-based RHCs exemption to the RHC payment limitAll other information remains the same.

To provide as much support as possible to RHCs and FQHCs and their patients during the COVID-19 PHE, both Congress and the Centers for Medicare & Medicaid Services (CMS) have made several changes to the RHC and FQHC requirements and payments. These changes are for the duration of the COVID-19 PHE, and we will make additional discretionary changes as necessary to assure that RHC and FQHC patients have access to the services they need during the pandemic. For additional information, please see the RHC/FQHC COVID-19 FAQs at https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf.

Read more…


https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf




Required Prior Authorization Suspended for the Duration of the COVID-19 Pandemic

Link to current version on the CGS website: https://www.cgsmedicare.com/jb/pubs/news/2020/04/cope16673.html

Effective on or after March 01, 2020, the Centers for Medicare & Medicaid Services (CMS) and the DME MACs are suspending the requirements to prior authorize certain power mobility devices (PMDs) and pressure reducing support surfaces (PRSS). Also, the implementation of Prior Authorization (PA) of Lower Limb Prostheses scheduled to begin on May 04, 2020 is delayed. This suspension of PA will last for the duration of the COVID-19 Public Health Emergency (PHE).

The DME MACs will continue to accept and review voluntary PA requests for the affected HCPCS codes on the Required Prior Authorization List; however, claims associated with a non-affirmation decision or claims submitted without requesting prior authorization that would normally cause a payment denial will be processed for payment for the duration of the COVID-19 PHE. Claims bypassing PA may be selected for post-payment review after the PHE has ended.

Claim Filing InstructionsSuppliers must continue to use the appropriate modifiers for all HCPCS codes on the Required Prior Authorization List. For the duration of the COVID-19 PHE, suppliers are to apply the CR modifier (CATASTROPHE/DISASTER RELATED) to the claim line(s) for the HCPCS code(s) billed. Additionally, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 498-PP of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form. These instructions also apply to all subsequent rental months’ claims in order to ensure continued payment throughout the rental series.

ReopeningsFor claims denied due to the COVID-19 PHE that are associated with PA submissions on or after March 01, 2020 and prior to this notice, suppliers may request a reopening of their claim by contacting their MAC.

Further communication and instruction will be provided once a date for resuming PA is established.

Publication HistoryApril 3, 2020 Originally Published

https://www.cgsmedicare.com/jb/pubs/news/2020/04/cope16673.html



Billing of Part B Drugs and Enteral Nutrition to DME MACs During COVID-19 Pandemic – Dispensing Amounts – Revised

- Joint DME MAC Publication


Under current Medicare rules, for immunosuppressive drugs used after an organ transplant, oral anticancer drugs, intravenous immune globulin (IVIG), and enteral nutrition, utilization requirements generally limit dispensing amounts to a 30-day supply. With the recent COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS), under their National Emergency authority, is allowing Medicare beneficiaries to obtain amounts of Part B drugs and enteral nutrition products in excess of the current monthly (30 day) limitation. This change is effective for claims with dates of service on or after March 1, 2020.

In the event that a treating practitioner prescribes more than a monthly (30 day) amount, the CR modifier (CATASTROPHE/DISASTER RELATED) must be added to the HCPCS code billed. In addition, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

In the event of an audit, review contractors will identify these claims by the “COVID-19” entry and assess if the amount was reasonable and necessary, based on the nature of the particular drug, the patient’s diagnosis, the extent and likely duration of disruptions to the drug supply chain during the COVID-19 national emergency, and other relevant factors.

Refer to the applicable Local Coverage Determinations and related Policy Articles for additional coverage, coding and documentation requirements.

Publication HistoryMay 11, 2020 Revised article title to include “and Enteral Nutrition,” added enteral nutrition to items

dispensed in excess of 30-day supply, and updated reference of “498-PP” to “390-BM”March 19, 2020 Originally Published




Correct Use of the KX Modifier During the COVID-19 PHE



Effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE), for the following LCDs in which the Face-to-Face evaluation or other services with an implied Face-to-Face evaluation such as a home assessment are waived during the PHE, the supplier must append the KX modifier if all other requirements specified in the policy are met:

� Knee Orthoses (L33318)

� Manual Wheelchair Bases (L33788)

� Negative Pressure Wound Therapy Pumps (L33821)

� Power Mobility Devices (L33789)*

� Pressure Reducing Support Surfaces - Group 1 (L33830)



� Speech Generating Devices (SGD) (L33739)

� Tumor Treatment Field Therapy (TTFT) (L34823)

� Urological Supplies (L33803)

� Wheelchair Options/Accessories (L33792)

� Wheelchair Seating (L33312)

*For Power Mobility Devices (PMDs), the face-to-face encounter with the ordering practitioner is mandated by Medicare statute at section 1834(a)(1)(E)(iv) of the Social Security Act, as codified in 42 CFR § 410.38. The regulation already permits the use of telehealth in accordance with Medicare guidelines. CMS has extended flexibilities to permit a broader use of telehealth services, locations, provider types and technologies during the COVID-19 PHE.

For the following LCDs, the supplier must append the KX modifier if all the requirements specified in the policy are met:

� Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686)

� Automatic External Defibrillators (L33690)

� Cervical Traction Devices (L33823)

� Commodes (L33736)

� Glucose Monitors (L33822) – with the exception of CGM as noted below

� Hospital Beds And Accessories (L33820)

� Immunosuppressive Drugs (L33824)

� Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics) (L33827)

� Orthopedic Footwear (L33641)

� Patient Lifts (L33799)

� Refractive Lenses (L33793)




� Transcutaneous Electrical Nerve Stimulators (TENS) (L33802)

� Walkers (L33791)

Additionally, suppliers should continue to bill the KX and/or CG modifiers for which LCDs’ clinical indications of coverage are not being enforced. For those LCDs listed below, application of the KX or CG modifier attests that a Standard Written Order (SWO) is on file for the item and the medical record supports the item is reasonable and necessary:

� Oxygen and Oxygen Equipment (L33797)

� Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718)

� Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)

� Respiratory Assist Devices (L33800)

� Mechanical In-exsufflation Devices (L33795)

� High Frequency Chest Wall Oscillation (L33785)

� Nebulizers (L33370)

� Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous Glucose Monitors (CGM) are not enforced

� External Infusion Pumps (L33794)

Suppliers are reminded to append a CR modifier and include a narrative of “COVID-19” to all claims that are affected by the COVID-19 PHE. The narrative should be entered into the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format, field 390-BM of the National Council for Prescription Drug Program (NCPDP) format, or Item 19 of paper claims.

This enforcement discretion will only apply during the PHE for the COVID-19 pandemic. At the conclusion of the PHE for the COVID-19 pandemic, the DME MACs will return to enforcement of these requirements.

Publication HistoryMay 14, 2020 Originally Published


CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) – COVID-19 Public Health Emergency - Revised



On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment (CMS-1744-IFC), establishing that certain requirements for face-to-face/in-person encounters will not apply during the COVID-19 public health emergency. In addition, CMS-1744-IFC stated that the chief medical officer or the equivalent individual of a facility may authorize a physician of a different specialty than specified in a national coverage determination (NCD) or local coverage determination (LCD) to perform a service, procedure, or portion of a procedure. The chief medical officer or equivalent may also authorize a different practitioner type than the one specified in the NCD or LCD to perform the service or procedure. In addition, CMS-1744-IFC finalized on an interim basis that CMS would not enforce various clinical indications of coverage found in specific NCDs, LCDs, and related policy articles. These interim final policies are effective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 Public Health Emergency (PHE). It is in the best interest of patients, health care professionals and suppliers to limit face-to-face encounters and avoid exposure of vulnerable Medicare beneficiaries to COVID-19. Furthermore, CMS believes that it is possible that patients receiving services for respiratory-related indications will be required to receive care in unexpected settings, including the home. This may be necessary as COVID-19 and other patients are shifted across healthcare settings to accommodate an increase in patient volume.

A subsequent CMS interim final rule with comment, CMS-5531-IFC, was put on display at the Office of the Federal Register on May 1, 2020, scheduled to be published on May 8, 2020. This IFC clarified that reasonable and necessary statutory requirements in section 1862(a)(1) of the Social Security Act are not being waived due to the COVID-19 PHE. CMS-5531-IFC additionally instructs that, unless expressly permitted by statute, items and services must be medically reasonable and necessary, and that the medical records must document the medical necessity of the item(s) and/or service(s) billed.

Finally, on an interim basis, CMS-5531-IFC expanded non-enforcement of clinical indications of coverage for therapeutic continuous glucose monitors (CGMs).

Face-To-Face/In-Person EncountersFor the duration of this PHE for the COVID-19 PHE, it is in the best interest of patients, health care professionals and suppliers to limit face-to-face encounters and avoid exposure of vulnerable Medicare beneficiaries to COVID-19. Therefore, on an interim basis, we are finalizing that to the extent an NCD or LCD (including policy articles) would otherwise require a face-to-face or in-person encounter for evaluations, assessments, certifications or other implied face-to-face services, those requirements would not apply during the COVID-19 PHE.

Exception: Note that the IFCs do not apply to Power Mobility Devices (PMDs) where the face-to-face encounter with the ordering practitioner is mandated by Medicare statute at section 1834(a)(1)(E)(iv) of the Social Security Act, as codified in 42 CFR § 410.38. The regulation already permits the use of telehealth in accordance with Medicare guidelines. CMS has extended flexibilities to permit a broader use of telehealth services, locations, provider types and technologies during the COVID-19 PHE.




Exception: Note that CMS Quality Standards Appendices, incorporated by reference in the DMEPOS Supplier Standards at 42 CFR §424.57 continue to apply during the COVID-19 PHE. The CMS-1744-IFC only addressed requirements in NCDs, LCDs and related articles.

Clinical Indications for CoverageEffective for claims with dates of service on or after March 1, 2020 and for the duration of this COVID-19 PHE, clinical indications for coverage found in respiratory, infusion pump, and therapeutic continuous glucose monitor NCDs or LCDs will not be enforced. These NCDs and LCDs include:

� Home Oxygen (NCD 240.2)

� Infusion Pumps (NCD 280.14)

� Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4)

� Intrapulmonary Percussive Ventilator (NCD 240.5)

� Durable Medical Equipment Reference List (NCD 280.1) – Only clinical indications for ventilators are not enforced

� Oxygen and Oxygen Equipment (L33797);

� Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718);

� Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)

� Respiratory Assist Devices (L33800);

� Mechanical In-exsufflation Devices (L33795)

� High Frequency Chest Wall Oscillation (L33785)

� Nebulizers (L33370)

� Suction Pumps (L33612) – Only clinical indications for respiratory suction pumps (E0600) are not enforced

� Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous Glucose Monitors (CGM) are not enforced

� External Infusion Pumps (L33794);

Treating practitioners and suppliers must still:

� Provide a standard written order (SWO) for all items. For PMDs, the treating practitioner must document and communicate to the DMEPOS supplier that the treating practitioner has had a face-to-face encounter with the beneficiary within the 6 months preceding the date of the written order/prescription, per section 1834(a)(1)(E)(iv) of the Act;

� Ensure that the items or services are reasonable and necessary;

� Continue documenting the medical necessity for all services. Accordingly, the medical record must be sufficient to support payment for the services billed (that is, the services were actually provided, were provided at the level billed, and were medically necessary);

� Make documentation available, upon request.

This enforcement discretion will only apply during the COVID-19 PHE. At the conclusion of the COVID-19 PHE, the DME MACs will return to enforcement of the clinical indications for coverage.

Requirements for Consultations or Services Furnished by or Supervised by a Particular Medical Practitioner or SpecialistEffective for claims with dates of service on or after March 1, 2020 and for the duration of the COVID-19 PHE, to the extent NCDs and LCDs require a specific practitioner type or physician specialty to furnish a service, procedure or any portion thereof, the chief medical officer or


equivalent of the facility can authorize another physician specialty or other practitioner type to meet those requirements. Additionally, to the extent NCDs and LCDs require a physician or physician specialty to supervise other practitioners, professionals or qualified personnel, the chief medical officer of the facility can authorize that such supervision requirements do not apply during the COVID-19 PHE.

Claim InstructionsSuppliers should continue to use the appropriate modifiers, including the KX and/or CG modifier where applicable, for all HCPCS codes included in the NCDs and LCDs listed above. In addition, the CR modifier (CATASTROPHE/DISASTER RELATED) should be added to the HCPCS code(s) billed. Finally, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

In addition, to ensure that the requirements of the Durable Medical Equipment benefit are met, and that claims payment will be made correctly, if the external infusion pump is still in the capped rental period, drug(s) administered with the external infusion pump should be billed on the same claim as the pump.

CMN and DIF Instructions – Oxygen (Form CMS 484.3) and External Infusion Pumps (Form 10125)CMS-1744-IFC stated that CMS would exercise enforcement discretion for clinical indications of coverage for the oxygen NCDs and LCDs during the PHE. Numerous fields on the Certificate of Medical Necessity (CMN) for oxygen are directly related to the clinical indications. After carefully reviewing the CMN and the related claims processing issues that would result from having missing information or having clinical information for which the form was intended, CMS has determined that requirements for a CMN for oxygen claims will not be enforced during the COVID-19 PHE. Suppliers should follow the guidance in the Claim Instruction section above for oxygen claims.

The same concerns that apply to the oxygen CMN also apply to the external infusion pumps (EIPs). Therefore, requirements for submission of a DIF will not be enforced for EIP claims. Suppliers should follow the guidance in the Claim Instruction section above for EIP claims.

ICD-10 CodesSuppliers and providers should use the following ICD-10 codes on all claims for DMEPOS associated with treatment of COVID-19-related illness:

For claims with dates of service before April 1, 2020, suppliers and providers should enter two ICD-10 codes on the claim. The first code entered should be used to describe the clinical diagnosis (pneumonia, bronchitis etc.). The second code entered should be B97.29 (OTHER CORONAVIRUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE).

For claims with dates of service on or after April 1, 2020, suppliers and providers should enter ICD-10 code U07.1 (COVID-19) on the claim.

Publication HistoryJune 29, 2020 Added non-enforcement of clinical indications of coverage for ventilators at DME Reference

List (NCD 280.1) and suction pumps LCD L33612 (respiratory suction only); updated the Claim Instructions section to reference “CG” as a modifier for use where applicable

May 21, 2020 Revised language in the first bullet under “Treating practitioners and suppliers must still:” to clarify the timing of the face-to-face encounter in relation to the SWO

May 7, 2020 Originally Published


Use of CR modifier and “COVID-19” narrative on Specified Claims Due to the COVID-19 PHE



On May 21, 2020, the DME MAC medical directors revised a joint bulletin article titled: “CMS Issues Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) - COVID-19 Public Health Emergency.” (https://cgsmedicare.com/jb/pubs/news/2020/05/cope17333.html) The bulletin article instructed suppliers to append the CR modifier and “COVID-19” narrative to claims for dates of service on or after March 1, 2020, where the coverage, coding or documentation requirements are impacted by the COVID-19 Public Health Emergency (PHE). This includes use of the CR modifier and “COVID-19” narrative, for the duration of the COVID-19 PHE, when billing for items and/or services included in the local coverage determinations (LCDs) and national coverage determinations (NCDs) listed in CMS-1744-IFC and CMS-5531-IFC.

A recent data analysis indicates that some suppliers are not following these instructions, leading to claim denials. In order to expedite a resolution, the DME MACs recommend suppliers resubmit these claims with the addition of the CR modifier and “COVID-19” narrative. Claim instructions in our prior bulletin article are noted below.

Claim Instructions:

Suppliers should continue to use the appropriate modifiers, including the KX modifier where applicable, for all HCPCS codes included in the NCDs and LCDs listed above. In addition, the CR modifier (CATASTROPHE/DISASTER RELATED) should be added to the HCPCS code(s) billed. Finally, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.

Additional information can be found on our websites and upcoming joint webinars by our Provider Outreach and Education (POE) departments.

Publication HistoryMay 28, 2020 Originally Published





COVERAGE & BILLING

L3960 – Coding Verification Review Requirement

- Joint DME MAC & PDAC Publication


The DME MACs have noticed a substantial increase in claim submission for HCPCS code L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT.

L3960 is a prefabricated shoulder “airplane design” abduction orthosis which includes the elbow wrist hand and fingers. There are adjustable rigid cuffs and joints/components to optimize the shoulder, elbow, wrist and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. Product is all-inclusive of soft interface and closures/straps. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand.

Effective for claims with dates of service on or after August 1, 2020 the only products which may be billed using code L3960 are those for which a written coding verification review has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the appropriate Product Classification list.”

For items containing elastic or other fabric components, suppliers are referred to the Joint DME MAC Article Correct Coding and Coverage - Braces Constructed Primarily of Elastic or Other Fabric Materials.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form (https://www.dmepdac.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=04) located on the PDAC Website (https://www.dmepdac.com/).

Publication HistoryMarch 12, 2020 Originally Published



https://www.dmepdac.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=04

https://www.dmepdac.com/palmetto/Feedback.nsf/Feedback?OpenForm&SendTo=04

https://www.dmepdac.com/


Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico SectionMLN Matters® Number: MM11778Related CR Release Date: May 15, 2020 Related CR Transmittal Number: R10135CP

Related Change Request (CR) Number: 11778Effective Date: June 16, 2020Implementation Date: June 16, 2020

This article informs you that Medicare will remove Section 20 (and all of its subsections) of the Medicare Claims Processing Manual (Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico). The key impact is that modifier CS is no longer to be used to denote services related to the 2010 oil spill. Read more…


New Medicare Beneficiary Identifier (MBI) Get It, Use ItMLN Matters® Number: SE18006 RevisedArticle Release Date: March 19, 2020 Related CR Transmittal Number: N/A


Note: We revised the article on March 19, 2020, to clarify that you need the beneficiary’s first name, last name, date of birth, and SSN to use MBI look-up tool. All other information remains the same.

Use MBIs for all Medicare transactions. The Centers for Medicare & Medicaid Services (CMS) replaced the Social Security Number (SSN)-based Health Insurance Claim Numbers (HICNs) with the MBI and mailed new Medicare cards to all Medicare beneficiaries. The cards with MBIs offer better identity protection.

With a few exceptions, Medicare will reject claims you submit with Health Insurance Claim Numbers (HICNs). Medicare will reject all eligibility transactions you submit with HICNs.

There are 3 ways you and your office staff can get MBIs. Read more…

View the entire article on the CMS website at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf



https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18006.pdf




Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any TypeMLN Matters® Number: SE20001Article Release Date: January 29, 2020 Related CR Transmittal Number: N/A


PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, providers, and suppliers billing Medicare Administrative Contractors (MACs) for HCPCS code L8679 (implantable neurostimulator, pulse generator any type).

PROVIDER ACTION NEEDEDThe Centers for Medicare & Medicaid Services (CMS) is aware that some providers are submitting claims incorrectly to Medicare using HCPCS code L8679. This article reminds providers of Medicare policy regarding these devices. Make sure your billing staff are aware of the correct policy. Read more…


Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original MedicareMLN Matters® Number: SE20009Article Release Date: March 3, 2020 Related CR Transmittal Number: N/A


PROVIDER TYPES AFFECTEDThis MLN Matters Article is for physicians, non-physician practitioners, other providers, and suppliers who may bill Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries who are enrolled in Health Maintenance Organization (HMO) Medicare Non-Risk plans.

WHAT YOU NEED TO KNOWThis MLN Matters article reinforces existing Medicare policy that allows non-network providers to bill original Medicare for services provided to Medicare cost plan enrollees. Read more…







Supplier Education on Use of Upgrades for Multi-Function VentilatorsMLN Matters® Number: SE20012Article Release Date: April 3, 2020 Related CR Transmittal Number: N/A


Medicare’s multi-function ventilator policy applies to beneficiaries who are prescribed and meet the medical necessity coverage criteria for a ventilator and at least one of the four additional functions (namely, oxygen concentrator, cough stimulator, suction pump, and nebulizer). HCPCS code E0467 is used to describe multi-function ventilators.

This article informs DME suppliers that effective immediately, you may provide and bill for multi-function ventilators described by code E0467 as an upgrade in situations where beneficiaries only meet the coverage criteria for a ventilator. Read more…


The next eight pages contain Dear Physician Letters related to this section, Coverage and Billing:

• Positive Airway Pressure (PAP) Devices: Replacement - Revised March 2020

• Positive Airway Pressure (PAP) Devices: Initial Qualification - Revised March 2020

• Glucose Monitors - Revised March 2020

• Documentation Requirements for Power Wheelchairs and Power Operated Vehicles - Revised March 2020



T W O VA N TAG E WAY | N AS H V I L L E , T N 37228 -1504 | C G S M E D I C A R E .C O M

© 2020, CGS Administrators, LLC CGS Administrators, LLC is a Medicare Part A, B, Home Health and Hospice, and DME Medicare Administrative Contractor for the Centers for Medicare & Medicaid Services.

We IMPACT Lives.POSITIVE AIRWAY PRESSURE (PAP) DEVICES: REPLACEMENT REPL ACEMENT PAP - REVISED MARCH 2020

Dear Physician,

Data from the Comprehensive Error Rate Testing (CERT) program projects that ~$500M in inappropriate payments are made each year for positive airway pressure (PAP) devices used to treat obstructive sleep apnea (OSA). A significant proportion of the claim errors observed in the data relate to inadequate or missing documentation supporting the need for the PAP device and/or supplies. The information below is intended to assist you in documenting that your patient meets Medicare guidelines for replacement of a PAP device or supplies. A separate “Dear Physician” letter addresses documentation necessary for your patient to receive their initial prescription of a PAP device.

There are two scenarios in which your patient diagnosed with OSA may qualify for a replacement device and/or supplies. First, they may have initially had their device paid for by Medicare. Alternatively, their device was initially prescribed prior to entering Medicare. The requirements for a replacement device differ for each of these scenarios and are described below.

Scenario 1: Initial Device Paid by Medicare

For your patient who was diagnosed with OSA while enrolled in Fee-For-Service (FFS) Medicare and Medicare paid for their PAP device, replacement of the device is based on the patient’s continuous use of the device and the statutory limitation for replacement based on a five (5) year reasonable useful lifetime (RUL) for the device. Medicare does not pay for routine replacement. A PAP device may be replaced prior to the 5-year RUL only if the device is lost, stolen, or incurs irreparable damage due to a specific incident. If the PAP device has exceeded the 5-year RUL, the patient may elect to receive a new device; however, there is no Medicare rule that requires the patient to do so.

Documentation requirements differ, depending on whether or not the patient is replacing their PAP device before or after the 5-year RUL:

• Replacement before 5 years: If a PAP device is replaced during the 5-year RUL because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test or trial period; however, you must provide:

○ A new standard written order (SWO); and, • Replacement after 5 years: If a PAP device is replaced after the 5-year RUL, there is no requirement for a

new sleep test or trial period; however, you must provide:

○ A new SWO; and, ○ Complete an in-person visit that documents that your patient:

- Has a condition that requires the use of the PAP device (i.e., OSA); and, - Continues to use the PAP device; and, - Is benefitting from use of the PAP device.

Scenario 2: Initial Device Received Prior to Medicare

For your patient who received a PAP device prior to enrollment in FFS Medicare and is now seeking Medicare coverage of either a replacement PAP device and/or accessories, the following coverage requirements must be met:

1. Sleep test – There must be documentation that the patient had a sleep test, prior to FFS Medicare, which meets the FFS Medicare AHI/RDI coverage criteria in effect at the time that your patient seeks a replacement PAP device and/or accessories. As a reminder, those current requirements are:

○ AHI or RDI is greater than or equal to 15 events per hour, with a minimum of 30 events; or, ○ AHI or RDI is 5-14 events per hour (minimum of 10 events) with documentation of excessive daytime

sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke.

(Note: For purposes of this policy, the calculation of the AHI or RDI includes only apneas and hypopneas. Respiratory effort-related arousals or RERAs must not be used in the calculation of the AHI or RDI. In addition, Medicare defines hypopnea as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation.)

2. Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have an in-person evaluation with you to document in their medical record that: a. They have a diagnosis of obstructive sleep apnea; and, b. They continue to use and benefit from the PAP device.

Additional coverage and payment rules for sleep tests may be found in the LCDs for the applicable Medicare A/B MAC contractor. We recommend you read these for your state. There may be differences between those LCDs and the DME MAC LCD. For the purposes of coverage of PAP therapy, the DME MAC coverage criteria take precedence.

The complete medical policy may be viewed on the DME MACs’ individual websites or in the CMS Medicare Coverage Database. The Epworth Sleepiness Scale may be found in the Appendices section of the LCD. Physicians are reminded that in order for these items to be reimbursed for your patients, the DME supplier may collect medical documentation including copies of your clinical evaluation and the report of the sleep study. Please cooperate with them so that they may provide the device that you have ordered for your patient.

Smitha M. Ballyamanda, MD, CAQSM Medical Director, DME MAC, Jurisdiction A Noridian Healthcare Solutions, LLC

Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C CGS Administrators, LLC

Stacey V. Brennan, MD, FAAFP Medical Director, DME MAC, Jurisdiction B CGS Administrators, LLC

Peter J. Gurk, MD, CPE, CHCQM Medical Director, DME MAC, Jurisdiction D Noridian Healthcare Solutions, LLC



We IMPACT Lives.POSITIVE AIRWAY PRESSURE (PAP) DEVICES: INITIAL QUALIFICATION IN ITIAL QUALIFICATION FOR PAP - REVISED MARCH 2020

Dear Physician,

Data from the Comprehensive Error Rate Testing (CERT) program projects that ~$500M in inappropriate payments are made each year for positive airway pressure (PAP) devices used to treat obstructive sleep apnea (OSA). A significant proportion of the claim errors observed in the data relate to inadequate or missing documentation supporting the need for the PAP device and/or supplies. The information below is intended to assist you in documenting that your patient meets Medicare guidelines for initial coverage of PAP devices. A separate “Dear Physician” letter addresses documentation necessary for your patient to receive a replacement PAP device or ongoing supplies.

For your patient diagnosed with OSA for the first time after becoming Medicare-eligible, the major requirements for coverage of a PAP device for OSA that pertain to the ordering practitioner are:

1. There must be an in-person evaluation visit with the treating practitioner prior to the sleep test. This should generally include the following elements: • Sleep history and symptoms which may be caused by OSA

• Pertinent physical examination — e.g., body mass index, neck circumference, upper airway exam, and focused cardiopulmonary exam

• Epworth Sleepiness Scale (a standardized patient questionnaire which helps to assess the likelihood of sleep apnea) or other validated sleep inventory

2. The patient must have a facility-based polysomnogram (Type I study) or a Type II, III, IV, or Other home sleep study. Home sleep studies are acceptable when performed by devices that either directly or indirectly allow calculation of an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI). Devices that allow direct calculation of AHI/RDI by measuring airflow or thoracoabdominal movement are acceptable. A list of criteria, specific to each type of home sleep test, is located in the DME MAC Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD (L33718).

3. For all PAP devices the sleep test (Type I -IV, Other) must be interpreted by a practitioner who holds either: • Current certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM); or

• Current subspecialty certification in Sleep Medicine by a member board of the American Board of Medical Specialties (ABMS) or American Osteopathic Association (AOA); or

• Completed residency or fellowship training by a program approved by an ABMS or AOA member board and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself and only until the time of reporting of the first examination for which the practitioner is eligible; or

• Active staff membership of a sleep center or laboratory accredited by the American Academy of Sleep Medicine, Accreditation Commission for Health Care (ACHC) or the Joint Commission (TJC, formerly the Joint Commission on Accreditation of Healthcare Organizations – JCAHO).

4. The sleep study results must demonstrate: • AHI or RDI is greater than or equal to 15 events per hour, with a minimum of 30 events; or,

• AHI or RDI is 5-14 events per hour (minimum of 10 events) with documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke.

Note: For purposes of this policy, the RDI includes only apneas and hypopneas. Respiratory effort-related arousals or RERAs must not be used in the calculation of the AHI or RDI. In addition, Medicare defines hypopnea as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation.

5. Standard Written Order (SWO): Prior to the supplier billing Medicare, you must write an order for the PAP device and any related accessories and/or supplies.

6. Continued coverage beyond the initial three (3) month trial: To continue coverage for the PAP device beyond an initial 3month trial period, no sooner than the 31st day but no later than the 91st day after initiating therapy, you must conduct a clinical re-evaluation and document that your patient is benefiting from PAP therapy. This is demonstrated by: • An in-person visit with your patient during the second or third month of the trial (but not before that

time) that documents an improvement in their sleep-disordered breathing symptoms; and,

• Review of the adherence report from the PAP device which documents use of the PAP device for at least 4 hours per night on 70% of nights for a 30 consecutive day period during the trial (i.e., 21 nights in a rolling 30 consecutive day period).

It is critical to stay in communication with your patient’s DME supplier or track compliance yourself so that once your patient meets the 30 day adherence metric, a follow-up visit can be scheduled within the 31st to 90th day window.

Additional coverage and payment rules for sleep tests may be found in the LCDs for the applicable Medicare A/B MAC contractor. There may be differences between those LCDs and the DME MAC LCD. For the purposes of coverage of PAP therapy, the DME MAC coverage criteria take precedence.

The complete medical policy may be viewed on the DME MACS’ individual websites or in the CMS Medicare Coverage Database. The Epworth Sleepiness Scale may be found in the Appendices section of the LCD. Practitioners are reminded that in order for these items to be reimbursed for your patients, the DME supplier may collect medical documentation including copies of your initial evaluation, the report of the sleep study, your re-evaluation during the PAP trial, and the data report from the PAP device indicating patient adherence to therapy during the trial. Please cooperate with them so that they can provide the device that you have ordered for your patient.







We IMPACT Lives.GLUCOSE MONITORS REVISED MARCH 2020

Dear Physician,

The following information is intended to provide you with guidance on Medicare’s coverage and documentation requirements for blood glucose monitors (BGMs) and testing supplies.

COVERAGE

Glucose monitors and related supplies are covered for patients with diabetes if they or their caregiver can be trained to use the prescribed device appropriately.

The quantity of test strips and lancets that are covered, if the basic criterion above is met, is shown below.

Treatment regimenBasic coverage Test strips and lancets

Insulin treated 300 per 3 months

Non-insulin treated 100 per 3 months

• Additional quantities of test strips can be covered if they are documented to be medically necessary –as outlined below.

• Coverage is also provided for a lancing device, calibration solution, and replacement batteries.

MEDICAL NECESSITY DOCUMENTATION

CMS expects that physician records will reflect the care provided to the patient including evidence of the medical necessity for the prescribed frequency of testing. You are not required to fill out additional forms from suppliers or to provide additional information to suppliers unless specifically requested of the supplier by the DME MAC.

It is critical that the patient’s medical record demonstrates the medical necessity for glucose testing supplies, which includes:

• Diagnosis

• Treatment regimen (insulin treated versus non-insulin treated)

• Basic coverage criteria for the BGM and any related supplies; and,

• Evidence of the patient’s use at this frequency

For quantities of supplies that exceed the limits specified in the LCD, there must be:

• Documentation by the physician in the patient’s medical record of the necessity for the higher frequency of testing, which may include some of the following elements (not all-inclusive):

○ Names, dosages, and frequency of administration of medications used to treat the diabetes; ○ Frequency and severity of symptoms related to hyperglycemia and/or hypoglycemia; ○ Review of patient-maintained log of glucose testing values;

- Logs of self-testing values including the date, time, and results; - Information about medication dosage adjustments related to the results is also helpful;

○ Changes in the patient’s treatment regimen as a result of glucose testing results review; ○ Dosage adjustments that the patient should make on their own based on self-testing results; ○ Laboratory tests indicating level of glycemic control (e.g., hemoglobin A1C); ○ Other therapeutic interventions and results.

Not every patient’s medical record will contain all of these elements; however, there must be enough information in the patient’s medical record to support the medical necessity for the quantity of item(s) ordered and dispensed.

ORDERS All durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) require a written order/prescription which must be received by the supplier prior to billing Medicare. Someone other than the treating practitioner may complete the standard written order (SWO) for the item unless statute, manual instructions, the contractor’s LCD or policy articles specify otherwise; however, the prescribing practitioner must review the content and sign the document.

Note: A new order for diabetic testing supplies is required only if:

• there is a change in the frequency of testing/quantity to be dispensed; or

• when replacing a BGM; or

• there is a change in supplier.

Note: If the supplier provides you with a prepared SWO for your signature, you should inspect this document carefully. Suppliers must not add unrelated items to the SWO, whether requested by the patient or not, in the absence of your explicit approval.

Please note that this article is only intended to be a general summary. It is not intended to take the place of the written law, regulations, or national or local coverage determinations. Please refer to the Glucose Monitors LCD and Policy Article (L33822, https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33822) for further information on Medicare coverage, documentation requirements, and orders which may be reviewed at the CMS Medicare Coverage Database at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.

Sincerely,





https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33822

https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx




We IMPACT Lives.

DOCUMENTATION REQUIREMENTS FOR POWER WHEELCHAIRS AND POWER OPER ATED VEHICLES REVISED MARCH 2020

Dear Physician,

For Medicare to provide reimbursement for a power wheelchair (PWC) or power operated vehicle (POV) (scooter), there are several requirements that must be met:

1. There must be an in-person visit with a clinician specifically addressing the patient’s mobility needs. 2. There must be a history and physical examination by the clinician or other medical professional (see below)

focusing on an assessment of the patient’s mobility limitation and needs. The results of this evaluation must be recorded in the patient’s medical record.

3. A standard written order (SWO) must be written AFTER the in-person visit has occurred and the medical evaluation is completed.

4. The SWO for the power mobility base device must be completed within 6 months of the face-to-face encounter and provided to the supplier prior to delivery of the power mobility device.

The in-person visit and mobility evaluation together are often referred to as the “face-to-face encounter”.

The complete history and physical examination must include a history of your patient’s medical condition(s) and past medical history that are relevant to their mobility; and a physical examination that is relevant to their limitations in accomplishing mobility-related activities of daily living (MRADLs).

The history should paint a picture of your patient’s functional abilities and limitations in their home on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient’s ambulatory difficulty or impact on the patient’s ambulatory ability. Vague terms such as “difficulty walking” or “upper extremity weakness” are insufficient, since they do not objectively address the mobility limitation or provide a clear picture of the patient’s mobility deficits in participating in MRADLs.

A power mobility device is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs their ability to perform their MRADLs within the home. Thus, in your evaluation you must clearly distinguish your patient’s mobility needs within the home from their needs outside the home.

You may elect to refer the patient to another medical professional, such as a physical therapist or occupational therapist, to perform part of the evaluation – as long as that individual has no financial relationship with the wheelchair supplier. However, you do have to personally see the patient before or after the PT/OT evaluation. You must review their report, indicate your agreement in writing on the report, and sign and date the report. This must be done within the 6-month timeframe described above. The date you first see the patient is considered to be the date of the face-to-face encounter.

You should record the visit and mobility evaluation in your usual medical record-keeping format. Many suppliers may provide forms for you to complete. Suppliers often try to create the impression that these documents are a sufficient record of the in-person visit and medical evaluation. Based upon our auditing experience, most of them are not.

You must forward a copy of your SWO to the supplier. The supplier is unable to deliver the power mobility device prior to receiving your SWO. It is also helpful to the supplier if you include your face-to-face encounter and copies of previous notes, consultations with other clinicians, and reports of pertinent laboratory, x-ray or other diagnostic tests if they will help to document the severity of your patient’s ambulatory problems.

After the supplier receives your order/prescription, they may also prepare a second SWO that describes additional options and accessories to be added to the power mobility base device. You must review it and, if you agree with what is being provided, sign and return it to the supplier. If you do not agree with any part of the SWO, you should contact the supplier to clarify what you want the beneficiary to receive.

Medicare does provide you additional reimbursement (HCPCS code G0372) to recognize the additional time and effort that are required to provide this documentation to the supplier. This code is payable in addition to the reimbursement for your E&M visit code.

This information is not intended to serve as a substitute for the complete DME MAC local coverage determination (LCD) on Power Mobility Devices. It is only a synopsis detailing the highlights of required medical documentation. Please refer to the complete LCD and Policy Article on the CMS Website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx for additional information.

Your participation in this process and cooperation with the supplier will allow your patient to receive the most appropriate type of mobility equipment. We appreciate all your efforts in providing quality services to your Medicare patients.

Sincerely,








MEDICAL POLICY

LCD and Policy Article Revisions Summary for March 5, 2020


Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, Spinal Orthoses: TLSO and LSO, Surgical Dressings, and Therapeutic Shoes for Persons with Diabetes. Please review the entire LCDs and related PAs for complete information.

Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea

LCDhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33718

Revision Effective Date: 01/01/2020

COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: • Revised: “face-to-face” to “in-person” where applicable • Revised: “practitioner” to “treating practitioner” • Revised: Order information as a result of Final Rule 1713

REFILL REQUIREMENTS: • Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS • Revised: “ordering physicians” to “treating practitioners”

CODING INFORMATION: • Removed: Field titled “Bill Type” • Removed: Field titled “Revenue Codes” • Removed: Field titled “ICD-10 Codes that Support Medical Necessity” • Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity” • Removed: Field titled “Additional ICD-10 Information”

GENERAL DOCUMENTATION REQUIREMENTS: • Revised: Prescriptions (orders) to SWO 03/05/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

PAhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52467


NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: • Removed: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g)

section

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):




https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleid=52467


• Added: Section and related information based on Final Rule 1713

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS: • Added: “in-person” to initial evaluation • Revised: “practitioner” to “treating practitioner” • Removed: Dispensing order and WOPD related information

ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY: • Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support

Medical Necessity”

ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY: • Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO

NOT Support Medical Necessity”03/05/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Spinal Orthoses: TLSO and LSO



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: Order information as a result of Final Rule 1713

CODING INFORMATION:• Removed: Field titled “Bill Type”• Removed: Field titled “Revenue Codes”• Removed: Field titled “ICD-10 Codes that Support Medical Necessity”• Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”• Removed: Field titled “Additional ICD-10 Information”

DOCUMENTATION REQUIREMENTS:• Revised: “physician’s” to “treating practitioner’s”

GENERAL DOCUMENTATION REQUIREMENTS:• Revised: Prescriptions (orders) to SWO 03/05/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).



REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):• Added: Section and related information based on Final Rule 1713

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Revised: “ordering physician” to “treating practitioner”• Revised: “prescribing practitioner” to “treating practitioner”

CODING GUIDELINES:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS • Revised: HCPCS codes referenced for body jacket type orthoses, to include L0651• Revised: HCPCS codes referenced for billing of prefabricated orthoses, to include L0640, L0641,

L0642, L0643, L0648, L0649, L0650, and L0651




ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support


ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:• Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO

NOT Support Medical Necessity” 03/05/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Surgical Dressings



POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Revised: Initial wound evaluation record specifications • Clarified: Direction on need for weekly evaluations • Added: Statement that the person doing the evaluation may have no financial relation with the

supplier • Clarified: Ongoing evaluations as “weekly or monthly”03/05/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Therapeutic Shoes for Persons with Diabetes



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Revised: Order information as a result of Final Rule 1713


GENERAL DOCUMENTATION REQUIREMENTS:• Revised: “Prescriptions (orders)” to “SWO” 03/05/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713



NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:• Revised: Order information as a result of Final Rule 1713






CODING GUIDELINES:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS • Revised: HCPCS codes referenced for inserts and modifications, to include A5514





Note: The information contained in this article is only a summary of revisions to the LCDs and PAs. For complete information on any topic, you must review the LCDs and/or PAs.



Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Lower Limb Prostheses, Power Mobility Devices, and Wheelchair Seating. Please review the entire LCDs and related PAs for complete information.

Lower Limb Prostheses



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: “physician” to “practitioner”• Revised: “physician’s” to “treating practitioner’s”• Revised: Order information as a result of Final Rule 1713



GENERAL DOCUMENTATION REQUIREMENTS:• Revised: Prescriptions (orders) to SWO03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).







NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:• Revised: Format of HCPCS codes referenced, from code ‘spans’ to individually-listed HCPCS • Revised: “physician’s” to “treating practitioner’s”• Revised: “physician” to “practitioner”


POLICY SPECIFIC DOCUMENTATION REQUIRMENTS:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: “ordering physician” to “treating practitioner”• Revised: “physician’s” to “treating practitioner’s”

CODING GUIDELINES:• Revised: Section to include sub-headers for organization of coding guidelines and related

information• Added: Information related to prosthetic systems, sockets, and Infinite Socket information• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Added: Coding guidelines and related information for Knees, Ankles, Feet, and Microprocessor

Ankle Foot Systems





Power Mobility Devices



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Added: Definition of “treating practitioner”• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS

MISCELLANEOUS:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: Reference to weight range capacity for heavy duty PWCs and POVs from “400” to “450”


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Revised: Section information to include SWO for options/accessories, WOPD for PMD base item,

and face-to-face encounter related information• Added: Statement indicating that if the supplier does not receive SWO (for the PMD base) prior to

delivery, the claim will deny as not reasonable and necessary




03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).



NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:• Revised: Order and face-to-face encounter denial-related information• Revised: Section information to include that if the treating practitioner does not conduct the face-

to-face encounter and write the SWO for the PMD base, the claim will deny as statutorily non-covered

FACE-TO-FACE ENCOUNTER:• Revised: Section information related to face-to-face encounters, LCMP evaluation, and 6-month

timeframe• Removed: Custom motorized/power wheelchair base (K0013) information


MISCELLANEOUS:• Added: Custom motorized/power wheelchair base (K0013) information, previously located in

FACE-TO-FACE ENCOUNTER section

CODE-SPECIFIC REQUIREMENTS:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS03/12/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Wheelchair Seating



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA• Added: Statement to refer to the ICD-10 code list in the LCD-related Policy Article • Revised: Order information as a result of Final Rule 1713









REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g):• Removed: Section due to Final Rule 1713


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Revised: “ICD-10 Codes that are Covered” to “ICD-10 code list”• Revised: Information related to GY modifier use, as a result of Final Rule 1713

CODING GUIDELINES:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS


Medical Necessity”• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS, in

Groups 2 and 3 Paragraphs








Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Article (PA) that have been revised and posted. The policy included is Wheelchair Options/Accessories. Please review the entire LCD and related PA for complete information.

Wheelchair Options/Accessories



COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: “physician” to “practitioner”• Revised: Order information as a result of Final Rule 1713






REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g):• Removed: Section due to Final Rule 1713


POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:• Revised: Information related to GY modifier use, as a result of Final Rule 1713

CODING GUIDELINES:• Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS• Revised: Column II of table, to include E2398 for manual wheelchair bases and power wheelchair

bases 03/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.







LCD and Policy Article Revisions Summary for April 2, 2020


Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Nebulizers and Standard Documentation Requirements for All Claims Submitted to DME MACs. Please review the entire LCD and related PAs for complete information.

Nebulizers

LCDhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370


COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY: • Added: Statement regarding base and related accessories and supplies (BPM Ch. 15, Section

110.3) • Clarified: “considered for coverage” to drug and equipment criteria • Added: Revefenacin to inhalation solutions for the management of obstructive pulmonary disease -

For Dates of Service on or after 11/9/2018 (FDA Approval Date) • Revised: “alpha” to “alfa” in relation to HCPCS code J7639 • Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA • Added: Statement to refer to ICD-10 codes in the LCD-related Policy Article • Revised: “alpha” to “alfa” in table with maximum milligrams/month • Added: Revefenacin to table with maximum milligrams/month • Added: Information regarding concurrent use of long-acting and short-acting muscarinic

antagonists • Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS

codes • Revised: “physician” to “practitioner” • Revised: Order information as a result of Final Rule 1713

REFILL REQUIREMENTS: • Revised: “ordering physicians” to “treating practitioners”

SUMMARY OF EVIDENCE: • Added: Information related to revefenacin

ANALYSIS OF EVIDENCE: • Added: Information related to revefenacin

HCPCS CODES: • Added: J7677 to Group 3 Codes in the HCPCS code table

CODING INFORMATION: • Removed: Field titled “Bill Type” • Removed: Field titled “Revenue Codes” • Removed: Field titled “ICD-10 Codes that Support Medical Necessity” • Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity” • Removed: Field titled “Additional ICD-10 Information”



https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370


GENERAL DOCUMENTATION REQUIREMENTS: • Revised: Prescriptions (orders) to SWO

BIBLIOGRAPHY: • Added: Section related to revefenacin

RELATED LOCAL COVERAGE DOCUMENTS: • Added: Response to Comments (A58035)

PAhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52466


NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: • Removed: STATUTORY PRESCRIPTION (ORDER) REQUIRMENTS section • Removed: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g)

section

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217): • Added: Section and related information based on Final Rule 1713

CODING GUIDELINES: • Revised: “alpha” to “alfa” in relation to HCPCS code J7639 • Added: Coding guidelines for J7677


Medical Necessity” • Added: HCPCS code J7677 to Group 8 Paragraph • Revised: ICD-10 code descriptor for J44.0, per ICD-10 code update



Standard Documentation Requirements for All Claims Submitted to DME MACs



REFILL DOCUMENTATION:• Added: “REQUIREMENTS” to title

PROOF OF DELIVERY (POD):• Added: Prohibition for billing prior to discharge date04/02/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.


https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52466



LCD and Policy Article Revisions Summary for April 16, 2020


Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Article (PA) that have been revised and posted. The policy included is External Infusion Pumps. Please review the entire LCD and related PA for complete information.

External Infusion Pumps

LCDhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794


COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:• Added: Statement regarding base and related accessories and supplies (BPM Ch. 15, Section

110.3)• Revised: “physician” to “practitioner”• Added: Xembify® to coverage criteria V(H)• Added: Statement regarding covered pumps for Xembify®• Revised: “physicians” to “practitioners”

GENERAL: • Revised: Order information as a result of Final Rule 1713

REFILL REQUIREMENTS: • Revised: “ordering physicians” to “treating practitioners”

SUMMARY OF EVIDENCE:• Added: Information related to Xembify®

ANALYSIS OF EVIDENCE:• Added: Information related to Xembify®


DOCUMENTATION REQUIREMENTS: • Revised: “physician’s” to “treating practitioner’s”

GENERAL DOCUMENTATION REQUIREMENTS:• Revised: Prescriptions (orders) to SWO

BIBLIOGRAPHY:• Added: Section related to Xembify®

RELATED LOCAL COVERAGE DOCUMENTS:• Added: Response to Comments document PAhttps://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52507


NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:






• Revised: “physician’s” to “practitioner’s”• Removed: REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g)

section


DME INFORMATION FORM (DIF):• Revised: “physician” to “practitioner”

MODIFIERS:• Added: J7799 (Xembify®) to the JB modifier requirements

CODING GUIDELINES:• Revised: ‘detailed order’ to ‘standard written order’• Added: UOS billing instruction for J7799 (Xembify®)

ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:• Added: J7799 (Xembify®) to the Group 3 paragraph04/16/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.


Policy Article Revisions Summary for April 30, 2020


Outlined below are the principal changes to the DME MAC Policy Article (PA) that has been revised and posted. The policy included is Enteral Nutrition. Please review the entire LCD and related PA for complete information.



CODING GUIDELINES:• Removed: Statement indicating calorically dense formulas that include characteristics of other

HCPCS codes, will be coded based on the calorically dense characteristic04/30/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.






Nebulizers Final LCD (L33370) and Response to Comments (RTC) Article Published



Today, the DME MACs published the Nebulizers Final LCD (L33370) (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33370) and LCD-related Policy Article (PA) (A52466) (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52466). The policy extends coverage of revefenacin for the management of obstructive pulmonary disease when coverage criteria are met. The posting of the final LCD marks the beginning of the 45-day notice period. The final LCD will be effective May 17, 2020.

The DME MACs have also posted a response to all written comments received during the comment period, in a Response to Comments (RTC) Article (A58035) (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=58035).

Please refer to each DME MAC website for additional information about policy development and copies of the final LCD.

� Jurisdiction A: https://med.noridianmedicare.com/web/jadme/policies/lcd/

� Jurisdiction B: https://www.cgsmedicare.com/jb/coverage/lcdinfo.html

� Jurisdiction C: https://www.cgsmedicare.com/jc/coverage/lcdinfo.html

� Jurisdiction D: https://med.noridianmedicare.com/web/jddme/policies/lcd/

External Infusion Pumps Final LCD (L33794) and Response to Comments (RTC) Article Published



Today, the DME MACs published the External Infusion Pumps Final LCD (L33794) (https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794) and LCD-related Policy Article (PA) (A52507) (https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52507). The policy extends coverage of Xembify® as reasonable and necessary for the treatment of beneficiaries with a diagnosis of primary immune deficiency (PID) disease, when coverage criteria are met. The posting of the final LCD marks the beginning of the 45-day notice period. The final LCD will be effective May 31, 2020.

The DME MACs have also posted a response to all written comments received during the comment period, in a Response to Comments (RTC) Article (A58071).

Please refer to each DME MAC website for additional information about policy development and copies of the final LCD.

� Jurisdiction A: https://med.noridianmedicare.com/web/jadme/policies/lcd/

� Jurisdiction B: https://www.cgsmedicare.com/jb/coverage/lcdinfo.html

� Jurisdiction C: https://www.cgsmedicare.com/jc/coverage/lcdinfo.html

� Jurisdiction D: https://med.noridianmedicare.com/web/jddme/policies/lcd/









https://med.noridianmedicare.com/web/jadme/policies/lcd/

https://www.cgsmedicare.com/jb/coverage/lcdinfo.html

https://www.cgsmedicare.com/jc/coverage/lcdinfo.html

https://med.noridianmedicare.com/web/jddme/policies/lcd/







https://med.noridianmedicare.com/web/jadme/policies/lcd/

https://www.cgsmedicare.com/jb/coverage/lcdinfo.html

https://www.cgsmedicare.com/jc/coverage/lcdinfo.html

https://med.noridianmedicare.com/web/jddme/policies/lcd/


Frequently Asked Questions – Final Rule CMS-1713-F – Standard Written Orders


Link to current version on the CGS website: https://www.cgsmedicare.com/jb/help/faqs/current/swo.html

On January 1, 2020, new rules took effect governing written orders for all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Suppliers have asked questions about the new standard written order (SWO) and other details outlined in the Standard Documentation Requirements Policy Article (A55426). The following Q&A is intended to provide answers to those frequently asked questions.

Question 1: The CMS final rule CMS-1713-F was effective January 1, 2020. When will CMS and the DME MACs publish updated information?

DME MAC Response: The DME MACs have published the Standard Documentation Requirements Policy Article (A55426) and it is effective now. The DME MACs and CMS are working diligently to update all educational material to reflect the new guidance, including the Program Integrity Manual, Local Coverage Determinations (LCDs) and other collateral educational material.

Question 2: Can a DME supplier dispense an item on a verbal dispensing order or must all orders now be in writing before dispensing?

DME MAC Response: For items that do not require a WOPD, a supplier may dispense an item without a written order. However, a SWO must be communicated to the supplier prior to claim submission. Note that suppliers should be aware that state laws, rules or regulations may require an order before dispensing an item.

Question 3: The new standard written order (SWO) has multiple elements, one of which is the “order date.” What should suppliers use for this date?

DME MAC Response: Ideally, it should be reflective of when the order was first communicated to the supplier, in order to support the dates of service on the claim.

Question 4: What will reviewers use when there’s an Order Date (based on the phone call from the TP) and then the TP elects to enter a date of their signature?

DME MAC Response: Since only one date is required, we will accept the date the order was communicated to the supplier as the “order date” and will review the reported date in concert with the medical record.

Question 5: The CMS final rule CMS-1713-F does not speak to any requirement for frequency of item dispensed. If frequency is no longer required, then would a new order be required for every dispense?

DME MAC Response: While frequency is no longer a required order element, the SWO does require Quantity to be Dispensed for those items where more than one (1) item is dispensed or where dispensing occurs on a periodic basis (e.g., dressings, drugs, supplies, etc). Note also that while the SWO has a limited number of required order elements, suppliers/providers are permitted to add elements that may provide clarity for issues such as LON, frequency of use, dosage form/strength, refills frequency, etc.

Suppliers may also wish to consult state law or regulation since some states may have additional requirements for the elements of an order/prescription.

https://www.cgsmedicare.com/jb/help/faqs/current/swo.html


Question 6: With LON no longer a requirement on the order/prescription, are orders good for lifetime?

DME MAC Response: Suppliers are reminded that length of need (LON) is not necessarily equated with the need for a new prescription. Note that some LCDs and NCDs time-limit prescriptions (i.e., the LCD or NCD stipulates that a new prescription is needed every XX months). In addition, there may be state laws, rules or regulations governing the valid length of a prescription. For LON specifically, reviewers will look to the medical records to determine LON.

Question 7: With respect to the “quantity to be dispensed, if applicable” requirement on the SWO, would it suffice to state that the quantity is “2 per day” or does the quantity have to read a specific number for a month supply, e.g., “60 per month”?

DME MAC Response: Either description of quantity would suffice; however, for claim review purposes, expressing the quantity as a weekly or monthly amount is preferable. Note that the “if applicable” applies to drugs, dressings and other DMEPOS items where the dispensed quantity is typically more than one (1) item or that dispensing happens on a recurring basis. Consult the applicable LCD and related Policy Article for additional details.

Question 8: How do the DME MACs define “treating physician?” For example, a surgeon in the hospital provides supplies that are needed immediately post-op but following discharge, the beneficiary sees their primary care provider for continued care. Will the patient’s primary care practitioner be considered the “treating practitioner” for subsequent supply orders?

DME MAC Response: Per the example, if the patient’s primary care practitioner has knowledge of, and documentation to support (e.g., face-to-face) the condition that requires his or her writing an order/prescription, there is no preclusion to the patient’s primary care practitioner providing subsequent orders/prescriptions.

Question 9: For items subject to the face-to-face encounter and written order prior to delivery requirement, must the SWO be signed by the same treating practitioner who completed the face-to-face encounter?

DME MAC Response: For power mobility devices, the treating practitioner that conducted the face-to-face encounter must complete the SWO.

For items other than power mobility devices that will appear on the “Required Face-to-Face Encounter and Written Order Prior to Delivery List,” the treating practitioner that conducted the face-to-face encounter does not need to be the prescriber for the DMEPOS item; however, to demonstrate compliance with the regulation, the prescriber must:

� Verify that a qualifying face-to-face encounter occurred within the 6-months prior to the date of their prescription; and,

� Have documentation of the qualifying face-to-face encounter that was conducted.

Question 10: If a patient experiences a change in treating practitioners, and a SWO is generated by the patient’s supplier that prepopulates the wrong treating practitioner’s name, is it acceptable for the supplier to strike through the wrong name, fill in the correct name, sign and date the change and submit the corrected order to the patient’s treating practitioner for signature?

DME MAC Response: Yes, it is acceptable to use standard clinical practice to strike through and provide the updated information.


Question 11: I am a treating practitioner but also a supplier. Do I have to write an SWO to myself to dispense DMEPOS?

DME MAC Response: No. The SWO regulations do not require that a treating practitioner (e.g. MD/DO or NP/PA/CNS) who is also the supplier to create a separate SWO so long as the elements of a SWO is included in the beneficiary’s medical record.

Question 12: Does the NPI of the MD/DO/DPM who is both the prescriber and supplier need to be in the patient’s chart on the ordered DOS? Physicians typically do not include the prescribing practitioner’s NPI in the medical records.

DME MAC Response: The SWO, or in this question the medical record serving as the SWO, requires either the NPI or the name of the treating practitioner. If the treating practitioner’s name is included in the medical records, there is no need for the NPI to be included as well.

Question 13: The final rule CMS-1713-F mentions a “Master List of DMEPOS Items Potentially Subject to Face-To-Face Encounter and Written Orders Prior to Delivery and/or Prior Authorization Requirements”, a “Required Face-to-Face Encounter and Written Order Prior to Delivery List” and a “Required Prior Authorization List.” Can you provide more information?

DME MAC Response: With the final rule CMS-1713-F, CMS set out criteria for identifying DMEPOS items potentially subject to face-to-face encounters and written order prior to delivery, in addition to prior authorization. These criteria define the DMEPOS items on the Master List, which is updated annually. From this Master List, CMS creates two Required Lists – a “Required Face-to-Face Encounter and Written Order Prior to Delivery List” and a “Required Prior Authorization List.” The Required Prior Authorization List was updated and published in the Federal Register on Friday, February 7, 2020. It may be viewed here (https://www.federalregister.gov/documents/2020/02/11/2020-02644/medicare-program-update-to-the-required-prior-authorization-list-of-durable-medical-equipment) with additional information on the CMS website here (https://www.cms.gov/index.php/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Process-for-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items). The Required Face-to-Face Encounter and Written Order Prior to Delivery List has not yet published. CMS will provide a minimum of a 60-day notice in the Federal Register for items appearing on either list.

Question 14: Since CMS has yet to publish the “Required Face-to-Face Encounter and Written Order Prior to Delivery List”, what DMEPOS items are currently subject to a face-to-face evaluation and written order prior to delivery?

DME MAC Response: The Medicare statute (see Social Security Act, Title XVIII, §1834(a)(1)(E)(iv)), stipulates for power mobility devices that “[P]ayment may not be made for such covered item unless a physician (as defined in section 1861(r)(1), a physician assistant, nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5)) has conducted a face-to-face examination of the individual and written a prescription for the item.” Furthermore, CMS regulation at 42 CFR 410.38 requires that the written order must be communicated to the supplier prior to delivery of the power mobility device. Until CMS publishes the “Required Face-to-Face Encounter and Written Order Prior to Delivery List”, only power mobility devices and items designated as requiring an in-person visit in an LCD or NCD, are subject to the face-to-face encounter and/or written order prior to delivery.

Question 15: For power mobility devices, are suppliers permitted to use a template for the SWO, like the previous 7-element order (7EO) template, so long as the information is completed by the treating practitioner?

DME MAC Response: For power mobility devices, the treating practitioner must complete the elements of the SWO. A supplier may create a template for use by the treating practitioner to

https://www.federalregister.gov/documents/2020/02/11/2020-02644/medicare-program-update-to-the-required-prior-authorization-list-of-durable-medical-equipment

https://www.federalregister.gov/documents/2020/02/11/2020-02644/medicare-program-update-to-the-required-prior-authorization-list-of-durable-medical-equipment

https://www.cms.gov/index.php/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/DMEPOS/Prior-Authorization-Process-for-Certain-Durable-Medical-Equipment-Prosthetic-Orthotics-Supplies-Items





complete the SWO elements. For items other than power mobility devices, the supplier may prepare the SWO for the treating practitioner’s signature.

Question 16: Is it permissible for the DMEPOS base item and all of the options and accessories to be ordered on one SWO?

DME MAC Response: The DME MAC prefer that the base item and all separately billed options and accessories be included on a single SWO; however, CMS final rule CMS-1713-F does allow for separately billed options and accessories to be on a different SWO.

Question 17: The final rule indicates there must be a face-to-face encounter with the treating practitioner within 6 months prior to the SWO being written for PMD. Does the date of the face-to-face encounter mean the day the treating practitioner saw the patient, or could it be the date that the treating practitioner countersigned the licensed/certified medical practitioner (LCMP) evaluation, if later than the treating practitioner’s face-to-face encounter?

DME MAC Response: As noted in the question, the final rule CMS-1713-F indicates there must be a qualifying face-to-face encounter with the treating practitioner within six (6) months prior to the SWO being written for PMD. The final rule CMS-1713-F defines a face-to-face encounter as an in-person or telehealth encounter, and defines a treating practitioner as both physicians, defined in section 1861(r)(1) of the Act, and non-physician practitioners (that is, PA, NP, and CNS) defined in section 1861(aa)(5) of the Act. The final rule CMS-1713-F makes no allowance for other dates resetting this timeframe, such as the treating practitioner’s co-signature and agreement/disagreement with an LCMP evaluation.

To accommodate the requirements at 42 CFR 410.38, when the treating practitioner sees the beneficiary, regardless of whether a referral to an LCMP is made, that visit date starts the six (6) month timeline for completion of the SWO. If the treating practitioner chooses to refer the beneficiary to an LCMP for a mobility evaluation, the treating physician’s co-signature, dating and indicating agreement or disagreement with the LCMP evaluation must occur within this six (6) month timeframe. In cases where the LCMP evaluation is being adopted into the physician’s documentation to substantiate the need for the item, the SWO may not be written until the LCMP report is signed, dated and agreement/disagreement indicated.

The PMD LCD-related Policy Article will be updated soon to reflect this updated guidance.

Question 18: Is a qualifying face-to-face encounter required each time a new order/prescription for one of the specified items the Required Face-to-Face Encounter and Written Order Prior to Delivery List?” is ordered.

DME MAC Response: A qualifying face-to-face encounter is required within six (6) months of writing the order for any item on the “Required Face-to-Face Encounter and Written Order Prior to Delivery List.” Note that a single face-to-face encounter may document the clinical conditions necessitating multiple DMEPOS items. In this situation, regardless of whether the DMEPOS items are prescribed on different dates, the single face-to-face encounter may be utilized in support of the multiple items, if the encounter date is within 6 months of the orders.

Publication HistoryMarch 12, 2020 Originally Published


MISCELLANEOUS

Claim Status Category and Claim Status Codes Update MLN Matters® Number: MM11467 RevisedRelated CR Release Date: April 10, 2020 Related CR Transmittal Number: R10045CP

Related Change Request (CR) Number: 11467Effective Date: April 1, 2020Implementation Date: April 6, 2020

Note: We revised this article on April 10, 2020, to reflect a revised Change Request (CR) 11467. CR 11467 was revised to update the Uniform Resource Locators (URLs) references (page 2 in this article) in Background Section in the CR. The CR release date, transmittal number and link to the transmittal were also changed. All other information remains the same. All other information remains the same.

CR 11467 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. Make sure your billing staff is aware of this update. Read more…


Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print UpdateMLN Matters® Number: MM11489 RevisedRelated CR Release Date: April 16, 2020 Related CR Transmittal Number: R10054CP


Note: We revised this article on April 16, 2020, to reflect an updated Change Request (CR) 11489 that revised the WPC website address in the background section of the CR (page 2 in this article). All other information remains the same.

CR 11489 updates the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs the ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) to update the Medicare Remit Easy Print (MREP) and PC Print software. Be sure your billing staffs are aware of these changes and obtain the updated MREP and PC Print if they use that software Read more…

View the entire article on the CMS website at https://www.cms.gov/files/document/MM11489



https://www.cms.gov/files/document/MM11489



Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) COREMLN Matters® Number: MM11490 RevisedRelated CR Release Date: April 23, 2020 Related CR Transmittal Number: R10064CP


Note: We revised this article on April 23, 2020, to reflect the revised CR11490 issued on April 23, 2020. The CR revision updated the WPC website address and the same change is made to this article. In the article, we also revised the CR release date, transmittal number, and the web address of the CR. All other information remains the same.

This article informs you that MACs and Medicare’s Shared System Maintainers (SSMs) updated systems based on the Committee on Operating Rules for Information Exchange (CORE) 360 Uniform use of Claim Adjustment Reason Code (CARC), Remittance Advice Remark Code (RARC), and Claim Adjustment Group Code (CAGC) rule publication. These system updates are based on the CORE Code Combination List scheduled to be published on or about February 1, 2020. Make sure your billing staffs are aware of these updates. Read more…

View the entire article on the CMS website at https://www.cms.gov/files/document/MM11490




Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update MLN Matters® Number: MM11638 RevisedRelated CR Release Date: April 15, 2020 Related CR Transmittal Number: R10052CP

Related Change Request (CR) Number: 11638Effective Date: July 1, 2020Implementation Date: July 6, 2020

Note: We revised this article on April 16, 2020, to reflect an updated Change Request (CR) 11638 that revised the WPC website address in the background section of the CR (page 2 in this article). All other information remains the same.

CR 11638 updates the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs the ViPS Medicare System (VMS) and Fiscal Intermediary Shared System (FISS) maintainers to update Medicare Remit Easy Print (MREP) and PC Print software. Be sure your billing staffs are aware of these changes and obtain the updated MREP and PC Print versions if they use that software. Read more…


Claim Status Category Codes and Claim Status Codes UpdateMLN Matters® Number: MM11699Related CR Release Date: May 22, 2020 Related CR Transmittal Number: R10148CP


CR 11699 updates the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions. Make sure your billing staff is aware of this update. Read more…







Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print UpdateMLN Matters® Number: MM11708Related CR Release Date: May 22, 2020 Related CR Transmittal Number: R10149CP


CR 11708 updates the Remittance Advice Remark Code (RARC) and Claims Adjustment Reason Code (CARC) lists and instructs the Viable Information Processing System (ViPS) Medicare System (VMS) and the Fiscal Intermediary Shared System (FISS) to update Medicare Remit Easy Print (MREP) and PC Print. Make sure your billing staffs are aware of these updates. If they use the MREP or PC Print software, they will need to get the updates of that software. Read more…


Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) COREMLN Matters® Number: MM11709Related CR Release Date: May 22, 2020 Related CR Transmittal Number: R10150CP


This article informs you of updates that the MACs and Shared System Maintainers (SSMs) will make to systems based on the CORE 360 Uniform use of CARC, RARC, and CAGC rule publications. These system updates are based on the CORE Code Combination List to be published on or about June 1, 2020. Make sure that your billing staffs are aware of these updates. Read more…







New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy ServicesMLN Matters® Number: MM11750Related CR Release Date: May 8, 2020 Related CR Transmittal Number: R10124CP and R10124FM


This article informs you of new physician specialty codes for Micrographic Dermatologic Surgery (MDS) (D7), and Adult Congenital Heart Disease (ACHD) (D8), and a new supplier specialty code for Home Infusion Therapy Services (D6). Make sure that your billing staffs are aware of these changes. Read more…


Value-Based Insurance Design (VBID) Model – Implementation of the Hospice Benefit ComponentMLN Matters® Number: MM11754Related CR Release Date: May 8, 2020 Related CR Transmittal Number: R10127DEMO

Related Change Request (CR) Number: 11754Effective Date: January 1, 2021Implementation Date: October 5, 2020

This article informs you of the implementation of the hospice benefit component associated with the VBID Model, being tested by the Centers for Medicare & Medicaid Services (CMS) Innovation Center and starting in Calendar Year (CY) 2021. The hospice benefit component of the Model will be tested through CY 2024.

Please make sure your billing staffs are aware of this update as providers MUST still submit claims for these services to Medicare. Non-contracting providers must also submit the same billing forms used to bill original Medicare to plans participating in the VBID Model’s hospice benefit component for payment. Read more…







Section 4.26.2 in Chapter 4 of Publication (Pub.) 100-08Pub 100-08 Medicare Program IntegrityRelated CR Release Date: March 6, 2020Related CR Transmittal Number: R944PI

Related Change Request (CR) Number: 11541 Effective Date: April 6, 2020 Implementation Date: April 6, 2020

The purpose of this Change Request (CR) is to re-insert a paragraph in section 4.26.2 in chapter 4 of Pub. 100-08 that was deleted in error. The paragraph permits a supplier to deliver a Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) item to the patient’s home approximately two (2) days prior to the patient’s anticipated discharge.

Read the entire CMS transmittal…

View the entire article on the CGS website at https://cgsmedicare.com/pdf/cope16274.pdf

https://cgsmedicare.com/pdf/cope16274.pdf

https://cgsmedicare.com/pdf/cope16274.pdf


FEES & PRICING

April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesMLN Matters® Number: MM11701Related CR Release Date: March 20, 2020 Related CR Transmittal Number: R10003CP


CR 11701 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4, Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes. Read more…


April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee ScheduleMLN Matters® Number: MM11702Related CR Release Date: March 20, 2020 Related CR Transmittal Number: R10004CP


CR 11702 informs DME MACs about the changes to the DMEPOS fee schedule that Medicare updates on a quarterly basis when necessary to implement fee schedule amounts for new codes. In addition, the update corrects any fee schedule amounts for existing codes and updates to the DMEPOS Rural ZIP code file. The update process for the DMEPOS fee schedule is available in the Medicare Claims Processing Manual, Chapter 23, Section 60 at: https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf. Make sure your billing staff is aware of this update. Read more…




https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf

https://www.cms.gov/files/document/chapter-23-fee-schedule-administration-and-coding-requirements.pdf




July 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing FilesMLN Matters® Number: MM11745Related CR Release Date: March 27, 2020 Related CR Transmittal Number: R10017CP


CR 11745 informs MACs about new and revised Average Sales Price (ASP) and ASP Not Otherwise Classified (NOC) drug pricing files for Medicare Part B drugs. The Centers for Medicare & Medicaid Services (CMS) supplies MACs with the ASP and NOC drug pricing files for Medicare Part B drugs on a quarterly basis. Payment allowance limits under the Outpatient Prospective Payment System (OPPS) are incorporated into the Outpatient Code Editor (OCE) through separate instructions that are available in Chapter 4 (https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf), Section 50 of the Medicare Claims Processing Manual. Make sure your billing staffs are aware of these changes.

Read more…


HCPCS UPDATES

The July 2020 HCPCS Updates – New, Revised, and Discontinued HCPCS Codes

- CGS Publication


The July 2020 Healthcare Common Procedure Coding System (HCPCS) File has been published. There are several additions, revisions, and discontinued HCPCS codes. The changes are effective July 1, 2020. Please keep in mind, the appearance of a HCPCS code is not an indication of coverage by the DME MAC.

The first listing contains the added HCPCS Codes that will take effect on July 01, 2020. HCPCS DescriptionJ0223 Injection, givosiran, 0.5 mgJ0591 Injection, deoxycholic acid, 1 mg

J0691 Injection, lefamulin, 1 mg

J0742 Injection, imipenem 4 mg, cilastatin 4 mg and relebactam 2 mg

J0791 Injection, crizanlizumab-tmca, 5 mg

J0896 Injection, luspatercept-aamt, 0.25 mg

J1201 Injection, cetirizine hydrochloride, 0.5 mg

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c04.pdf






HCPCS DescriptionJ1429 Injection, golodirsen, 10 mg

J1558 Injection, immune globulin (xembify), 100 mg

J3399 Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x10^15 vector genomes

J9177 Injection, enfortumab vedotin-ejfv, 0.25 mg

J9198 Injection, gemcitabine hydrochloride, (infugem), 100 mg

J9246 Injection, melphalan (evomela), 1 mg

J9358 Injection, fam-trastuzumab deruxtecan-nxki, 1 mg

Q5119 Injection, rituximab-pvvr, biosimilar, (ruxience), 10 mg

Q5120 Injection, pegfilgrastim-bmez, biosimilar, (ziextenzo), 0.5 mg

Q5121 Injection, infliximab-axxq, biosimilar, (avsola), 10 mg

The listing of HCPCS Codes with description/verbiage changes that will take effect July 01, 2020 is as follows:

HCPCS DescriptionJ9245 Injection, melphalan hydrochloride, not otherwise specified, 50 mg

The last listing contains discontinued HCPCS Codes along with the cross-walked HCPCS Code (if applicable). However, not all discontinued HCPCS Codes will have a cross-walked HCPCS Code. The list is as follows:

HCPCS DISCONTINUE DATE CROSSWALK HCPCS CODEJ9199 06/30/2020

COMPETITIVE BIDDING

Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2020MLN Matters® Number: MM11718Related CR Release Date: March 20, 2020 Related CR Transmittal Number: R10006CP


Medicare updates the DMEPOS Competitive Bidding Program (CBP) files on a quarterly basis to implement necessary changes to the Healthcare Common Procedure Coding System (HCPCS), ZIP code, and supplier files. CR11718 provides specific instruction for implementing the DMEPOS CBP files. Read more…





MLN CONNECTS®

MLN Connects® for Thursday, May 21, 2020

HTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-21-mlnc

PDF: https://www.cms.gov/files/document/2020-05-21-mlnc.pdf

News

� CMS Releases Additional Waivers for Hospitals and Ground Ambulance Organizations � Hospice Quality Reporting Program: Quarterly Update for January - March � Nursing Home Quality Initiative: Updated MDS 3.0 Item Sets � Hospitals: Submit Medicare GME Affiliation Agreements by October 1 During the COVID-19 PHE

Events

� COVID-19: Lessons from the Front Lines Calls — May 22 and 29 � COVID-19: Home Health and Hospice Call — May 26 � COVID-19: Office Hours Call — May 26 � COVID-19: Nursing Home Call — May 27 � COVID-19: Dialysis Organization Call — May 27 � COVID-19: Nurses Call — May 28 � Prior Authorization Process and Requirements for Certain Outpatient Hospital Department Services Special Open Door Forum — May 28

MLN Matters® Articles

� COVID-19 Blanket Swing Bed Waiver for Addressing Barriers to Nursing Home Placement for Hospitalized Individuals

� Manual Update to Pub. 100-04, Chapter 38, to Remove Identification of Items or Services Related to the 2010 Oil Spill in the Gulf of Mexico Section

� National Coverage Determination (NCD) 20.19 Ambulatory Blood Pressure Monitoring (ABPM)

� National Coverage Determination (NCD 30.3.3): Acupuncture for Chronic Low Back Pain (cLBP)

� New Physician Specialty Code for Micrographic Dermatologic Surgery (MDS) and Adult Congenital Heart Disease (ACHD) and a New Supplier Specialty Code for Home Infusion Therapy Services

� Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - July 2020 Update

� Therapy Codes Update

Multimedia

� Procedure Coding: Using the ICD-10-PCS Web-Based Training Course — Revised

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-21-mlnc


https://www.cms.gov/files/document/2020-05-21-mlnc.pdf


MLN Connects® Special Edition for Tuesday, May 19, 2020

COVID-19: Payment for Lab Tests, Safely Reopening Nursing Homes, Lab & Ambulance ClaimsHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-19-mlnc-se

PDF: https://www.cms.gov/files/document/2020-05-19-mlnc-se.pdf

News

� COVID-19: Payment for Diagnostic Laboratory Tests � Trump Administration Issues Guidance to Ensure States Have a Plan in Place to Safely Reopen Nursing Homes

� COVID-19: Which Laboratory Claims Require the NPI of the Ordering/Referring Professional?

� COVID-19: Ambulance Claims for Alternative Sites

MLN Connects® Special Edition for Friday, May 15, 2020

COVID-19: Nursing Home Deadline, Telephone E&M Visits, Hospital Time Studies, and CallsHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-15-mlnc-se


News

� Deadline Approaching: Notification Requirements of Confirmed and Suspected COVID-19 Cases Among Nursing Home Residents and Staff

� CMS Releases Nursing Home Toolkit with Best Practices and Additional Resources � Telephone Evaluation and Management Visits � Hospitals: Physician Time Studies During the COVID-19 PHE � Trump Administration Announces Call for Nominations for Nursing Home Commission � COVID-19: Home Health and Hospice Call — May 19 � COVID-19: Nursing Home Call — May 20 � COVID-19: Dialysis Organization Call — May 20 � COVID-19: Nurses Call — May 21 � COVID-19: Office Hours Calls —21 � COVID-19: Lessons from the Front Lines Call — May 22

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-19-mlnc-se


https://www.cms.gov/files/document/2020-05-19-mlnc-se.pdf








News

� IPPS and LTCH PPS: FY 2021 Proposed Rule � Medicare FFS 2nd Level Appeals: Submission Options

Events

� COVID-19: Office Hours Call — May 14 � COVID-19: Lessons from the Front Lines Call — May 15


� Medicare Clarifies Recognition of Interstate License Compacts � Extension of Payment for Section 3712 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act)

� International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs)--October 2020 Update

� Updates to Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) to Correct the Adjustment Process

� Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised

Publications

� How to Use the Medicare Coverage Database — Revised

MLN Connects® Special Edition for Tuesday, May 12, 2020

COVID-19: Additional Waivers, Price Transparency, and CMS Letter to Nursing HomesHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-12-mlnc-se


News

� CMS Releases Additional Waivers for Hospitals and Other Facilities � Price Transparency: Requirement to Post Cash Prices Online for COVID-19 Diagnostic Testing

� CMS Letter to Nursing Home Facility Management and Staff








MLN Connects® Special Edition for Friday, May 8, 2020

COVID-19: Nursing Home Reporting, Updated Telehealth Video, Pharmacies & Other Suppliers Can Enroll as Labs, IRF Flexibilities HTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-05-08-mlnc-se


News

� New Guidance Available on Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes

� Telehealth Video: Medicare Coverage and Payment of Virtual Services � Medicare Pharmacies and Other Suppliers May Temporarily Enroll as Independent Clinical Diagnostic Laboratories to Help Address COVID-19 Testing MLN Matters® Article

� COVID-19: IRF Flexibilities During the PHE � COVID-19: IRF Interdisciplinary Team Meetings During the Pandemic




News

� CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes

� Home Health Plans of Care: NPs, CNSs and PAs Allowed to Certify � Health Care Supply Chain, Provider Self-Care, and Emergency Preparedness Resources

Claims, Pricers & Codes

� COVID-19: Modified Ordering Requirements for Laboratory Billing � Hospital OPPS: New Coronavirus Specimen Collection Code

Events

� COVID-19: Office Hours Call — May 7 � COVID-19: Lessons from the Front Lines Calls — May 8


� Addition of the QW modifier to Healthcare Common Procedure Coding System (HCPCS) code U0002 and 87635

� Modify Edits in the Fee for Service (FFS) System when a Beneficiary has a Medicare Advantage (MA) Plan

� New Codes for Therapist Assistants Providing Maintenance Programs in the Home Health Setting

� Updates to Ensure the Original 1-Day and 3-Day Payment Window Edits are Consistent








with Current Policy — Revised

Publications

� Evaluation and Management Services — Revised

MLN Connects® Special Edition for Thursday, April 30, 2020

COVID-19: Second Round of Sweeping Changes, RHC & FQHC Flexibilities, EMTALAHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-30-mlnc-se


MLN Connects® for Thursday, April 30, 2020



News

� Infection Control Guidance to Home Health Agencies on COVID-19 � Now Available: Nursing Home Five Star Quality Rating System Updates, Nursing Home Staff Counts, and Frequently Asked Questions

� CMS Adds New COVID-19 Clinical Trials Improvement Activity to the Quality Payment Program

� Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier


� Home Health Claims: Correcting Recoding Errors

Events

� COVID-19: Lessons from the Front Lines Calls — May 1 and 8 � COVID-19: Home Health and Hospice Call — May 5 � COVID-19: Office Hours Call — May 5 � COVID-19: Nursing Homes Call — May 6


� July 2020 Quarterly Update to the Inpatient Prospective Payment System (IPPS) Fiscal Year (FY) 2020 Pricer

� Quarterly Update to the Long Term Care Hospital (LTCH) Prospective Payment System (PPS) Fiscal Year (FY) 2020 Pricer

� Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendment (CLIA) Edits — Revised

� Implement Operating Rules - Phase III Electronic Remittance Advice (ERA) Electronic








Funds Transfer (EFT): Committee on Operating Rules for Information Exchange (CORE) 360 Uniform Use of Claim Adjustment Reason Codes (CARC), Remittance Advice Remark Codes (RARC) and Claim Adjustment Group Code (CAGC) Rule - Update from Council for Affordable Quality Healthcare (CAQH) CORE — Revised

Publications

� April 2020 Medicare Quarterly Provider Compliance Newsletter � Advanced Practice Registered Nurses, Anesthesiologist Assistants, and Physician Assistants — Revised

� Ambulatory Surgical Center Payment System — Revised � Dual Eligible Beneficiaries Under Medicare and Medicaid — Revised � Hospital Outpatient Prospective Payment System — Revised � How to Use the Searchable Medicare Physician Fee Schedule — Revised � Long-Term Care Hospital Prospective Payment System — Revised

Multimedia

� Combating Medicare Parts C and D Fraud, Waste, and Abuse Web-Based Training Course — Revised

� Medicare Parts C and D General Compliance Training Web-Based Training Course — Revised

MLN Connects® Special Edition for Monday, April 27, 2020

COVID-19: CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment ProgramHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-27-mlnc-se





News � Trump Administration Champions Reporting of COVID-19 Clinical Trial Data through Quality Payment Program, Announces New Clinical Trials Improvement Activity

� CMS Releases Additional Blanket Waivers for Long-Term Care Hospitals, Rural Health Clinics, Federally Qualified Health Centers and Intermediate Care Facilities

� IRF PPS FY 2021 Proposed Rule � Bill Correctly for Inhalant Drugs

Events

� Ground Ambulance Organizations: Data Collection for Medicare Providers Call — May 7









� New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-19 Public Health Emergency (PHE)

� New Waived Tests � April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1 — Revised

� April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System — Revised � Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised

� Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update — Revised

� Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update — Revised

Publications

� Provider Compliance Tips for Nebulizers and Related Drugs Fact Sheet — Revised

Multimedia

� Medicare Home Health Benefit Web-Based Training Course — Revised

MLN Connects® Special Edition for Monday, April 20, 2020

COVID-19: Nursing Home Transparency, Recommendations for Areas with Low Incidence of DiseaseHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-20-mlnc-se


MLN Connects® Special Edition for Friday, April 17, 2020

COVID-19: RHC & FQHC Flexibilities, Increased Payment for Lab Tests, Hospital Waivers, Call Audio and TranscriptHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-17-mlnc-se












News

� Hospice Payment Rate Update Proposed Rule for FY 2021 � IPF Prospective Payment System Proposed Rule for FY 2021 � SNF Proposed Payment and Policy Changes for FY 2021

Events



� April 2020 Update of the Hospital Outpatient Prospective Payment System (OPPS) � Quarterly Update to the Fiscal Year 2020 Inpatient Psychiatric Facilities Pricer � Claim Status Category and Claim Status Codes Update — Revised � Quarterly Update for Clinical Laboratory Fee Schedule and Laboratory Services Subject to Reasonable Charge Payment — Revised

Publications

� Inpatient Rehabilitation Facility Prospective Payment System — Revised � Medicare Overpayments — Revised � Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services— Revised

Multimedia

� Medicare Fraud & Abuse: Prevent, Detect, and Report Web-Based Training Course — Revised

� Medicare Part C and Part D Data Validation Web-Based Training Course — Revised

MLN Connects® Special Edition for Wednesday, April 15, 2020

COVID-19: Reprocessing Hospital Claims, Essential Diagnostic Services, Non-Invasive VentilatorsHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-15-mlnc-se


News � IPPS Hospitals, LTCHs: Reprocessing Claims for CARES Act � Trump Administration Announces Expanded Coverage for Essential Diagnostic Services Amid COVID-19 Public Health Emergency

� Removal of Non-Invasive Ventilator Product Category from DMEPOS Competitive Bidding Program









COVID-19: Infection Control, Maximizing Workforce, Updated Q&A, CS Modifier for Cost-Sharing, Payment Adjustment SuspendedHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-10-mlnc-se


News

� CMS Issues New Wave of Infection Control Guidance to Protect Patients and Healthcare Workers from COVID-19

� Trump Administration Acts to Ensure U.S. Healthcare Facilities Can Maximize Frontline Workforces to Confront COVID-19 Crisis

� Updated Questions and Answers on COVID-19 � Using CS Modifier When Cost-Sharing is Waived � Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)




News

� CMS Approves Approximately $34 Billion for Providers with the Accelerated/Advance Payment Program for Medicare Providers in One Week

� COVID-19: Dear Clinician Letter � COVID-19: Non-Emergent, Elective Medical Services and Treatment Recommendations � Quality Payment Program: MIPS Extreme and Uncontrollable Circumstances Policy in Response to COVID-19

� Multi-Factor Authentication Requirement Delayed for PECOS, I&A, and NPPES � Open Payments: Pre-Publication Review and Dispute through May 15


� Pneumococcal Pneumonia Vaccination: Eligibility Transactions Includes DOS Starting April 13

Events



� Supplier Education on Use of Upgrades for Multi-Function Ventilators � Second Update to CR 11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM) — Revised








Publications

� Civil Rights, HIPAA, and COVID-19 � Medicare Advance Written Notices of Noncoverage — Revised � Medicare Preventive Services — Revised � Medicare Preventive Services Poster — Revised

MLN Connects® Special Edition for Tuesday, April 7, 2020

COVID-19: Telehealth Video, Coinsurance and Deductible Waived, ASC Attestations, Ambulance Modifiers, Lessons From Front Lines, MLN Call TodayHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-07-mlnc-se


News

� New Video Available on Medicare Coverage and Payment of Virtual Services � Families First Coronavirus Response Act Waives Coinsurance and Deductibles for Additional COVID-19 Related Services

� Guidance for Processing Attestations from Ambulatory Surgical Centers (ASCs) Temporarily Enrolling as Hospitals during the COVID-19 Public Health Emergency

� COVID-19: Expanded Use of Ambulance Origin/Destination Modifiers � Lessons from The Front Lines: COVID-19 � CMS COVID-19 Update Call Today


COVID-19: Telehealth Billing Correction, Nursing Home Recommendations, Billing for Multi-Function Ventilators, New ICD-10-CM Diagnosis CodeHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-04-03-mlnc-se

PDF: https://www.cms.gov/files/document/2020-04-03-special-edition.pdf

News � Billing for Professional Telehealth Distant Site Services During the Public Health Emergency — Revised

� Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments

� Billing for Multi-Function Ventilators (HCPCS Code E0467) under the COVID-19 Public Health Emergency and Otherwise

� New ICD-10-CM diagnosis code, U07.1, for COVID-19






https://www.cms.gov/files/document/2020-04-03-special-edition.pdf





News

� IRF Provider Preview Reports: Review Your Data by April 13 � LTCH Provider Preview Reports: Review Your Data by April 13 � Hospice Provider Preview Reports: Review Your Data by April 13

Events

� Interoperability and Patient Access Final Rule Call — April 7


� July 2020 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

� NCD (20.32) Transcatheter Aortic Valve Replacement (TAVR) � Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) - July 2020

� Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.2, Effective July 1, 2020

� Activation of Systematic Validation Edits for OPPS Providers with Multiple Service Locations – Update — Revised

� Quarterly Update to the National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) Edits, Version 26.1, Effective April 1, 2020 — Revised

Publications

� MLN Catalog – April 2020 Edition

Multimedia

� Open Payments Call: Audio Recording and Transcript





MLN Connects® Special Edition for Tuesday, March 31, 2020

COVID-19: Regulatory Changes, Telehealth Billing, and Specimen Collection CodesHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-31-mlnc-se

PDF: https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf

News

� Trump Administration Makes Sweeping Regulatory Changes to Help U.S. Health Care System Address COVID-19 Patient Surge

� Billing for Professional Telehealth Services During the Public Health Emergency � New Specimen Collection Codes for Laboratories Billing for COVID-19 Testing

MLN Connects® Special Edition for Monday, March 30, 2020

COVID-19: Financial Relief, Nursing Home Telehealth, Quality Reporting, Clinical Laboratories, Hospital Data SharingHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-30-mlnc-se


News

� Trump Administration Provides Financial Relief for Medicare Providers � Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit � Quality Payment Program and Quality Reporting Program/Value Based Purchasing Program COVID-19 Relief

� Clinical Laboratory Improvement Amendments (CLIA) Guidance During COVID-19 Emergency

� Trump Administration Engages America’s Hospitals in Unprecedented Data Sharing



https://www.cms.gov/files/document/mln-connects-special-edition-3-31-2020.pdf





MLN Connects® Special Edition for Thursday, March 26, 2020

COVID-19: Enrollment Relief, Open Payments, Beneficiary NoticesHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-26-mlnc-se

PDF: https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf

News

� 2019-Novel Coronavirus (COVID-19) Medicare Provider Enrollment Relief Frequently Asked Questions (FAQs)

� Frequently Asked Questions (FAQs) on Enforcing Open Payments Deadlines � Beneficiary Notice Delivery Guidance in light of COVID-19

MLN Connects® for Thursday, March 26, 2020



News

� CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Health Care Facility Inspections in light of COVID-19

� SNF Quality Reporting Program: MDS 3.0 v1.18.1 Release Delayed � Home Health Quality Reporting Program: Draft OASIS-E Instrument � Medicare Diabetes Prevention Program: Become a Medicare Enrolled Supplier


� Medicare Diabetes Prevention Program: Valid Claims


� The Supplemental Security Income (SSI)/Medicare Beneficiary Data for Fiscal Year 2018 for Inpatient Prospective Payment System (IPPS) Hospitals, Inpatient Rehabilitation Facilities (IRFs), and Long Term Care Hospitals (LTCHs)

� April 2020 Update of the Ambulatory Surgical Center (ASC) Payment System � April 2020 Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

� April Quarterly Update for 2020 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule

� New Medicare Beneficiary Identifier (MBI) Get It, Use It — Revised � Add Dates of Service (DOS) for Pneumococcal Pneumonia Vaccination (PPV) Health Care Procedure Code System (HCPCS) Codes (90670, 90732), and Remove Next Eligible Dates for PPV HCPCS — Revised

Multimedia

� Ground Ambulance Data Collection System Call: Audio Recording and Transcript



https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf

https://www.cms.gov/files/document/mln-connects-special-edition-thursday-march-26-2020.pdf






COVID-19: Relief for Quality Reporting Programs and Provider EnrollmentHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-23-mlnc-se


MLN Connects® Special Edition for Friday, March 20, 2020

COVID-19: Telehealth and Non-Essential ProceduresHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-20-mlnc-se





News

� Quality Payment Program: 2020 Facility-Based Status � Lower Extremity Joint Replacement: Comparative Billing Report in March � IRF Provider Preview Reports: Review Your Data by April 13 � LTCH Provider Preview Reports: Review Your Data by April 13 � Hospice Provider Preview Reports: Review Your Data by April 13 � IRF Compare Refresh � LTCH Compare Refresh � LTCH CARE Data Submission Specifications � Hospital Quality Reporting: Updated 2020 QRDA I Schematron and Sample File � Influenza Activity Continues: Are Your Patients Protected?

Compliance

� Provider Minute Video: The Importance of Proper Documentation


� SNF Claims Incorrectly Cancelled











Events

� Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2 � Interoperability and Patient Access Final Rule Call — April 7


� Ensure Required Patient Assessment Information for Home Health Claims � Healthcare Common Procedure Coding System (HCPCS) Codes Subject to and Excluded from Clinical Laboratory Improvement Amendments (CLIA) Edits

� Medicare FFS Response to the Public Health Emergency on the Coronavirus (COVID-19) — Revised

Publications

� Administrative Simplification: Code Set Basics � Medicare Parts A & B Appeals Process — Revised � Clinical Laboratory Fee Schedule — Revised

Multimedia

� Part A Appeals Demonstration Call: Audio Recording and Transcript � Introduction to IRF Quality Reporting Program Web-Based Training � Introduction to SNF Quality Reporting Program Web-Based Training

MLN Connects® Special Edition for Tuesday, March 17, 2020

COVID-19: President Trump Expands Telehealth Benefits for Medicare Beneficiaries During COVID-19 OutbreakHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-17

PDF: https://www.cms.gov/files/document/2020-03-17-mlnconnects-se.pdf


COVID-19: FFS Response and Nursing Home Visitor GuidanceHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-16-mlnc-se


https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-17


https://www.cms.gov/files/document/2020-03-17-mlnconnects-se.pdf






COVID-19: Test Pricing, Diagnostic Lab Tests, Pricing & Codes, and EHB CoverageHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-13-mlnc-se





News � CMS Sends More Detailed Guidance to Providers about COVID-19 � HHS Finalizes Historic Rules to Provide Patients More Control of Their Health Data � Quality Payment Program: MIPS 2019 Data Submission Deadline March 31 � Hospital Quality Reporting: Comment on Draft QRDA I Implementation Guide by April 1 � Inclusion of Lower Limb Prosthetics in DMEPOS Prior Authorization � Clean Hands Count: Prevent and Control Infections � March is National Colorectal Cancer Awareness Month

Compliance � Incorrect Billing of HCPCS L8679 - Implantable Neurostimulator, Pulse Generator, Any Type

Events � Open Payments: Your Role in Health Care Transparency Call — March 19 � Medicare Promoting Interoperability Program Call for Measures Webinar — March 19 � Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2 � Interoperability and Patient Access Final Rule Call — April 7 � LTCH and IRF Quality Reporting Programs: SPADEs Webinar — April 14

MLN Matters® Articles � NCD 20.4 Implantable Cardiac Defibrillators (ICDs) � Section 1876 and 1833 Cost Plan Enrollee Access to Care through Original Medicare � April 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.1 � Proper Use of Modifier 59 — Revised � Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update — Revised

Publications � Evacuating and Receiving Patients in the Midst of a Wildfire � Administrative Simplification: Eligibility and Benefits Transaction Basics

Multimedia � Dementia Care Call: Audio Recording and Transcript









COVID-19 Response: CMS Issues FAQs to Assist Medicare ProvidersHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-09-mlnconnects-se



CMS Develops Additional Code for Coronavirus Lab TestsHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-06-mlnconnects-se



HTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-05

PDF: https://www.cms.gov/files/document/2020-03-05.pdf

News

� DMEPOS Suppliers: HCPCS Codes Affected by Further Consolidated Appropriations Act � Medicare Promoting Interoperability Program: CAH Reconsideration Forms due March 6 � Medicare Promoting Interoperability Program: Submit Proposals for New Measures by July 1

� PEPPERs for Short-term Acute Care Hospitals � 2018 Geographic Variation Public Use File � Help Your Patients Make Informed Food Choices

Compliance

� Ambulance Fee Schedule and Medicare Transports


� Average Sales Price Files: April 2020

Events

� Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12

https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-09-mlnconnects-se








https://www.cms.gov/files/document/2020-03-05.pdf


� Open Payments: Your Role in Health Care Transparency Call — March 19 � Anesthesia Modifiers: Comparative Billing Report Webinar — March 19 � Ground Ambulance Organizations: Data Collection for Medicare Providers Call — April 2 � LTCH and IRF Quality Reporting Programs: SPADEs In-Depth Training Event — June 9-10


� Standard Elements for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements

� Remittance Advice Remark Code (RARC), Claims Adjustment Reason Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update

� Quarterly Update for the Temporary Gap Period of the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program (CBP) — April 2020

� International Classification of Diseases, 10th Revision (ICD-10) and Other Coding Revisions to National Coverage Determination (NCDs) — July 2020 Update

Publications

� Administrative Simplification: Claim Status Basics � Hospice Quality Reporting Program: Timeliness Compliance Threshold for HIS Submissions

� Guide to Reducing Chronic Kidney Disease Disparities in the Primary Care Setting

Multimedia

� Ambulance Services Call: Audio Recording and Transcript

MLN Connects® Special Edition for Wednesday, March 4, 2020

CMS Announces Actions to Address Spread of CoronavirusHTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-03-04

PDF: https://www.cms.gov/files/document/cms-announces-actions-address-spread-coronavirus.pdf

MLN Connects® for Thursday, February 27, 2020

HTML: https://www.cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2020-02-27

PDF: https://www.cms.gov/files/document/2020-02-27.pdf

News

� Quality Payment Program: MIPS 2019 Data Submission Period Open through March 31 � Anesthesia Modifiers: Comparative Billing Report in March



https://www.cms.gov/files/document/cms-announces-actions-address-spread-coronavirus.pdf

https://www.cms.gov/files/document/cms-announces-actions-address-spread-coronavirus.pdf



https://www.cms.gov/files/document/2020-02-27.pdf


Compliance

� Inpatient Rehabilitation Facility Services: Follow Medicare Billing Requirements


� COVID-19: New ICD-10-CM Code and Interim Coding Guidance � SNF PDPM Claims Issue � FQHC: Mass Adjustment of Claims

Events

� Dementia Care: CMS Toolkits Call — March 3 � Part A Providers: QIC Appeals Demonstration Call — March 5 � Ground Ambulance Organizations: Data Collection for Public Safety-Based Organizations Call — March 12

� Open Payments: Your Role in Health Care Transparency Call — March 19


� Quarterly Update to the Medicare Physician Fee Schedule Database (MPFSDB) - April 2020 Update

� Implementation of the Long Term Care Hospital (LTCH) Discharge Payment Percentage (DPP) Payment Adjustment

� Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging- Approval of Using the K3 Segment for Institutional Claims — Revised

� Accepting Payment from Patients with a Medicare Set-Aside Arrangement — Revised � January 2020 Integrated Outpatient Code Editor (I/OCE) Specifications Version 21.0 — Revised


Contact for: Contact Information:EDI – Electronic Claim Submission; Electronic Remittance Notices

Jurisdiction B CEDI website: https://www.ngscedi.com E-mail: [email protected]

Jurisdiction B CEDI (toll-free): 1.866.311.9184 Mon - Fri, 8:00 a.m. - 6:00 p.m. CT

Paper Claim Submission Address: CGS - Jursidiction B PO Box 20013 Nashville, TN 37202

Provider Customer Service Calls IVR (Interactive Voice Response): 1.877.299.7900 Mon - Fri, 6:00 a.m. - 8:00 p.m. CT; Sat, 6:00 a.m. - 4:00 p.m. CT

Customer Service: 1.866.590.6727 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Hearing Impaired: 1.888.897.7534 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Beneficiary Customer Service Calls Phone: 1.800.Medicare

Written Inquiries Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Claim Reopenings (Adjustments) Address: CGS - Jursidiction B PO Box 20007 Nashville, TN 37202

Fax (for underpayments): 1.615.660.5978 Fax (for overpayments): 1.615.782.4508

Telephone requests for Reopenings: 1.866.240.7490 Mon - Fri, 7:00 a.m. - 4:00 p.m. CT

Claim Status Inquiry Security Access Issues/Password Reset, E-mail: [email protected]

Enrollment Status: 1.866.270.4909

Appeals – Redetermination Requests

Address: CGS - Jurisdiction B PO Box 23070 Nashville, TN 37202

Fax: 1.615.660.5976

Electronic Funds Transfer Address: CGS Attn: EFT-DME PO Box 20013 Nashville, TN 37202

Refunds Address: CGS DME MAC Jurisdiction B PO Box 953479 St. Louis, MO 63195-3479

Overnight or Special Shipping Address: CGS DME MAC Jurisdiction B Suite ST610 26 Century Blvd. Nashville, TN 37214

DME MAC Jurisdiction B Website Website: https://www.cgsmedicare.com/jb/index.htmlAdvance Determination of Medicare Coverage (ADMC) - Requests

Address: CGS - Jurisdiction B Attn: ADMC PO Box 20007 Nashville, TN 37202

Fax: 1.615.660.5988

Prior Authorization Address: CGS Medical Review - Prior Authorization PO Box 23110 Nashville, TN 37202

Fax: 1.615.660.5992

Supplier Enrollment Address: National Supplier Clearinghouse Palmetto GBA * AG-495 PO Box 100142 Columbia, SC 29202-3142

Phone: 1.866.238.9652

https://www.ngscedi.com


Documents

EDITION 17 | SUMMER 2020 · met, and that claims payment will be made correctly, if the external infusion pump is still in the capped rental period, drug(s) administered with the