-
This newsletter should be shared with all health care
practitioners and managerial members of the provider/supplier
staff. Newsletters issued after January 1997 are available at no
cost from our website.
© 2017 Copyright, CGS Administrators, LLC.
EDITION 40 ∙ SUMMER 2017
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EDITION 40 ∙ SUMMER 2017 2© 2017 Copyright, CGS Administrators,
LLC.
Table of Contents
News from the InsideReceive Your Medicare Payment Information
Faster! - CGS Publication
....................................................................4
2017 DME POE Workshop Registration is Open! - CGS Publication
....................................................................5
21st Century CURES Act Mass Adjustments – What You Need to Know!
- CGS Publication ...........................6
All Claim Denial Information Now Available in MR WIZARD - CGS
Publication ..............................................7
myCGSHow to Use Wild Cards in myCGS - CGS Publication
............8
Attention myCGS Users: Change to EIDM Password Requirements -
CGS Publication .............................................9
Requesting Additional Tax IDs in myCGS - CGS Publication
....................................................................9
Coverage & BillingItems Provided on a Recurring Basis and
Request for Refill Requirements – Annual Reminder - DME MAC Joint
Publication ................................................10
Correct Coding and Coverage – Braces Constructed Primarily of
Elastic or Other Fabric Materials - Revised - DME MAC Joint
Publication ................................................13
Correct Coding – Interferential Current (IFC) Therapy Devices -
DME MAC Joint Publication ..................................16
DME Information Forms (DIFs) Usage for Enteral and Parenteral
Nutrition and External Infusion Pumps - Revised - DME MAC Joint
Publication ................................................17
Billing Instructions – Continuous Glucose Monitors - DME MAC
Joint Publication
................................................19
Continuous Glucose Monitors – Frequently Asked Questions - DME
MAC Joint Publication ...............................20
Modifier Tools - CGS
Publication...........................................22
Physicians! Are You Ordering Diabetic Shoes for Your Patients? -
DME MAC Joint Publication ................................23
Updated Advance Beneficiary Notice – Required for Use June 21,
2017 - DME MAC Joint Publication .........................25
Capped Rentals and PEN Pumps RT and LT Modifier Alert - DME MAC
Joint Publication
................................................25
Payment for Oxygen Volume Adjustments and Portable Oxygen
Equipment (MM9848 – Revised) ..............................26
New Common Working File (CWF) Medicare Secondary Payer (MSP)
Type for Liability Medicare Set-Aside Arrangements (LMSAs) and
No-Fault Medicare Set-Aside Arrangements (NFMSAs) (MM9893 –
Revised) ....................28
Qualified Medicare Beneficiary Indicator in the Medicare
Fee-For-Service Claims Processing System (MM9911 – Revised)
..............................................................30
The Process of Prior Authorization (MM9940 – Revised)
.....32
Two New “K” Codes for Therapeutic Continuous Glucose Monitors
(MM10013 – Revised)
.............................................34
Prohibition on Billing Dually Eligible Individuals Enrolled in
the Qualified Medicare Beneficiary (QMB) Program (SE1128)
................................................................................36
Medical PolicyLCD and Policy Article Revisions Summary for March
16, 2017
......................................................................40
LCD and Policy Article Revisions Summary for March 23, 2017
......................................................................48
LCD and Policy Article Revisions Summary for March 30, 2017
......................................................................51
LCD and Policy Article Revisions Summary for April 6, 2017
...........................................................................54
LCD and Policy Article Revisions Summary for April 20, 2017
.........................................................................57
LCD and Policy Article Revisions Summary for April 27, 2017
.........................................................................60
LCD and Policy Article Revisions Summary for May 4, 2017
...........................................................................65
LCD and Policy Article Revisions Summary for May 11, 2017
..........................................................................71
LCD and Policy Article Revisions Summary for May 18,
2017..........................................................................77
LCD and Policy Article Revisions Summary for May 25, 2017
.........................................................................79
Glucose Monitors LCD and Related Policy Article – Revised - DME
MAC Joint Publication ..................................81
DMEPOS Order Requirements for Changing Suppliers (MM9886)
..............................................................................82
APPEALSImprovements to the Adjudication Process of Serial Claims
(SE17010)
..............................................................................84
MiscellaneousHealthcare Provider Taxonomy Codes (HPTCs) April
2017 Code Set Update (MM9869)
..................................................93
Remittance Advice Remark Code (RARC), Claims Adjustment Reason
Code (CARC), Medicare Remit Easy Print (MREP) and PC Print Update
(MM9878) ......................94
Guidance on Implementing System Edits for Certain Durable
Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
(MM9904).............................................96
Updates to the “Medicare Claims Processing Manual,” Pub. 100-04,
Chapters 12, 17 and 23 to Correct Remittance Advice Messages
(MM9906) .................................................98
The CMS articles in this edition of the Insider are current as
of May 30, 2017.
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EDITION 40 ∙ SUMMER 2017 3© 2017 Copyright, CGS Administrators,
LLC.
Table of Contents continued...
Fees & PricingExtension of the Transition to the Fully
Adjusted Durable Medical Equipment Prosthetics, Orthotics, and
Supplies Payment Rates Under Section 16007 of the 21st Century
Cures Act (MM9968)
.............................................................99
April Quarterly Update for 2017 Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule (MM9988
– Revised) .................101
July 2017 Quarterly Average Sales Price (ASP) Medicare Part B
Drug Pricing Files and Revision to Prior Quarterly Pricing Files
(MM10016)
......................................................103
July Quarterly Update for 2017 Durable Medical Equipment,
Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule
(MM10071) .................................105
HCPCS UPDATESQuarterly Healthcare Common Procedure Coding System
(HCPCS) Drug/Biological Code Changes – July 2017 Update (MM10107)
..............................................................107
COMPETITIVE BIDDINGQuarterly Update for the Durable Medical
Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive
Bidding Program (CBP) - July 2017
(MM10004)...........................................................................108
eNews
..............................................................................110
DME MAC Jurisdiction C Contact Information
.................................................. 111
http://go.cms.gov/MLNGenInfo
The CMS articles in this edition of the Insider are current as
of May 30, 2017.
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EDITION 40 ∙ SUMMER 2017 4© 2017 Copyright, CGS Administrators,
LLC.
NEWS FROM THE INSIDE
Receive Your Medicare Payment Information Faster!
- CGS Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0417/cope2979.html
Would you like to receive faster payment notification from
Medicare? What if we could eliminate mail and deposit time of your
Medicare checks? The solution to both questions is just a few easy
steps away. Sign up for Electronic Remittance Advices (ERAs) and
Electronic Funds Transfer (EFT)!
ERAs are the recommended method for suppliers to receive their
remittance advices and there are many benefits to switching to
electronic:
y Faster communication and payment notification
y Faster account reconciliation through electronic posting
y Ability to create various reports
y Ability to search for information on claims
y Ability to print the remittance advice with the free software
supported by Medicare and provided by CEDI
Switching to ERAs is as easy as 1, 2, 3:
1. Verify you are capable of receiving the 835 transaction
file.
y If you are a self-biller, verify this information with your
software vendor.
y If you are using a 3rd party biller, verify the information
with your billing service/ clearinghouse.
2. Once the capability is confirmed, you will need to complete
the required enrollment forms located the CEDI Web site
www.ngscedi.com and follow the guided enrollment.
3. You will receive an e-mail confirmation once your request has
been completed.
Once you have signed up to receive electronic remittance
notices, consider signing up for electronic funds transfer as well!
The EFTs are the most convenient method to receive your Medicare
payments. EFT is the process through which payment on Medicare
claims is electronically transferred directly to your bank account.
This process eliminates mail and deposit time and is available to
all DME POS suppliers at no cost. Other benefits of the EFT process
include:
y Quicker payment
y Assurance of timely payment in the bank
y Prevention of lost or delayed checks
y Easier bank reconciliation
y Administration efficiency
https://www.cgsmedicare.com/jc/pubs/news/2017/0417/cope2979.htmlhttps://www.cgsmedicare.com/jc/pubs/news/2017/0417/cope2979.htmlhttp://www.ngscedi.com/
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EDITION 40 ∙ SUMMER 2017 5© 2017 Copyright, CGS Administrators,
LLC.
To sign up for EFT, you or your authorized representative must
complete the Authorization for Electronic Funds Transfer agreement
form and send to your local Durable Medical Equipment Medicare
Administrative Contractor (DME MAC). This form is available at
http://www.cms.gov/cmsforms/downloads/CMS588.pdf.
ERNs and EFTs are a perfect way to ensure you receive your
payments and your payment information as quickly as possible! For
additional information, review the resources provided below.
Resources y Remittance Advice Information: An Overview
(https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Remit-Advice-Overview-Fact-Sheet-ICN908325.pdf)
y CEDI (https://www.ngscedi.com/ngs/portal/ngscedi)
2017 DME POE Workshop Registration is Open!
- CGS Publication
The Jurisdiction C DME Provider Outreach and Education team is
looking forward to meeting you at our live events in 2017! There
are four remaining workshop locations for this year.
y San Antonio, TX (July 12, 2017)
y Atlanta, GA (August 9, 2017)
y Tampa, FL (September 2017)
y Dallas, TX (October 2017)
Our San Antonio workshop will be the final “mega-style” workshop
for 2017, allowing suppliers to select from multiple sessions
throughout the day to tailor your day to your business needs. One
“track” that will be available is for suppliers who provide
orthotics and prosthetics to Medicare beneficiaries. In addition,
there are sessions geared toward new suppliers, as well as those
suppliers involved in the respiratory industry.
Our comprehensive events in the Atlanta, Tampa, and Dallas areas
will be a great way to get your questions answered as the Provider
Outreach representatives conduct focused education on issues and
trends that affect all DME suppliers. There are numerous
opportunities for discussion during the workshop day, so be sure to
bring your questions! Suppliers always leave with new knowledge or
a new approach to an existing problem back at the office.
Go to https://www.cgsmedicare.com/jc/education/workshops.html to
register today!
http://www.cms.gov/cmsforms/downloads/CMS588.pdfhttp://www.cms.gov/cmsforms/downloads/CMS588.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Remit-Advice-Overview-Fact-Sheet-ICN908325.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Remit-Advice-Overview-Fact-Sheet-ICN908325.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Remit-Advice-Overview-Fact-Sheet-ICN908325.pdfhttps://www.ngscedi.com/ngs/portal/ngscedihttps://www.cgsmedicare.com/jc/education/workshops.html
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EDITION 40 ∙ SUMMER 2017 6© 2017 Copyright, CGS Administrators,
LLC.
21st Century CURES Act Mass Adjustments – What You Need to
Know!
- CGS Publication
MLN Matters MM9968 - Extension of the Transition to the Fully
Adjusted Durable Medical Equipment, Prosthetics, Orthotics and
Supplies Payment Rates under Section 16007 of the 21st Century
Cures Act was published in CGS News on May 9, 2017. This article
provides guidelines for DME MACs to reprocess non-competitive bid
claims affected by the 21st Century Cures Act for dates of service
July 1, 2016, through December 31, 2016. In mid-May, per
authorization from CMS, CGS conducted a Beta test and sent a batch
of these claims through for adjustment. CGS will begin the full
mass adjustment process in accordance with CMS instruction. Most
adjustments will result in a higher payment. These mass adjustments
will continue until they are completed, which will be approximately
24 weeks. A certain volume of claims will be released and adjusted
each day. We expect the vast majority of claim adjustments will be
processed to completion without any manual adjudication.
Suppliers should review their remittance advices for adjusted
claims. CMS has authorized that DME MACs can add remittance code
N689 to the remittance notice for these claims. The message
associated with N689 is “Alert: This reversal is due to a
retroactive rate change.” N689 will be in the 2100.MOA segment of
the Electronic Remittance Advice and in the claim header MIA/MOA
section on the printed remittance statement, known as the Standard
Paper Remittance.
Please be aware, these CURES Act adjusted claims will be
processed against all online and common working file edits such as
inpatient stays in a skilled nursing facility, Medicare advantage
plan enrollment, and home health episodes and could deny based on
these edits. You will receive an overpayment demand letter for
these claims. It is also important to note that if there is a
crossover agreement in place for adjusted claims; CGS will forward
these claims to the appropriate health insurance carrier.
There is no need for suppliers to call the Provider Contact
Center to see if their claims have been adjusted or when their
claims will be adjusted as we expect the mass adjustment process to
take approximately 24 weeks to complete. CGS will notify suppliers
once the mass adjustment process is complete via ListServ
announcements as well as postings on our social media accounts
Facebook and Twitter.
Once the mass adjustment process is complete in approximately 24
weeks, suppliers should submit a request to reopen the claim if it
should have been processed with the KE modifier. CGS recommends
that requests to append the KE modifier be faxed to Written
Reopenings at 615.782.4649 for Jurisdiction C. Suppliers should use
fax number 615.660.5978 for any claim for a Jurisdiction B
beneficiary. Use the Reopening Request template located on our
website under “Forms.” You may submit a spreadsheet if there are
multiple claims involved, but you must include the following
information:
y Provider Transaction Account number (PTAN)
y Health Identification Claim number (HICN)
y Name of the Beneficiary
y Date of Service
y Claim Control Number
y HCPCS code
y Must clearly state to add the KE modifier.
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EDITION 40 ∙ SUMMER 2017 7© 2017 Copyright, CGS Administrators,
LLC.
Please do not include more than 250 claims per Reopening
request.
CGS will keep you updated on the overall adjustment process and
will schedule some follow-up webinars focusing on MM9968. These
will take place in July and August, with the likelihood of more to
come throughout the fall. Watch the Jurisdiction ListServs for
these webinars to be announced.
All Claim Denial Information Now Available in MR WIZARD
- CGS Publication
The CGS MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
has been expanded to allow you to view all claim denials! Simply
enter your valid 14-digit claim control number (CCN) and MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
will display detailed denial information for both MR and non-MR
claims! It’s that easy!
Here’s how it works. When you enter a CCN, MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
will display the claim and denial details. If the CCN is for a
standard claim and one or more line items denied, MR WIZARD will
automatically provide you with the detailed claim denial
information. If the CCN you entered has a medical review denial, MR
WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
will automatically display the detailed denial information. If the
CCN you entered has an additional documentation request (ADR)
associated with it, MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
will provide you with the status of the ADR.
The expansion of MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
continues our commitment to providing you with easy access to
detailed claim denial information directly from our website. We
provide a level of detail that is typically only available through
a web portal.
Additional expansion activities are underway so you will have
access to claim and medical review denial information on a rolling
one-year basis. Watch your listserv and remember to like us on
Facebook so you receive our next update on additional MR WIZARD
(https://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx)
expansion activities.
http://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspxhttp://www.cgsmedicare.com/medicare_dynamic/jc/mrwizard/denials.aspx
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EDITION 40 ∙ SUMMER 2017 8© 2017 Copyright, CGS Administrators,
LLC.
myCGS
How to Use Wild Cards in myCGS
- CGS Publication
In myCGS there are multiple ways to check same or similar
equipment, including CMN Status and Claim History. When searching
for same or similar equipment using these options, there is a wild
card feature that allows you to search for multiple HCPCS codes at
one time, bringing back all the results of HCPCS codes beginning
with the letter you choose. It is important to note that the way
the wild card feature works is different between the CMN Status and
Claim History options.
The CMN Status option looks for CMNs on file—both real and
dummy—for the HCPCS code entered and provides detailed information
about the CMN. To perform a wild card search, enter the first
letter of the HCPCS code followed by an asterisk (*) and myCGS will
return only CMNs on file for the beneficiary that begin with the
designated letter. For instance, searching for E* will return any
results for a HCPCS code that begins with the letter E.
The Claim History option provides detailed information about
specific claims for the HCPCS code entered within the dates of
service you designate. To perform a wild card search, enter only
the first letter of the HCPCS code and myCGS will return all items
beginning with that letter for the designated dates of service. Do
NOT use an asterisk when performing a Claim History search.
Same or similar information is just one of many benefits to
using myCGS. Learn more by visiting our myCGS page at
https://www.cgsmedicare.com/jc/mycgs/index.html.
Try myCGS Today! Not a myCGS user? Why not give it a try? We
think that you will find myCGS to be a fast and user-friendly
application that will help you save time and money.
Visit our myCGS page at
https://www.cgsmedicare.com/jc/mycgs/index.html to get started
today!
https://www.cgsmedicare.com/jc/mycgs/index.htmlhttps://www.cgsmedicare.com/jc/mycgs/index.html
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EDITION 40 ∙ SUMMER 2017 9© 2017 Copyright, CGS Administrators,
LLC.
Attention myCGS Users: Change to EIDM Password Requirements
- CGS Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3362.html
The CMS Enterprise Identification Management (EIDM) website
(https://portal.cms.gov/), which is used by the myCGS Web Portal
(https://www.cgsmedicare.com/jc/mycgs/index.html) for user
registration and ID management, has recently implemented a
restriction on passwords prohibiting the use of any password that
contains words consisting of three or more letters of a dictionary
word. For example, you will not be able to use passwords such as
test123, password123, desk321#, etc. Instead of using dictionary
words within your password, you should use combinations of letters,
numbers, and symbols.
In addition to this new requirement, the previous rules listed
below are also still in place for passwords in EIDM.
Your password must:
y Be changed at least every 60 days.
y Be a minimum of 8 and a maximum of 20 characters.
y Be changed only once a day.
y Contain at least 1 letter and 1 number.
y Contain at least 1 upper case and 1 lower case letter.
y Contain at least 1 special character.
y The following special characters may not be used ? < > (
) ‘ “ / \ &.
y Be different from the previous 6 passwords used.
y Not contain your User ID.
y Not contain commonly used words.
For additional information about myCGS, visit our myCGS page
(https://www.cgsmedicare.com/jc/mycgs/index.html).
Requesting Additional Tax IDs in myCGS
- CGS Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3471.html
myCGS (https://www.cgsmedicare.com/jc/mycgs/index.html)
registration is based around a supplier’s Tax ID. All NPI/PTAN
combinations that are associated with your Tax ID are automatically
added to your myCGS account upon successful registration. Some
suppliers, however, may have multiple Tax IDs, with different
NPI/PTAN combinations under each Tax ID. If your company has more
than one Tax ID, then your Authorized Official (AO) will need to
assign the additional Tax ID to the existing Designated Approver
(DA). To do so, the AO must
https://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3362.htmlhttps://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3362.htmlhttps://portal.cms.gov/https://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3471.htmlhttps://www.cgsmedicare.com/jc/pubs/news/2017/0617/cope3471.htmlhttps://www.cgsmedicare.com/jc/mycgs/index.html
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EDITION 40 ∙ SUMMER 2017 10© 2017 Copyright, CGS Administrators,
LLC.
complete and submit the myCGS Additional Tax ID Form
(https://www.cgsmedicare.com/jc/forms/pdf/mycgs_additional_tax_id.pdf)
(which you can access on our Forms page
(https://www.cgsmedicare.com/jc/forms/index.html)).
When submitting the myCGS Additional Tax ID Form, please be
aware that any Tax IDs that are added to a DA’s account will also
automatically be added to all associated End User accounts. If you
are a DA who receives additional Tax IDs and you have End Users who
should not have access to a particular NPI/PTAN, it is your
responsibility to log into myCGS and modify your users’ specific
access (refer to the myCGS User Manual
(https://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_UserManual.pdf) for
instructions on modifying End User access).
Note that End Users will only receive the additional Tax ID
access if they have registered using the same original Tax ID as
the DA who is assigned the additional Tax ID(s). If an End User is
not specifically tied to the DA via the same original Tax ID, then
any additional Tax IDs will NOT be granted to the End User. For
this reason, you may wish to ensure that everyone in your company
originally registers for myCGS in EIDM using the same Tax ID.
Example:Susan, Sarah, Jim, and Joe all work for a DMEPOS company
with multiple locations and Tax IDs. Susan and Sarah are DAs, while
Jim and Joe are End Users. Susan is the DA for Tax ID xx-xxx1111
and Sarah is the DA for Tax ID xx-xxx2222. Jim registers for myCGS
under Tax ID xx-xxx1111, which associates him with Susan. Joe
registers for myCGS under Tax ID xx-xxx2222, associating him with
Sarah. The company has a third Tax ID, xx-xxx3333. Sarah is
assigned this Tax ID via the myCGS Additional Tax ID Form. All
NPIs/PTANs associated with Tax ID xx-xxx3333 are added to Sarah’s
account. Because Joe is associated with Sarah, Joe also receives
access to Tax ID xx-xxx3333 and the associated NPIs/PTANs. Jim, on
the other hand, is not associated with Sarah’s original Tax ID and
therefore does not receive the additional Tax ID assigned to
Sarah.
A few other important things to note about adding Tax IDs:
y You cannot add a Tax ID to a brand new DA. A Tax ID can only
be added to an existing DA. Please wait to send any Additional Tax
ID requests until a DA has been approved and is a user of
myCGS.
y Changing your Organizational information in EIDM will NOT
successfully add a new Tax ID; instead it will cause errors in your
account. Do not change this information.
y CGS only accepts requests for adding Tax IDs from the
Authorized Official in PECOS. A DA who is not the AO in PECOS
cannot request another Tax ID, nor can any End User.
NOTE: Your EIDM account is limited to one Tax ID. Additional Tax
IDs are only added within myCGS itself.
For more detailed information about myCGS registration, refer to
the myCGS Registration Guide
(https://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_registration_guide.pdf).
For additional information about myCGS, visit our myCGS page
(https://www.cgsmedicare.com/jc/mycgs/index.html).
https://www.cgsmedicare.com/jc/forms/pdf/mycgs_additional_tax_id.pdfhttps://www.cgsmedicare.com/jc/forms/pdf/mycgs_additional_tax_id.pdfhttps://www.cgsmedicare.com/jc/forms/index.htmlhttps://www.cgsmedicare.com/jc/forms/index.htmlhttps://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_UserManual.pdfhttps://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_UserManual.pdfhttps://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_registration_guide.pdfhttps://www.cgsmedicare.com/jc/mycgs/index.htmlhttps://www.cgsmedicare.com/jc/mycgs/index.html
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EDITION 40 ∙ SUMMER 2017 11© 2017 Copyright, CGS Administrators,
LLC.
COVERAGE & BILLING
Items Provided on a Recurring Basis and Request for Refill
Requirements – Annual Reminder
- DME MAC Joint Publication
Published March 16, 2017
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0317/cope2484.html
RequirementsFor all DMEPOS items and supplies provided on a
recurring basis, billing must be based on prospective, not
retrospective use. For DMEPOS products that are supplied as refills
to the original order, suppliers must contact the beneficiary prior
to dispensing the refill and not automatically ship on a
pre-determined basis, even if authorized by the beneficiary. This
shall be done to ensure that the refilled item remains reasonable
and necessary, existing supplies are approaching exhaustion, and to
confirm any changes or modifications to the order. Contact with the
beneficiary or designee regarding refills must take place no sooner
than 14 calendar days prior to the delivery/shipping date. For
delivery of refills, the supplier must deliver the DMEPOS product
no sooner than 10 calendar days prior to the end of usage for the
current product. This is regardless of which delivery method is
utilized.
For all DMEPOS items that are provided on a recurring basis,
suppliers are required to have contact with the beneficiary or
caregiver/designee prior to dispensing a new supply of items.
Suppliers must not deliver refills without a refill request from a
beneficiary. Items delivered without a valid, documented refill
request will be denied as not reasonable and necessary.
Suppliers must not dispense a quantity of supplies exceeding a
beneficiary’s expected utilization. Suppliers must stay attuned to
changed or atypical utilization patterns on the part of their
clients. Suppliers must verify with the ordering physicians that
any changed or atypical utilization is warranted. Regardless of
utilization, a supplier must not dispense more than a one- or
three-month quantity at a time. See below for billing
frequencies.
Documentation RequirementsA routine refill prescription is not
needed. A new prescription (order) is required:
y For all claims for purchases or initial rentals
y If there is a change in the order for the accessory, supply,
drug, etc.
y On a regular basis (even if there is no change in the order)
only if it is so specified in the documentation section of a
particular medical policy
y When an item is replaced
y When there is a change in the supplier
For items that the patient obtains in person at a retail store,
the signed delivery slip or copy of itemized sales receipt is
sufficient documentation of a request for refill.
For items that are delivered to the beneficiary, documentation
of a request for refill must be either a written document received
from the beneficiary or a contemporaneous written record of a phone
conversation/contact between the supplier and beneficiary. The
refill request must
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EDITION 40 ∙ SUMMER 2017 12© 2017 Copyright, CGS Administrators,
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occur and be documented before shipment. A retrospective
attestation statement by the supplier or beneficiary is not
sufficient. The refill record must include:
y Beneficiary’s name or authorized representative if different
from the beneficiary
y A description of each item that is being requested
y Date of refill request
y For consumable supplies i.e., those that are used up (e.g.,
ostomy or urological supplies, surgical dressings, etc.) - The
Supplier should assess the quantity of each item that the
beneficiary still has remaining, to document that the amount
remaining will be nearly exhausted on or about the supply
anniversary date.
y For non-consumable supplies i.e., those more durable items
that are not used up but may need periodic replacement (e.g.,
Positive Airway Pressure and Respiratory Assist Device supplies) -
The supplier should assess whether the supplies remain functional,
providing replacement (a refill) only when the supply item(s) is no
longer able to function. Document the functional condition of the
item(s) being refilled in sufficient detail to demonstrate the
cause of the dysfunction that necessitates replacement
(refill).
This information must be kept on file and be available upon
request.
Billing FrequenciesFor refills of surgical dressings, enteral
and parenteral nutrients and supplies, immunosuppressive drugs,
oral anti-cancer drugs, intravenous immune globulin, and oral
antiemetic drugs, only a one-month quantity of supplies may be
dispensed.
For all other refills that are provided on a recurring basis
suppliers may dispense no more than a three-month supply at any one
time.
MiscellaneousThese requirements are not limited to DMEPOS
refills for items addressed in LCDs only. All DMEPOS items that are
refilled on a recurring basis are subject to these
requirements.
For additional information, refer to the DME MAC Standard
Documentation Language article attached to each Local Coverage
Determination and the DME MAC Supplier Manual
(https://cgsmedicare.com/jc/pubs/supman/index.html).
https://cgsmedicare.com/jc/pubs/supman/index.htmlhttps://cgsmedicare.com/jc/pubs/supman/index.html
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EDITION 40 ∙ SUMMER 2017 13© 2017 Copyright, CGS Administrators,
LLC.
Correct Coding and Coverage – Braces Constructed Primarily of
Elastic or Other Fabric Materials - Revised
- DME MAC Joint Publication
Published March 16, 2017
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0317/cope2492.html
BENEFIT CATEGORY All orthoses are covered under the Medicare
Braces Benefit (Social Security Act §1861(s)(9)). For coverage
under this benefit, the orthosis must be a rigid or semi-rigid
device that is used for the purpose of supporting a weak or
deformed body member or restricting or eliminating motion in a
diseased or injured part of the body. Items that are not
sufficiently rigid to be capable of providing the necessary
immobilization or support to the body part for which it is designed
do not meet the statutory definition of the Braces Benefit.
Therefore, claims for these items will be denied as noncovered, no
benefit category.
The following spinal orthoses HCPCS codes contain both elastic
and inelastic items in the same HCPCS code. The applicable codes
are:
y L0450 - TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, UPPER THORACIC
REGION, PRODUCES INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE
INTERVERTEBRAL DISKS WITH RIGID STAYS OR PANEL(S), INCLUDES
SHOULDER STRAPS AND CLOSURES, PREFABRICATED, OFF-THE-SHELF
y L0454 - TLSO, FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM
SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS GROSS
MOTION IN THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE TO
REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR
PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED ITEM
THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE
CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH
EXPERTISE
y L0455 - TLSO FLEXIBLE, PROVIDES TRUNK SUPPORT, EXTENDS FROM
SACROCOCCYGEAL JUNCTION TO ABOVE T-9 VERTEBRA, RESTRICTS GROSS
TRUNK MOTION IN THE SAGITTAL PLANE, PRODUCES INTRACAVITARY PRESSURE
TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS WITH RIGID STAYS OR
PANEL(S), INCLUDES SHOULDER STRAPS AND CLOSURES, PREFABRICATED,
OFF-THE-SHELF
y L0621 - SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL
SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES
STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN,
PREFABRICATED, OFF-THE-SHELF
y L0625 - LUMBAR ORTHOSIS, FLEXIBLE, PROVIDES LUMBAR SUPPORT,
POSTERIOR EXTENDS FROM L-1 TO BELOW L-5 VERTEBRA, PRODUCES
INTRACAVITARY PRESSURE TO REDUCE LOAD ON THE INTERVERTEBRAL DISKS,
INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN,
SHOULDER STRAPS, STAYS, PREFABRICATED, OFF-THE-SHELF
y L0628 - LUMBAR-SACRAL ORTHOSIS, FLEXIBLE, PROVIDES
LUMBO-SACRAL SUPPORT, POSTERIOR EXTENDS FROM SACROCOCCYGEAL
JUNCTION TO T-9 VERTEBRA, PRODUCES INTRACAVITARY PRESSURE TO REDUCE
LOAD ON THE
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EDITION 40 ∙ SUMMER 2017 14© 2017 Copyright, CGS Administrators,
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INTERVERTEBRAL DISKS, INCLUDES STRAPS, CLOSURES, MAY INCLUDE
STAYS, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED,
OFF-THE-SHELF
There are special HCPCS modifier coding instructions that must
be used to separate items made of elastic and inelastic materials.
(See below)
CODING GUIDELINESFor the spinal garment codes listed above
(L0450, L0454, L0455, L0621, L0625, L0628), effective for claims
with dates of service on or after April 1, 2009:
y Items that are primarily constructed of elastic or other
stretchable materials (e.g. support items made of material such as
neoprene or spandex (elastane, Lycra®) (not all-inclusive)) must
add the GY modifier to the code.
y Items that are primarily constructed of elastic or other
stretchable materials (e.g. support items made of material such as
neoprene or spandex (elastane, Lycra®) (not all-inclusive)) that
contain stays and/or panels must add the GY modifier to the
code.
y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) capable of
providing the necessary immobilization or support to the body part
for which it is designed must add the CG modifier to the code.
y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) capable of
providing the necessary immobilization or support to the body part
for which it is designed and that have stays and/or panels capable
of providing the required immobilization or support to the body
part for which it is designed must add the CG modifier to the
code.
y Items that are not capable of providing the necessary
immobilization or support to the body part for which it is designed
(regardless of materials) must add the GY modifier to the code.
If the CG or GY modifier is not used with one of the preceding
HCPCS codes, the claim will be rejected as incorrect coding.
For items where the HCPCS code specifies “elastic” use the
specific HCPCS code that is applicable.
For items where the HCPCS code does not specify elastic (other
than the spinal codes listed above), the following guidelines
apply:
y Items that are primarily constructed of elastic or other
stretchable materials (e.g. support items made of material such as
neoprene or spandex (elastane, Lycra®) (not all-inclusive)) must be
coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY
TYPE).
y Items that are primarily constructed of elastic or other
stretchable materials (e.g. support items made of material such as
neoprene or spandex (elastane, Lycra®]) (not all-inclusive)) that
contain stays and/or panels must be coded as A4467 (BELT, STRAP,
SLEEVE, GARMENT, OR COVERING, ANY TYPE).
y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) that are
incapable of providing the necessary immobilization or support to
the body part for which it is designed must be coded using A4467
(BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) that are
incapable of providing the necessary immobilization or support to
the body part for which it is designed and that have stays and/or
panels capable of providing the required immobilization or support
to the body part for which it is designed, must be coded using
A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE).
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EDITION 40 ∙ SUMMER 2017 15© 2017 Copyright, CGS Administrators,
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y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) capable of
providing the necessary immobilization or support to the body part
for which it is designed must be coded using the applicable
specific HCPCS code for the type of product. A NOC (Not Otherwise
Classified) or miscellaneous HCPCS code must not be used instead of
the specific code. Refer to the long code narrative and any
relevant coding guideline for the criteria applicable for each
HCPCS code.
y Items that are primarily constructed of inelastic material
(e.g., canvas, cotton or nylon (not all-inclusive)) capable of
providing the necessary immobilization or support to the body part
for which it is designed and that have stays and/or panels capable
of providing the required immobilization or support to the body
part for which it is designed, must be coded using the applicable
specific HCPCS code for the type of product. A NOC (Not Otherwise
Classified) or miscellaneous HCPCS code must not be used instead of
the specific code. Refer to the long code narrative and relevant
coding guideline for the criteria applicable for each HCPCS
code.
y Items that are not capable of providing the necessary
immobilization or support to the body part for which it is designed
(regardless of materials) must be coded using A9270 (NONCOVERED
ITEM OR SERVICE).
Effective for dates of service on or after January 1, 2017,
A4466 is deleted and replaced by A4467. Additional coding scenarios
are added as a result of the new HCPCS code narrative for A4467
This information will be incorporated into a future revision of
the Ankle-Foot/Knee-Ankle-Foot Orthoses (AFO/KAFO)
(https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33686),
Knee Orthoses (KO)
(https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33318),
and Spinal Orthoses (LSO/TLSO)
(https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33790)
LCDs and related Policy Articles.
For questions about correct coding, contact the Pricing, Data
Analysis and Coding (PDAC) contractor Contact Center at (877)
735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday
through Friday, or e-mail the PDAC by completing the DME PDAC
Contact Form (https://www.dmepdac.com/contact/index.html).
Revised 07/28/16
Original Publication Date: 01/28/09
Revision Effective Date: 03/09/2017 Note: Deleted HCPCS Code
A4466 Added A4467 Revised narrative consistent with code changes
and added coding scenarios.
Publication Date: July 28, 2016 Revised DAC Article “Elastic
Garments – Noncovered” to provide a more comprehensive discussion
of statutory benefit category requirements and HCPCS coding
guidelines applicable to these items.
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33686https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33686https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33318https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33318https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33790https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?lcdid=33790https://www.dmepdac.com/contact/index.html
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EDITION 40 ∙ SUMMER 2017 16© 2017 Copyright, CGS Administrators,
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Correct Coding – Interferential Current (IFC) Therapy
Devices
- DME MAC Joint Publication
Published April 6, 2017
Link to current version on the CGS website:
https://www.cgsmedicare.com/articles/cope2493.html
Interferential Current (IFC) Therapy is a form of electrotherapy
in which two currents are applied and “crossed” resulting in a
different frequency at the interference (crossing) point. This
approach allows a higher frequency current to be applied to the
skin to overcome skin resistance with a lower frequency current
created in the underlying tissue. Lower frequency currents are
thought to produce stronger effects with less discomfort. A recent
product review identified inconsistent HCPCS coding for these
products.
IFC devices can be configured to allow use for pain relief like
transcutaneous electrical nerve stimulators (TENS). Other settings
can be selected to mimic the effects of neuromuscular stimulators
(NMES) used for the treatment of disuse atrophy. For claims
submitted to the DME MACs the following HCPCS codes must be used
when billing for IFC devices:
When used as TENS:
E0730 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE,
FOUR OR MORE LEADS, FOR MULTIPLE NERVE STIMULATION
When used as NMES:
E0745 NEUROMUSCULAR STIMULATOR, ELECTRONIC SHOCK UNIT
Supplies (leads, electrodes, batteries, etc.) used with IFC
devices are billed using the existing TENS and NMES supply codes. A
TENS supply allowance (A4595) includes electrodes (any type),
conductive paste or gel (if needed, depending on the type of
electrode), tape or other adhesive (if needed, depending on the
type of electrode), adhesive remover, skin preparation materials,
batteries (9 volt or AA, single use or rechargeable), and a battery
charger (if rechargeable batteries are used).
Not otherwise classified (NOC) or miscellaneous codes must not
be used to bill Medicare for IFC devices or for supplies used with
an IFC device.
Refer to the Transcutaneous Electrical Nerve Stimulation LCD
(https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33802&ContrID=140)
and related Policy Article
(https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52520&ContrID=140)
for additional information on coverage, coding and documentation.
CMS Manual System, Pub. 100-03, Medicare National Coverage
Determinations Manual
(http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961.html),
Chapter 1, Sections 10.2, 160.12, 160.13, and 160.27 also contain
information about TENS and NMES.
For questions about correct coding, contact the Pricing, Data
Analysis, and Coding (PDAC) contractor (https://www.dmepdac.com/)
at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT,
Monday through Friday, or email the PDAC by completing the DME PDAC
Contact Form at https://www.dmepdac.com/.
https://www.cgsmedicare.com/articles/cope2493.htmlhttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33802&ContrID=140https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33802&ContrID=140https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52520&ContrID=140https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52520&ContrID=140http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961.htmlhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961.htmlhttps://www.dmepdac.com/https://www.dmepdac.com/
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EDITION 40 ∙ SUMMER 2017 17© 2017 Copyright, CGS Administrators,
LLC.
DME Information Forms (DIFs) Usage for Enteral and Parenteral
Nutrition and External Infusion Pumps - Revised
- DME MAC Joint Publication
Publication Date: April 6, 2017
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0417/cope2774.html
The DME MACs use DME Information Forms (DIF) when processing
claims to assure the most current information is on file and to
allow the claims to pay correctly. Claims for enteral and
parenteral nutrition and external infusion pumps require a DIF to
be submitted with the initial claim as well as when changes in the
items or quantities provided are made. DIFs are completed entirely
by the supplier and do not need to be signed by the treating
physician. DIFs are required to be signed and dated by the
supplier.
The following table indicates the DIFs for external infusion
pumps and enteral/parenteral nutrition.
DME MAC FORM CMS FORM ITEMS ADDRESSED09.03 10125 External
Infusion Pumps10.03 10126 Enteral and Parenteral Nutrition
Initial DIF:A new Initial DIF is required when:
1. An enteral formula billed with a different code, which has
not been previously certified, is ordered; or,
2. For either enteral formulas or administration via pump
(B9002), there has been a break in billing of more than 60 days
(plus the remaining days in the rental month) and there has been a
change in the underlying medical condition that justifies coverage
for the item(s).
3. A beneficiary receiving enteral nutrition by the syringe or
gravity method is changed to administration using a pump*
(B9002).
*Change in method of administration from gravity or syringe to a
pump (B9002) requires a new initial DIF for the pump and a revised
DIF for the enteral nutrient (See chart below).
Revised DIF:A Revised DIF is required when there has been a
change in any of the information recorded on the DIF. The table
below lists changes that require a Revised DIF to be submitted:
External Infusion Pumps
• Changes in the existing drug HCPCS code
• Substitution of drug HCPCS code for existing drug HCPCS
code
• Addition of drug HCPCS code
• Change in the route of administration
• Change in method of administration
• Extend expired length of need
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Enteral and Parenteral Nutrition
• Change in HCPCS code for the current nutrient provided
• Change (increase or decrease) in the calories prescribed
• Change in the method of administration from gravity to syringe
or syringe to gravity (See above for gravity or syringe to
pump)
• Change in the number of days per week of administration
• Change in route of administration from tube feedings to oral
feedings (if billing for denial)
• When the length of need previously entered on the DIF has
expired and the ordering physician is extending the length of need
for the item(s)
The DIFs for External Infusion Pumps
(http://cgsmedicare.com/jc/forms/pdf/cms-10125_ext_inf_pump.pdf)
and Enteral Nutrition or Parenteral Nutrition
(https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10126.pdf)
can be located on each DME MAC website.
For additional information, refer to the Supplier Manual
(https://cgsmedicare.com/jc/pubs/supman/), the applicable Local
Coverage Determination
(https://cgsmedicare.com/jc/coverage/lcdinfo.html) and related
Policy Article, and the Standard Documentation Requirements Policy
Article.
Revision HistoryPublication Date: April 2017 Revised: Clarifies
that a Revised DIF instead of a Recertification DIF is required for
Parenteral and Enteral Nutrition when the ordering physician
extends length of need.Deleted: HCPCS Code B9000, which was cross
walked to HCPCS Code B9002 Publication Date: January 2017
Revised: Corrects a clerical error that at the end of the
article, which inadvertently left the instructions for suppliers to
obtain a recertification DIF for External Infusion Pumps when
length of need expires and the ordering physician extends the
length of need.
Publication Date: June 2015 Revised: A Revised DIF instead of a
Recertification DIF is required for External Infusion Pumps when
the ordering physician extends length of need.
Original Publication Date: January 2015
http://cgsmedicare.com/jc/forms/pdf/cms-10125_ext_inf_pump.pdfhttp://cgsmedicare.com/jc/forms/pdf/cms-10125_ext_inf_pump.pdfhttps://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10126.pdfhttps://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS10126.pdfhttps://cgsmedicare.com/jc/pubs/supman/https://cgsmedicare.com/jc/pubs/supman/https://cgsmedicare.com/jc/coverage/lcdinfo.htmlhttps://cgsmedicare.com/jc/coverage/lcdinfo.html
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EDITION 40 ∙ SUMMER 2017 19© 2017 Copyright, CGS Administrators,
LLC.
Billing Instructions – Continuous Glucose Monitors
- DME MAC Joint Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/articles/cope2916.html
Questions have arisen about the proper billing of continuous
glucose monitors (CGM) and the related supply allowance. The
following instructions apply to all claims for CGM and related
supplies.
Therapeutic CGM y All claims must be billed with codes E1399 for
the therapeutic CGM receiver and A9999 for the supply allowance.
Only one (1) month of the supply allowance (one (1) Unit of
Service) may be billed to the DME MACs at a time.
y All claims must include the diagnosis code that describes the
beneficiary’s disease condition.
y Modifier KX or KS must be added to the claim line for the
therapeutic CGM receiver and supply allowance code:
Use modifier KX if the beneficiary is insulin treated; or,
Use modifier KS if the beneficiary is non-insulin treated.
y Modifier CG must be added to the claim line for the
therapeutic CGM receiver and supply allowance code if all of the
coverage requirements are met. If any of the coverage requirements
for a therapeutic CGM are not met, modifier CG must not be
used.
Non-therapeutic CGM y All claims for devices classified by
Medicare as non-therapeutic CGM devices and related supplies must
be billed using codes A9276, A9277 and A9278.
y All claims for non-therapeutic CGM devices must include the
diagnosis code that describes the beneficiary’s disease
condition.
y Modifiers KX, KS and CG are not used when billing
non-therapeutic CGM devices and related supplies.
Refer to the March 23, 2017 DME MAC joint publication titled
“Coding and Coverage – Therapeutic Continuous Glucose Monitors
(CGM)” for additional coverage, coding and documentation
requirements. The Glucose Monitors Local Coverage Determination and
Related Policy Article will be updated with this information in a
future revision.
https://www.cgsmedicare.com/articles/cope2916.html
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EDITION 40 ∙ SUMMER 2017 20© 2017 Copyright, CGS Administrators,
LLC.
Continuous Glucose Monitors – Frequently Asked Questions
- DME MAC Joint Publication
Published May 4, 2017
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0517/cope3049.html
1. What is the effective date for coverage of continuous glucose
monitors? Response: Coverage of therapeutic continuous glucose
monitors (CGM), as defined in the CMS Ruling 1682R, is effective
for claims with dates of service (DOS) on or after January 12,
2017. Continuous glucose monitors classified as non-therapeutic
CGMs remain non-covered (No Medicare benefit).
2. When will the Glucose Monitors LCD and related Policy Article
be updated to include CGM coverage? Response: The Glucose Monitors
LCD and related Policy Article will be updated shortly to reflect
the coverage, coding and documentation requirements for therapeutic
CGM devices.
3. Are claims for therapeutic CGMs and the related supply
allowance currently accepted and processed by the DME MACs? If so,
what rules for coverage should a supplier follow until the Glucose
Monitor LCD and related Policy Article are published? Response:
Yes, claims for therapeutic CGMs and the related supply allowance
are being accepted and processed by the DME MACs. Suppliers should
refer to the following articles for additional information on the
coverage, coding and documentation requirements for CGM devices and
the supply allowance:
9Coding and Coverage – Therapeutic Continuous Glucose Monitors
(CGM) (Published March 23, 2017)
9 Billing Instructions – Continuous Glucose Monitors (Published
April 20, 2017)
4. Suppliers are currently required to bill the therapeutic CGM
and the related supply allowance using miscellaneous codes E1399
and A9999. CMS recently published new HCPCS codes for therapeutic
CGM and the related supply allowance. When can suppliers use these
new codes? Response: These two new codes have a future effective
date for claims with dates of service on or after July 1, 2017. The
new codes are:
K0553 - SUPPLY ALLOWANCE FOR THERAPEUTIC CONTINUOUS GLUCOSE
MONITOR (CGM), INCLUDES ALL SUPPLIES AND ACCESSORIES, 1 MONTH
SUPPLY = 1 UNIT OF SERVICE
K0554 - RECEIVER (MONITOR), DEDICATED, FOR USE WITH THERAPEUTIC
CONTINUOUS GLUCOSE MONITOR SYSTEM
5. What is included in the supply allowance code A9999 (K0553
for DOS on or after July 1, 2017)? Response: As noted in the March
23, 2017 DME MAC joint publication titled Coverage and Coding –
Therapeutic Continuous Glucose Monitors, the supply allowance for
supplies used with a therapeutic CGM system encompasses all items
necessary for the
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EDITION 40 ∙ SUMMER 2017 21© 2017 Copyright, CGS Administrators,
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use of the device and includes, but is not limited to: CGM
sensor, CGM transmitter, home blood glucose monitor and related
blood glucose monitor (BGM) supplies (test strips, lancets, lancing
device, and calibration solutions) and batteries.
6. Do the supply allowance codes (A9999/K0553) require a date
span? Response: No. One unit of service (UOS) of the A9999 supply
allowance (K0553 for dates of service on or after July 1, 2017) is
for a monthly supply. Suppliers may only bill one (1) UOS at a
time.
7. May suppliers bill multiple months of the supply allowance at
a time? Response: No, only one (1) UOS of the supply allowance may
be billed at a time. Suppliers must deliver a sufficient quantity
of all necessary supplies to last for an entire month to correctly
bill for the CGM monthly supply allowance. A supplier does not have
to deliver supplies used with a therapeutic CGM every month to bill
code A9999/K0553 every month. To bill for supplies, the supplier
must have previously delivered quantities of supplies that are
expected to be sufficient to last for one full month following the
DOS on the claim. Suppliers must monitor usage of supplies. Billing
may continue monthly if sufficient supplies remain to last for one
full month as previously described. If there are insufficient
supplies to be able to last for a full month, additional supplies
must be provided before the supply allowance is billed.
8. May beneficiaries who were previously testing frequently with
a blood glucose monitor and who elect to change to a therapeutic
CGM continue to receive separate reimbursement for glucose monitor
test strips? Response: No. For beneficiaries who qualify for
reimbursement of a therapeutic CGM, all supplies, including a BGM
and all related BGM supplies, are included in the monthly supply
allowance payment. Thus, separate billing of a BGM and/or related
BGM supplies is considered unbundling.
9. If a patient tells us they are using their smart phone as a
receiver, can we use an ABN and inform the patient that the system
is not medically necessary? Response: As noted in the March 23,
2017 article:
“Coverage of the CGM system supply allowance is limited to those
therapeutic CGM systems where the beneficiary ONLY uses a receiver
classified as DME to display glucose data. If a beneficiary uses a
non-DME device (smart phone, tablet, etc.) as the display device,
either separately or in combination with a receiver classified as
DME, the supply allowance is non-covered by Medicare.”
A smart device is not covered under the DME benefit. Supplies
used with non-DME items are not covered because the base item is
not covered. You may use a voluntary ABN to inform the beneficiary
that the claims will be denied as non-covered. Non-covered denials
receive a “patient responsibility” (PR) denial with or without an
ABN.
10. Are the same modifiers used to bill CGMs and the related
supply allowance, like those used for billing blood glucose
monitors and related supplies? Response: As noted in the April 2017
DME MAC joint publication titled Billing Instructions – Continuous
Glucose Monitors, certain modifiers are required when billing
therapeutic CGMs (E1399/K0554) and their related supply allowance
(A9999/K0553):
Use modifier KX if the beneficiary is insulin treated; or,
Use modifier KS if the beneficiary is non-insulin treated;
Use modifier CG if all the coverage requirements are met.
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EDITION 40 ∙ SUMMER 2017 22© 2017 Copyright, CGS Administrators,
LLC.
11. What HCPCS codes should be used to bill for therapeutic CGMs
and the supply allowance? Response: The proper code to use
depending on the DOS for the claim:
Dates of Service prior to July 1, 2017:
- Therapeutic CGM - E1399
- Supply Allowance - A9999
Dates of Service on or after July 1, 2017:
- Therapeutic CGM – K0554
- Supply Allowance – K0553
Refer to the March 23, 2017 DME MAC joint publication entitled
Coverage and Coding – Therapeutic Continuous Glucose Monitors for
instructions on how to annotate therapeutic CGMs and related supply
allowance claims when using a “not otherwise classified” (NOC)
HCPCS code.
Modifier Tools
- CGS Publication
CGS has developed two new self-service tools to improve your
access to specific modifiers needed to bill for services provided
in competitive and non-competitive bid situations.
The KE/KY modifier tool helps eliminate the confusion related to
billing for options/accessories used with a non-competitive bid
base. Our easy-to-use online tool offers you the ability to find
information pre-/post-competitive bid rounds 1 and 2. When you
enter the accessory code and base code, our self-service tool will
provide information on the appropriate KE and/or KY modifier
combinations required. In addition to our search function, CGS has
also created a new spreadsheet option which can be downloaded and
filtered.
The Repair Modifier Tool provides you with information to
determine the modifiers for use when billing a replacement for
wheelchair accessories incident to a repair and it includes
frequently billed wheelchair replacement codes and modifier
suggestions – including the KU modifier. Just like our new KE/KY
modifier tool, you have the ability to find repair modifier
information pre-post-competitive bid round 1 and 2. We also
included a new spreadsheet option which can be downloaded and
filtered.
Suppliers who wish to use the spreadsheet options are reminded
that CGS will update the KE/KY and Repair modifier spreadsheets as
new information is available. You should review the spreadsheets on
a regular basis to ensure you are using the most recent
information.
CGS created these self-service tools based on feedback you
provide through the website satisfaction survey and through your
interactions with our POE team and the JB/JC Council and POE
Advisory Groups.
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EDITION 40 ∙ SUMMER 2017 23© 2017 Copyright, CGS Administrators,
LLC.
“The following was published in the News section of the
Jurisdiction B/Jurisdiction C CGS website on May 30, 2017. This
article was written as an additional tool for suppliers to use with
their referral sources to help them understand their role in
providing diabetic shoes to Medicare beneficiaries.”
Physicians! Are You Ordering Diabetic Shoes for Your
Patients?
- DME MAC Joint Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/archive/17/index.html
The following section outlines roles of various practitioners
that are involved in the decision-making and provision process for
Diabetic Shoes:
y Certifying Physician: The practitioner actively treating and
managing the patient’s systemic diabetic condition. This
practitioner must be an M.D. (Doctor of Medicine) or D.O. (Doctor
of Osteopathy) as outlined in the Social Security Act §1861(s)
(12).
y Prescribing Practitioner: The Certifying Physician, a
different MD or DO, physician’s assistant (PA), nurse practitioner
NP), clinical nurse specialist (CNS), or podiatrist (DPM). One of
these practitioners may conduct the foot exam and write the
detailed written orders required for Medicare’s coverage of
Therapeutic Shoes for Persons with Diabetes if the Certifying
Physician does not complete the foot exam.
y Supplier: The person or entity that provides the shoes and/or
inserts to the Medicare beneficiary and bills the Medicare program.
A supplier may be a podiatrist, pedorthist, orthotist, prosthetist
or other qualified individual. The Prescribing Practitioner may be
the supplier.
Therapeutic shoes, inserts and/or modifications to therapeutic
shoes are covered if all of the following criteria are met:
1. The beneficiary has diabetes mellitus (Reference diagnosis
code section in Policy Article (A52501)); and
2. The certifying physician has documented in the beneficiary’s
medical record one or more of the following conditions:
a. Previous amputation of the other foot, or part of either
foot, or
b. History of previous foot ulceration of either foot, or
c. History of pre-ulcerative calluses of either foot, or
d. Peripheral neuropathy with evidence of callus formation of
either foot, or
e. Foot deformity of either foot, or
f. Poor circulation in either foot; and
3. The certifying physician has certified that indications (1)
and (2) are met and that he/she is treating the beneficiary under a
comprehensive plan of care for his/her diabetes and that the
beneficiary needs diabetic shoes. The Certifying Physician
must:
y Have an in-person visit with the beneficiary during which
diabetes management is addressed within six months prior to
delivery of the shoes/inserts; and
y Sign the certification statement on or after the date of the
in-person visit and within three months prior to delivery of the
shoes/inserts.
https://www.cgsmedicare.com/jb/pubs/news/2017/05/cope3334.htmlhttps://www.cgsmedicare.com/jc/pubs/news/archive/17/index.html
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EDITION 40 ∙ SUMMER 2017 24© 2017 Copyright, CGS Administrators,
LLC.
4. Prior to selecting the specific items that will be provided;
the supplier must conduct and document an in-person evaluation of
the beneficiary.
5. At the time of in-person delivery to the beneficiary of the
items selected, the supplier must conduct an objective assessment
of the fit of the shoe and inserts and document the results.
The Certifying Physician must either:
1. Personally document one or more of the qualifying foot
conditions above in the medical record of an in-person visit within
six months prior to delivery of the shoes/inserts; or
2. Obtain, initial, date (prior to signing the certification
statement), and indicate agreement with information from the
medical records of an in-person visit with a podiatrist, other
Physicians! Are You Ordering Diabetic Shoes for Your
Patients?M.D. or D.O., physician assistant, nurse practitioner, or
clinical nurse specialist that is within six months prior to
delivery of the shoes/inserts. In this scenario, a different
practitioner conducts the foot examination.
The certification statement must be completed on or after the
date of the in-person visit and within three months prior to
delivery of the diabetic shoes by the supplier. The documentation
in the medical record must support the information on the
certification statement and the statement must be signed prior to,
or the same day, as the order for the diabetic shoes and inserts.
The certification statement by itself is not sufficient to meet the
required documentation in the medical record and must be
corroborated by the medical record.
Just a few reminders:
y The Certifying Physician must be an MD or DO that is managing
the beneficiary’s systemic diabetic condition.
y Another practitioner may conduct the foot exam that includes
evidence of at least one of the qualifying foot issues. If this
happens, the Certifying Physician must obtain a copy of that
medical record, indicate agreement, sign and date it.
y The certification statement must be completed before the
orders for the diabetic shoes.
y The Diabetic Shoe benefit is an annual benefit. Medicare will
consider payment for one pair of diabetic shoes and up to three
pairs of insoles per calendar year.
y The supplier must have valid detailed written orders in their
possession prior to submitting the claim to the DME MAC.
All orders and medical records must meet CMS Signature
Requirements
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdf
Following this guidance will help your patients and the Medicare
program by verifying there is medical documentation to support the
provisions for Therapeutic Shoes for Persons with Diabetes, allow
your patients to receive the items needed to treat their diabetic
condition, and allow Medicare to pay claims appropriately.
Local Coverage Determinations for Therapeutic Shoes for Persons
with Diabetes (L33369):
y Jurisdiction A -
https://med.noridianmedicare.com/web/jadme/policies/lcd/active
y Jurisdiction B -
https://www.cgsmedicare.com/jb/coverage/lcdinfo.html
y Jurisdiction C -
https://www.cgsmedicare.com/jc/coverage/lcdinfo.html
y Jurisdiction D -
https://med.noridianmedicare.com/web/jddme/policies/lcd/active
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM6698.pdfhttps://med.noridianmedicare.com/web/jadme/policies/lcd/activehttps://www.cgsmedicare.com/jb/coverage/lcdinfo.htmlhttps://www.cgsmedicare.com/jc/coverage/lcdinfo.htmlhttps://med.noridianmedicare.com/web/jddme/policies/lcd/active
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EDITION 40 ∙ SUMMER 2017 25© 2017 Copyright, CGS Administrators,
LLC.
Updated Advance Beneficiary Notice – Required for Use June 21,
2017
- DME MAC Joint Publication
Link to current version on the CGS website:
https://www.cgsmedicare.com/jc/pubs/news/2017/0517/cope3142.html
In March 2017, the Office of Management and Budget approved the
Advance Beneficiary Notice (ABN) (Form CMS-R-131) for another 3
years. There are no changes to the form, except the new expiration
date of March 2020. Starting June 21, 2017, the most recent version
of the form must be used to deliver a valid ABN; however, the new
form may be used immediately.
The revised form and additional information is available on the
CMS Beneficiary Notices Initiative (BNI) webpage
(https://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.html).
Capped Rentals and PEN Pumps RT and LT Modifier Alert
- DME MAC Joint Publication
The Centers for Medicare and Medicaid Services (CMS) has given
instruction to the Common Electronic Data Interchange (CEDI)
contractor to remove the Accredited Standards Committee (ASC) X12
837 front-end claim edit (that requires RT & LT modifiers for
Capped Rentals and Pen Pumps when units = two (2)), in order for
the claim to accept through the CEDI front-end and be sent onto the
DME MAC claim system for processing. This system update will be
implemented July 3, 2017. Prior to the system update, claims were
rejecting against the CEDI edit due to the limitation of the number
of modifiers that can be reported in the ASC X12 837P claim format
combined with the Medicare system limitations. The CEDI rejections
were because certain procedure codes were moved to the Capped
Rental category with the July of 2016 quarterly release.
The CGS Repair Modifiers Tool and spreadsheet have been updated
to reflect the system changes.
The Repair Modifiers Tool is located at:
https://www.cgsmedicare.com/medicare_dynamic/dme/repair_modifier_tool.asp
https://www.cgsmedicare.com/jc/pubs/news/2017/0517/cope3142.htmlhttps://www.cgsmedicare.com/jc/pubs/news/2017/0517/cope3142.htmlhttps://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.htmlhttps://www.cms.gov/Medicare/Medicare-General-Information/BNI/ABN.htmlhttps://www.cgsmedicare.com/medicare_dynamic/dme/repair_modifier_tool.asp
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EDITION 40 ∙ SUMMER 2017 26© 2017 Copyright, CGS Administrators,
LLC.
Payment for Oxygen Volume Adjustments and Portable Oxygen
Equipment
Link to current version on the CMS website:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9848.pdf
MLN Matters® Number: MM9848 RevisedRelated CR Release Date:
March 3, 2017 Related CR Transmittal #: R3730CP
Related Change Request (CR) #: CR 9848Effective Date: April 1,
2017Implementation Date: April 3, 2017
Note: This article was revised on March 6, 2017, to reflect the
release of an updated Change Request (CR). That update added an
instruction for the MACs. The transmittal number, CR release date
and link to the transmittal also changed. All other information
remains the same.
Provider Types AffectedThis MLN Matters® Article is intended for
providers and suppliers submitting claims to Durable Medical
Equipment Medicare Administrative Contractors (DME MACs) for oxygen
services provided to Medicare beneficiaries.
Provider Action NeededCR 9848 updates Chapter 20, Section 130.6
of the “Medicare Claims Processing Manual” to provide additional
instructions in processing claims for oxygen and oxygen equipment.
Make sure that your billing staffs are aware of these changes.
Key Points of CR9848The fee schedule amount for stationary
oxygen equipment is increased under the following conditions. If
both conditions apply, DME MACs use the higher of either of the
following add-ons, but may not pay both add-ons:
Volume Adjustment
If the prescribed amount of oxygen for stationary equipment
exceeds 4 liters per minute, the fee schedule amount for stationary
oxygen rental is increased by 50 percent. If the prescribed liter
flow for stationary oxygen is different than for portable or
different for rest and exercise, DME MACs use the prescribed amount
for stationary systems and for patients at rest. If the prescribed
liter flow is different for day and night use, DME MACs use the
average of the two rates.
Portable Add-on
If portable oxygen is prescribed, the fee schedule amount for
portable equipment is added to the fee schedule amount for
stationary oxygen rental.
The following HCPCS code modifiers should be used to denote when
the oxygen flow exceeds 4 liters per minute:
y QF - Prescribed amount of oxygen is greater than 4 Liter Per
Minute (LPM) and portable oxygen is prescribed
y QG - Prescribed amount of oxygen is greater than 4 Liters Per
Minute (LPM)
The modifier “QF” should be used in conjunction with claims
submitted for stationary oxygen (codes E0424, E0439, E1390, or
E1391) and portable oxygen (codes E0431, E0433, E0434, E1392, or
K0738) when the prescribed amount of oxygen is greater than 4
LPM.
Effective April 1, 2017, stationary and portable oxygen and
oxygen equipment QF fee schedule
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9848.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9848.pdf
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EDITION 40 ∙ SUMMER 2017 27© 2017 Copyright, CGS Administrators,
LLC.
amounts will be added to the DMEPOS fee schedule file. The
stationary oxygen and oxygen equipment QF fee schedule amount on
the file will represent 100 percent of the stationary oxygen and
oxygen equipment allowed fee schedule amount. The portable oxygen
equipment add-on QF fee schedule amount on the file by state will
represent the higher of:
1. 50 percent of the monthly stationary oxygen payment amount
(codes E0424, E0439, E1390, E1391) or
2. The fee schedule amount for the portable oxygen add-on (codes
E0431, E0433, E0434, E1392 or K0738).
The following are possible claims processing scenarios:
Scenario 1 – A claim for stationary oxygen equipment is
submitted with the QG modifier. Medicare reviews the history and
discovers that portable oxygen equipment was billed AND paid within
the last 30 days prior to the date of service for the stationary
oxygen equipment. Since the portable oxygen equipment add-on
payment has already been made for this month, the volume adjustment
add-on payment shall not be made in accordance with the rules of
the statute. Use of the QG modifier is inappropriate in this case,
and the claim should be returned as unprocessable.
Scenario 2 – A claim for stationary oxygen equipment is
submitted with the QG modifier, and within 30 days the beneficiary
needs portable oxygen equipment. In this case, the volume add-on
payment has already been made for this month, so the portable
oxygen equipment add –on payment shall not be made in accordance
with the rules of the statute. The claim for the portable oxygen
equipment should be returned as unprocessable.
Scenario 3 – A claim for stationary oxygen equipment is
submitted with the QG modifier AND a claim for portable oxygen
equipment is submitted with the same date of service. In this case
EVERYTHING is returned as unprocessable due to the incorrect use of
the modifier, and neither the claim for stationary oxygen equipment
with the QG modifier nor the claim for portable oxygen equipment is
valid.
NOTE: All these claims are being returned as unprocessable since
there is no way for Medicare to know whether the first submitted
claim was billed incorrectly or the subsequent claim was billed
incorrectly.
Unprocessable claims will be returned with the following
messages:
y Group Code: CO (Contractual Obligation) y Claim Adjustment
Reason Code (CARC) 4 - The procedure code is inconsistent with the
modifier used or a required modifier is missing. Note: Refer to the
835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present.
y Remittance Advice Remarks Code (RARC) MA130 - Your claim
contains incomplete and/or invalid information, and no appeal
rights are afforded because the claim is unprocessable. Please
submit a new claim with the complete/correct information.
Additional InformationThe official instruction, CR9848, issued
to your MAC regarding this change is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3730CP.pdf.
If you have any questions, please contact your MAC at their
toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Disclaimer The article above was prepared as a service to the
public and is not intended to grant rights or impose obligations.
This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is
only intended to be a general summary. It is not intended to take
the place of either the written law or regulations. We encourage
readers to review the specific statutes, regulations and other
interpretive materials for a full and accurate statement of their
contents. CPT only copyright 2015 American Medical Association. All
rights reserved.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3730CP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3730CP.pdfhttps://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/
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EDITION 40 ∙ SUMMER 2017 28© 2017 Copyright, CGS Administrators,
LLC.
New Common Working File (CWF) Medicare Secondary Payer (MSP)
Type for Liability Medicare Set-Aside Arrangements (LMSAs) and
No-Fault Medicare Set-Aside Arrangements (NFMSAs)
Link to current version on the CMS website:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9893.pdf
MLN Matters® Number: MM9893 RevisedRelated CR Release Date: May
10, 2017 Related CR Transmittal #: R1845OTN
Related Change Request (CR) #: CR 9893Effective Date: October 1,
2017Implementation Date: October 2, 2017
Note: This article was revised on May 10, 2017, due to the
release of an updated Change Request (CR). The CR date, transmittal
number and the link to the transmittal changed. All other
information remains the same.
Provider Types AffectedThis MLN Matters® Article is intended for
physicians, providers and suppliers submitting claims to Medicare
Administrative Contractors (MACs) for services to Medicare
beneficiaries.
What You Need to KnowThis article is based on CR 9893. To comply
with the Government Accountability Office (GAO) final report
entitled Medicare Secondary Payer (MSP): Additional Steps Are
Needed to Improve Program Effectiveness for Non-Group Health Plans
(GAO 12-333) (, the Centers for Medicare & Medicaid Services
(CMS) will establish two (2) new set-aside processes: a Liability
Insurance Medicare Set-Aside Arrangement (LMSA), and a No-Fault
Insurance Medicare Set-Aside Arrangement (NFMSA). An LMSA or an
NFMSA is an allocation of funds from a liability or an
auto/no-fault related settlement, judgment, award, or other payment
that is used to pay for an individual’s future medical and/or
future prescription drug treatment expenses that would otherwise be
reimbursable by Medicare.
Please be sure your billing staffs are aware of these
changes.
BackgroundCMS will establish two (2) new set-aside processes: a
Liability Medicare Set-aside Arrangement (LMSA), and a No-Fault
Medicare Set-aside Arrangement (NFMSA).
CR 9893 addresses (1) the policies, procedures, and system
updates required to create and utilize an LMSA and an NFMSA MSP
record, similar to a Workers’ Compensation Medicare Set-Aside
Arrangement (WCMSA) MSP record, and (2) instructs the MACs and
shared systems when to deny payment for items or services that
should be paid from an LMSA or an NFMSA fund.
Pursuant to 42 U.S.C. Sections 1395y(b)(2) and 1862(b)(2)(A)(ii)
of the Social Security Act, Medicare is precluded from making
payment when payment “has been made or can reasonably be expected
to be made under a workers’ compensation plan, an automobile or
liability insurance policy or plan (including a self-insured plan),
or under no-fault insurance.” Medicare does not make claims payment
for future medical expenses associated with a settlement, judgment,
award, or other payment because payment “has been made” for such
items or services through use of LMSA or NFMSA funds. However,
Liability and No- Fault MSP claims that do not have a Medicare
Set-Aside Arrangement (MSA) will continue to be processed under
current MSP claims processing instructions.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9893.pdfhttps://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM9893.pdfhttp://www.gao.gov/products/GAO-12-333
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EDITION 40 ∙ SUMMER 2017 29© 2017 Copyright, CGS Administrators,
LLC.
Key Points of CR9893Medicare will not pay for those services
related to the diagnosis code (or related within the family of
diagnosis codes) associated with the open LMSA or NFMSA MSP record
when the claim’s date of service is on or after the MSP effective
date and on or before the MSP termination date. Your MAC will deny
such claims using Claim Adjustment Reason Code (CARC) 201 and Group
Code “PR” will be used when denying claims based on the open LMSA
or NFMSA MSP auxiliary record.
In addition to CARC 201 and Group Code PR, when denying a claim
based upon the existence of an open LMSA or NFMSA MSP record, your
MAC will include the following Remittance Advice Remark Codes
(RARCs) as appropriate to the situation:
y N723—Patient must use Liability Set Aside (LSA) funds to pay
for the medical service or item.
y N724—Patient must use No-Fault Set-Aside (NFSA) funds to pay
for the medical service or item.
Where appropriate, MACs may override and make payment for claim
lines or claims on which:
y Auto/no-fault insurance set-asides diagnosis codes do not
apply, or
y Liability insurance set-asides diagnosis codes do not apply,
or are not related, or
y When the LMSA and NFMSA benefits are exhausted/terminated per
CARC or RARC and payment information found on the incoming claim as
cited in CR9009.
On institutional claims, if the MAC is attempting to allow
payment on the claim, the MAC will include an “N” on the ‘001’
Total revenue charge line of the claim.
Additional InformationThe official instruction, CR9893, issued
to your MAC regarding this change, is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1845OTN.pdf.
The GAO report related to this issue is available at
http://www.gao.gov/products/GAO-12-333.
CR9009 is available at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R113MSP.pdf.
If you have any questions, please contact your MAC at their
toll-free number. That number is available at
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/.
Document HistoryDATE OF CHANGE DESCRIPTIONMay 10, 2017 The
article was revised due to the release of an updated Change Request
(CR). The CR
date, transmittal number and the link to the transmittal
changed.February 17, 2017 Initial article released
Disclaimer The above article was prepared as a service to the
public and is not intended to grant rights or impose obligations.
This article may contain references or links to statutes,
regulations, or other policy materials. The information provided is
only intended to be a general summary. It is not intended to take
the place of either the written law or regulations. We encourage
readers to review the specific statutes, regulations and other
interpretive materials for a full and accurate statement of their
contents. CPT only copyright 2016 American Medical Association. All
rights reserved.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1845OTN.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R1845OTN.pdfhttp://www.gao.gov/products/GAO-12-333https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R113MSP.pdfhttps://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R113MSP.pdfhttps://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/
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EDITION 40 ∙ SUMMER 2017 30© 2017 Copyright, CGS Administrators,
LLC.
Qualified Medicare Beneficiary Indicator in the Medicare
Fee-For-Service Claims Processing System
Link to current version on the CMS website:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles