Written Statements of Intent (SOI)

DMERC

Medicare

NewsDMERC Region A Service Office • P.O. Box 6800 • Wilkes-Barre, PA 18773-6800 • Phone (570) 735-9445 • www.medicare-link.com

Number 55 • September 2000 Edition

Written Statements of Intent (SOI)to Claim Medicare Benefits

This policy is effective for claims filing period ending December 31, 2000 (i.e., for services furnished fromOctober 1, 1998 through September 30, 1999 and is extended through January 2, 2001 because December 31,2000 is a federal non-workday).

Purpose of Statement of Intent

The purpose of a SOI is to extend the timely filingperiod for the submission of an initial claim. ASOI,by itself, does not constitute a claim, but rather isused as a placeholder for filing a timely and properclaim. Medicare regulations at 42 CFR §§424.32and 424.44 require that Medicare claims be filed onMedicare designated claim forms pursuant toMedicare instructions by the end of the yearfollowing the year in which the service(s) arefurnished (services furnished in the last 3 monthsof a calendar year are deemed to be furnished in thesubsequent year). The timely filing period to file aspecific Medicare claim may be extended when avalid SOI, with respect to that claim, is furnished tothe appropriate Medicare carrier or intermediary(i.e., the one that will be responsible for processingthe claim), or regional office (RO) serving the areaof the beneficiary’s residence within the timelyfiling period. (If a RO receives a SOI, it should datestamp the SOI and forward it to the appropriateMedicare contractor.)

A SOI to claim Medicare benefits must be post-marked on or before, or received by theappropriate RO or contractor, no later than the lastday of the timely filing period that pertains to theservice(s) covered by the SOI. (See §3305.3 of theMIM.) If someone wishes to simultaneouslysubmit more than one SOI to a RO, then he or shemust sort them by Medicare contractor before sub-mitting them. If a SOI contains the necessary

information for some services, but not for others,then the SOI will be accepted only for thoseservices for which the necessary information hasbeen submitted.

After a valid SOI has been filed, a completed claimthat meets the requirements of 42 CFR §424.32(a),§§3005- 3005.4 of the MCM, and §§3605.2-3605.3 ofthe MIM, must be submitted to the appropriateMedicare contractor within 6 months after themonth in which the contractor notifies the partywho submitted the SOI that a claim may be filed, orby the end of the applicable timely filing period,whichever is later. (The month in which the con-tractor notifies the party is determined by thedate of the contractor’s notification letter, unlessthe recipient of the notice can establish by a pre-ponderance of the evidence that the notice wassent on a materially different date. Also, “party”and “parties” are used herein in their genericsense, and are not meant to imply that an individ-ual or entity that submits a SOI to file hasstanding to file a claim or pursue an appeal of adenied claim.) In order to ensure that a filed claim,which is purportedly has been protected by a pre-viously submitted SOI (and, which would beuntimely if not so protected), does in fact relateback to the SOI, a SOI must be for an “identifiedbeneficiary” and for “specified services.” (See 42CFR §424.45(b).)

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In This Issue

Billing

Breathing Circuits – Billing Instructions · · · · · · · · · · · 7

Oxygen Modifiers · · · · · · · · · · · · · · · · · · · · · · 6

Seatlift Mechanisms · · · · · · · · · · · · · · · · · · · · 6

Written Statements of Intent (SOI) to Claim

Medicare Benefits· · · · · · · · · · · · · · · · · · · · · · 1

HCPCS

New NDC Numbers for Methotrexate and

Cyclophosphamide · · · · · · · · · · · · · · · · · · · · · 9

Medical Policy

Batteries for Power Wheelchairs and POVs · · · · · · · · 9

Flolan (Epoprostenol) – J1325 · · · · · · · · · · · · · · · 8

Immunosuppressive Drugs – DMERC Information Form · · 8

New Policy on Negative Pressure Wound Therapy· · · · · 8

Osteogenesis Stimulators· · · · · · · · · · · · · · · · · · 8

Oxygen Enriching Systems (E1405, E1406) · · · · · · · · 7

Tracheostoma Filters · · · · · · · · · · · · · · · · · · · · 7

Professional Relations

Announcements from the Professional Relations Unit · · 11

Appeals Analysis: HCPCS Code E0260 · · · · · · · · · 10

Contractor Updating of the International Classification

of Disease · · · · · · · · · · · · · · · · · · · · · · · · · 11

DMERCs to Attend Medtrade Show · · · · · · · · · · · · 12

Fall 2000 Continuing Education Workshops· · · · · · · · 10

SADMERC

Differences in Fee Schedule and Non-Fee Schedule

Items· · · · · · · · · · · · · · · · · · · · · · · · · · · · 12

SADMERC Website Training · · · · · · · · · · · · · · · 12

Supplier Notices

Correction: Coding of Clinitron Beds (SN 2000-20) · · · · 13

Delay in Third Quarter Release (SN 2000-21) · · · · · · 13

Facial Prosthesis Fee Schedule (SN2000-23) · · · · · · 15

Year 2000 Fee Revisions for L2405, L2415, L2425

and L2430 (SN 2000-22) · · · · · · · · · · · · · · · · · 14

This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.Bulletins issued after October 1, 1999 are available at no cost from our website at www.medicare-link.com.

2 DMERC Medicare News, No. 55 • September 2000

DMERC Region A Contacts

United HealthCare Region A DMERC (570) 735-9400

United HealthCare Region A DMERC Fax (570) 735-9402

Accounting (570) 740-9002

Accounting/MSP Fax (570) 735-9594

Beneficiary Help Line (570) 735-7383

Beneficiary Toll Free Help Line (800) 842-2052

EDI Fax (570) 735-9510

EDI Help Desk (570) 735-9429

Hearings Fax (570) 735-9422

Hearings Voice Mail (570) 735-9513

Medicare Secondary Payer (MSP) (570) 740-9001

National Supplier Clearinghouse (803) 754-3951

Professional Relations Fax (570) 735-9442

Professional Relations (570) 735-9666

Program Integrity Toll Free Line (888) 697-7849

Reconsiderations Fax (570) 735-9599

SADMERC (803) 736-6809

Supplier Help Line (570) 735-9445

Internet Address

Region A DMERC Office www.medicare-link.com

HCFA Office www.hcfa.gov

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(continued from page 1)

Note: The filing of an invalid SOI doesnot extend the timely filing period, sothat if a party submits an invalid SOIprior to the end of the timely filingperiod, and the contractor or the ROdoes not discover the invalidity andalert the submitter of the invalidity untilshortly before, or even after the timelyfiling period has expired, the party maynot correct or resubmit the SOI after thetimely filing period has expired. In thisregard, a party that submits an invalidSOI bears the full risk that he or she maybe unable to resubmit a valid SOIwithin the applicable timely filingperiod.

Medicare contractors are not required todevelop a claim under the SOI proce-dures. All claims for services must meetMedicare’s timely filing requirements.(See 42 CFR §424.44.) Timely filing re-quirements are further discussed in §3004of the MCM and in §§3307-3312.5 of theMIM.

Who Can Submit Statements ofIntent

Only the following parties may submit aSOI to claim Medicare benefits:

• Providers, as defined in 42 CFR§400.202, and parties to whom theymay assign their payment per 42 CFR§424.73, for items or services theyhave furnished or are entitled to billMedicare.

• Suppliers, as defined in 42 CFR§400.202, and parties to whom theycan reassign payment per 42 CFR§424.80, for items or services theyhave furnished or are entitled to billMedicare.

• Medicaid State agencies and partiesauthorized to act on behalf ofMedicaid State agencies, with respectto items and services rendered todually eligible beneficiaries.

• Beneficiaries and their authorizedrepresentatives, but only where theSOI relates to (1) a claim for servicesfurnished by a nonparticipatinghospital that has elected not to claimpayment for emergency services, or(2) a claim for services for which aphysician or other supplier, or properresignee, was required to file a claimunder §1848(g)(4) of the Act but hasnot done so.

Contents of a Valid Statement ofIntent

A SOI must be signed, and the personsigning must indicated the capacity inwhich he or she is signing (e.g., benefi-ciary or beneficiary’s authorizedrepresentative, provider, supplier,Medicaid State agency official, or partyauthorized to act on behalf of theMedicaid State agency).

For a SOI to be considered valid, it mustbe submitted to the appropriate contrac-tor, and if a provider or supplier (or theparty to whom payment can be assigned),or Medicaid State agency (or a party au-thorized to act on its behalf) submits aSOI, then the following information mustbe submitted with the SOI:

• Beneficiary name;

• Medicare Health Insurance Claim(HIC) number;

• Name, address, and Medicare billingnumber of provider/physician/supplier at time of service;

• Dates of service for which a specificclaim will be filed (dates must bereported in a manner that comportswith the Medicare claims filing in-structions; range of dates are accept-able only if a range of dates isproperly reportable on the Medicareclaim form); and,


DMERC Medicare News, No. 55 • September 2000 3

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• Applicable revenue, DRG, CPT,HCPCS or other applicable code, andappropriate modifiers for eachservice. (Codes must be reported in amanner consistent with the reportingof the codes on the Medicare claimform. Diagnosis codes by themselvesare not acceptable.)

In order for a SOI that is submitted to aRO to be valid, the SOI must include all ofthe above information, and must alsoinclude the correct name and address ofthe Medicare contractor that will be re-sponsible for processing the subsequentclaim or claims.

If a beneficiary or authorized representa-tive submits a SOI, it must be submittedto the appropriate contractor and mustinclude all of the information listedbelow.

• Beneficiary name;

• Medicare Health Insurance Claim(HIC) number;

• Name, address, and if available, theMedicare billing number of theprovider/physician/supplier at timeof service;

• Date(s) of service for which a specificclaim will be filed (dates must bereported in a manner that comportswith the Medicare claims filing in-structions; ranges of dates are accept-able only if a range of dates isproperly reportable on the Medicareclaim); and,

• Item(s) or service(s) received.

In order for a SOI that is submitted to aRO by a beneficiary or a beneficiary’s au-thorized representative to be valid, itmust include the information listedabove and also must include the nameand address of the Medicare contractorthat will be responsible for processing thesubsequent claim or claims.

Submitters may obtain the name andaddress of the appropriate Medicare con-tractor (i.e., Medicare carrier or fiscalintermediary) at the following website:

http://www.medicare.gov/contacts/contact1.asp

Claims Processing Instructionsfor Claims Submitted With aWritten Statement of Intent

Effective October 1, 2000, the Health CareFinancing Administration (HCFA) hasprovided instructions to intermediariesand carriers on processing claims where astatement of intent (SOI) was used toextend the timely filing period for sub-mission of claims. This is effective for theclaims filing period ending December 31,2000.

Part I, General Instructions toIntermediaries and Carriers onReceiving and Processing the SOI

Processing the SOI

The SOI should arrive at the appropriateMedicare contractor or be forwarded tothe correct Medicare contractor from theappropriate HCFA regional office. It isthe submitter’s responsibility to submitthe SOI to the appropriate Medicare con-tractor. If a contractor receives an SOIwhich should have been submitted to adifferent contractor, then that contractorshould return the SOI to the submitterwith instructions that they must forwardthe SOI to the appropriate contractor.

Contractors must return a letter of ac-knowledgment to the submitting entity,(provider, supplier, Medicaid StateAgency, or entity acting on behalf of theMedicaid State Agency, or beneficiary)upon receipt of a valid or invalid SOI(according to PM AB-00-43). Examples ofletters can be found in PM AB-99-100.Before sending out the acknowledgmentletter, the contractor will search history toassure that a claim has not previouslybeen submitted for these services.

The proper claimant then has six monthsafter the month in which the acknowledg-ment letter for a valid SOI is issued tosubmit a claim to Medicare (42 CFR424.45(c)). Contractors are not required todevelop a claim from the submitted SOI.Contractors will not solicit the submis-



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sion of claims from entities that havesubmitted SOIs.

Contractors must keep the SOI for aminimum of six months after the monthof acknowledgment of the claim, in orderto match the SOI with incoming claims.Contractors must be able to match thestatement of intent with the claim.

Part II, Processing of Claims Sub-mitted Beyond the Filing Deadline

Within six months after the month of theSOI acknowledgment letter, a valid claimform (either electronic or hardcopy) mustbe submitted in accordance withMedicare claims standards. When theclaim denies for dates of service beyondthe timely filing deadline, contractorsmust develop a way to determine if anSOI exists for this claim.

When a claim is submitted beyond thefiling deadline, the contractor will verifythat the six-month acknowledgmentletter time limit has not expired.

If more than six months have passed afterthe month of the SOI acknowledgmentletter, the claim will be denied.

If less than six months have passed, thecontractor will verify that a valid SOIexists. If a valid SOI does not exist, theclaim will be denied.

If the information on the claim does notmatch the information on the SOI, theclaim will be denied.

If the SOI was filed correctly and theclaim is submitted timely (within sixmonths after the month of the acknowl-edgment letter), the contractor willprocess the claim as usual, according tothe claims processing sections of theMedicare Intermediary Manual andMedicare Carriers Manual.

Special Coding Instructions

Some Medicare contractors have alreadydeveloped internal systems to handle thefunction of matching an SOI with a claim.

To facilitate this process:

• Effective October 1, 2000, modifierQQ has been approved for providers/suppliers to place on the claim at theline level. This modifier is defined as“service for which a statement ofintent was submitted, deemed asvalid, and an acknowledgment letterwas received.” The claim will bypassany late filing auto denials forservices with this modifier, and thecontractor will compare the serviceson the statement of intent with theservices on the claim. If the servicesdo not match, the contractor willdeny the service.

• Effective October 1, 2000, conditioncode H0 (zero) has been approved bythe National Uniform Bill ingCommittee to facilitate this process.When a claim comes in with thiscondition code, this signals to thesystem that an SOI exists for thisclaim before the claim is rejected fortimely filing. The claim will suspendthus allowing the contractor to verifythat an SOI exists for this claim. It isthe contractor’s responsibility todetermine if the SOI matches the in-formation on the claim. If the SOIdoes not match the informa-tion/service on the claim, or an SOIcannot be found, the claim will bedenied. If the SOI and the claimmatch, the claim will process asusual.

On the SOI acknowledgment letter, thesubmitter will be informed of the propermodifier or condition code. If thesubmitter of the SOI is not theprovider/supplier who will be submit-ting the claim, they must instruct theprovider/supplier to place one of thesecodes on the claim.



All SOI requests for theRegion A DMERC shouldbe sent to the attention ofBeth Chabala.

SOI requests for the claimfiling period endingDecember 31, 2000 must bereceived by January 2, 2001.

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Billing

Seatlift Mechanisms

Aseatlift mechanism is covered if allof the following criteria is met:

1. The patient must have severe arthri-tis of the hip or knee, or have a severeneuromuscular disease.

2. The seatlift mechanism must be apart of the physician’s course of treat-ment and be prescribed to effectimprovement, arrest, or retard deteri-oration in the patient’s condition.

3. The patient must be completely inca-pable of standing up from a regulararmchair or any chair in their home.

4. The fact that a patient has difficulty oris even incapable of getting up from achair, particularly a low chair, is notsufficient justification for a seatliftmechanism. Almost all patients whoare capable of ambulating can get outof an ordinary chair if the seat heightis appropriate and the chair has arms.

5. Once standing, the patient must havethe ability to ambulate.

The physician ordering the seatliftmechanism must be the attendingphysician or a consulting physician forthe disease or condition resulting in aneed for a seatlift. The physician’s recordmust document that all appropriate ther-apeutic modalities have been tried andfailed to enable the patient to transferfrom a chair to a standing position.

An order for a seatlift mechanism, signedand dated by the physician, must bereceived by the supplier prior to thedelivery of the item. A CMN completed,signed, and dated by the orderingphysician may be substituted for theorder if returned to the supplier prior todelivery. Otherwise, the prior completed

order and subsequent CMN must be kepton file by the supplier.

Please reference the Region A DurableMedical Equipment Supplier Manual PolicySection 14.5 Seatlift Mechanisms for anyadditional information.

Oxygen Modifiers

For dates of service on or afterJanuary 1, 2001, all oxygen claims

submitted to Region A DMERC musthave the correct modifiers included withthe HCPCS Codes.

The revised Oxygen policy (effective July1, 2000) states “The appropriate modifiermust be used if the prescribed flow rate isless than 1LPM (QE) or greater than4LPM (QF or QG).”

Modifiers Required:

QE Prescribed amount of oxygen isless than 1 liter per minute (LPM).

QF Prescribed amount of oxygen isgreater than 4 liters per minute(LPM) and portable oxygen is alsoprescribed.

QG Prescribed amount of oxygen isgreater than 4 liters per minute(LPM) and portable oxygen is notprescribed.

QH Oxygen conserving device is be-ing used with oxygen deliverysystem.

For all claims submitted with dates ofservice on or after January 1, 2001, thecorrect modifier must be used on oxygencodes. Claims submitted without amodifier or an incorrect modifier will bedenied. This denial will not have appealrights. A new claim submission will berequired.



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Breathing Circuits – Billing Instructions

Code A4618 describes the breathing circuit used with a volume ventilator (E0450)(see below). A breathing circuit is a series of hoses and connectors that deliver the

“breath” generated by the ventilator to the patient. Breathing circuits are not used withoxygen equipment or nebulizers, therefore, do not bill code A4618 as an accessory usedwith these devices.

While code A4618 describes a breathing circuit for use with a ventilator, it is not sepa-rately reimbursable since code E0450 is in the frequently serviced items paymentcategory. Claims for A4618, when billed with an E0450, will be denied as not separatelypayable.

Medical Policy

Oxygen EnrichingSystems (E1405, E1406)

Codes E1405 and E1406 describeoxygen and water vapor enriching

systems with or without heated delivery,respectively. The revised oxygen policyand a newsletter article published in June2000 stated that these codes were nolonger valid for claim submission to theDMERC. That decision is rescinded.Codes E1405 and E1406 may continue tobe submitted–but only for products forwhich a written coding determinationdated on or after July 1, 2000 specifyinguse of these codes has been made by theDMERC. At the present time, the onlyproduct that may be billed using codeE1405 or E1406 is the Oxygen Enrichermanufactured by the Oxygen EnrichmentCompany (OECO). If a manufacturer orsupplier has a different device that theybelieve qualifies for coding as E1405 orE1406, they should contact theSADMERC for a written coding determi-nation. Effective for claims with dates ofservice on or after December 1, 2000, allclaims for E1405 or E1406 must be accom-

panied by the manufacturer’s name andproduct name of the item provided. Thisinformation should be entered in the HA0record of an electronic claim or attachedto a hard copy claim.

Tracheostoma Filters

HCPCS Code A4481 (Tracheostomafilter, any type, any size, each)

describes a soft foam filter designed toprovide air filtration for the trachealstoma. In a recent publication (DMERCMedicare News, December 1998), a “usualmaximum” guideline of one A4481 perday was published. Effective for dates ofservice on or after October 1, 2000, this“usual maximum” parameter will beremoved.

Suppliers are reminded that there shouldbe documentation in the patient’smedical record supporting the number offilters ordered. The patient’s medicalrecord is not limited to the physician’soffice records. It may include hospital,



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nursing home, or home health agencyrecords, and records from other profes-sionals, including, but not limited to,nurses, physical or occupational thera-pists, prosthetists, and orthotists. Thisinformation does not have to be routinelysent to the DMERC, but must be madeavailable to the DMERC upon request.

New Policy on NegativePressure Wound Therapy

A new regional medical review policy onNegative Pressure Wound Therapy(NPWT) is being published in the accom-panying Region ADMERC Supplier Manualrevision. The policy is effective for dates ofservice on or after October 1, 2000.

Flolan (Epoprostenol) –J1325

A revision of the External InfusionPumps policy is included in the ac-

companying Region A DMERC SupplierManual revision. The only revision is inthe coverage criteria for epoprostenol(Flolan). The revised criteria represent anexpansion of the current publishedcriteria, and therefore, are effective forclaims with dates of service on or afterOctober 1, 2000.

Osteogenesis Stimulators

A revision to the OsteogenesisStimulators policy is published in

the accompanying Region A DMERCSupplier Manual revision. The descriptionof a fracture nonunion is being clarifiedby indicating that the required radio-graphs must show no clinical lysignificant healing. An article in theMarch 2000 Region A DMERC MedicareNews stated that until the wording ofquestion 6a on the Osteogenesis Stimula-tors CMN is revised to more clearlydescribe the new definition of a fracturenonunion, suppliers must attach a

specific statement to each CMN that issent to the physician. This statement isrevised to say: “For purposes ofanswering question 6a on the attachedCertificate of Medical Necessity (CMN), afracture nonunion is considered to existonly when a minimum of two sets of ra-diographs obtained prior to startingtreatment with the osteogenesisstimulator, separated by a minimum of 90days and each including multiple viewsof the fracture site, have been interpretedby a physician in writing as showing thatthere has been no clinically significantevidence of fracture healing between thetwo sets of radiographs. If this definitionof nonunion is not met, question 6a mustbe answered No.”

ImmunosuppressiveDrugs – DMERCInformation Form

A revision of the Immuno-suppressive Drugs policy is

included in the accompanying Region ADMERC Supplier Manual revision. TheDMERC Information Form (DIF) isrevised to include additional possibleresponses to question #5, which asks toidentify the organ that was transplanted.The new responses include (6) Wholeorgan pancreas, simultaneous with orsubsequent to a kidney transplant and (9)Other. If response (9) is given, the name ofthe organ transplanted must be entered inthe HA0 record of an electronic claim orattached to a hard copy claim. The Docu-mentation section of the policy wasrevised by eliminating one paragraphthat related to the use of the prior DIF.

There is a six-month “grace period” forthe use of the new DIF. Suppliers may useeither the old or new DIF for claimsreceived on or after October 1, 2000;however, use of the new DIF will berequired for claims received on or afterApril 1, 2001. Refer to the Immuno-suppressive Drugs policy for additionalinformation on Coverage and PaymentRules, Coding Guidelines, and Docu-mentation.



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Batteries for Power Wheelchairs and POVs

Effective for dates of service on orafter October 1, 2000, the DMERC

medical policy on Wheelchair Optionsand Accessories will be revised to allowpayment for gel cell and/or Group 24batteries for power wheelchairs if theyare ordered by a physician and are rea-sonable considering the patient’s use ofthe wheelchair. The paragraph in theCoverage and Payment Rules section ofthe policy concerning batteries will berevised to say:

“Up to two batteries (K0082-K0087) atany one time are allowed if required for apower wheelchair. Abattery is separatelypayable from the wheelchair base.”

Any type battery will also be covered if itis provided as a replacement in a POV, isordered by a physician, and is reasonableconsidering the patient’s use of the POV.When provided as a replacement in aPOV, batteries are coded E1399, and theclaim must include a description of thetype of battery provided. Batteries areincluded in the allowance for a POV andmust not be billed separately with theinitial issue of a POV.

HCPCS

New NDC Numbers for Methotrexate andCyclophosphamide

Suppliers are currently instructed to bill oral anticancer drugs to the DMERCs usingthe appropriate National Drug Code (NDC) number.

Five additional NDC numbers have been added for methotrexate products:

Methotrexate, 2.5 mg, oral (NDC #00005-4507-04)





Two additional NDC numbers have been added for cyclophosphamide products:

Cyclophosphamide, 25 mg, oral (NDC #00054-4129-25)

Cyclophosphamide, 50 mg, oral (NDC #00054-4130-25)

These numbers are valid for claims with dates of service on or after October 1, 2000.



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Professional Relations

Fall 2000 Continuing Education Workshops

Region A DMERC announces the Fall 2000 continuing education workshops. Thetopics for the workshops are: Mobility, Parenteral & Enteral Nutrition, and

EDI/HIPAA. Each session will also include updates from Region A, noting recentchanges affecting DMERC Medicare policy. During these sessions, suppliers will havethe opportunity to receive information and instruction on each topic. Stay tuned foradditional information regarding workshop dates, locations, and registration.

Appeals Analysis: HCPCS Code E0260

The Region A DMERC has recentlycompleted its analysis of claims

appealed and overturned for the thirdquarter of Fiscal Year 2000. Through thisresearch, the DMERC has noted that alarge volume of previously denied claimssubmitted for semi-electric hospital beds,HCPCS code E0260, have been over-turned through appeal. It has beenidentified that initial denials resulted dueto a lack of required documentation.

HCPCS code E0260 is described as ahospital bed, semi-electric (head and footadjustment), with any type of side rails,with mattress. Chapter 14.15 of theRegion A DMERC Supplier Manualprovides instruction to suppliersregarding coverage and payment forthese items of DME. “If the documenta-tion does not support the medicalnecessity of a semi-electric bed, but doessupport the necessity of a lower level bed,the payment will be based on theallowance for the least costly alternative.”(p. 14.15-2)

Additionally, please be sure to attach theproper modifier when submitting claimsfor HCPCS E0260, a capped rental item.

Modifiers applicable to monthly billingfor hospital beds and other capped rentalitems include:

KH DMEPOS item, initial claim, pur-chase or capped rental,

KI DMEPOS item, second or thirdmonth rental,

KJ DMEPOS item, parenteral enteralnutrition pump (PEN) or cappedrental, months four to fifteen.

Please note that additional modifiers arerequired by the DMERC in order to accu-rately record the beneficiary’s election topurchase or continue renting the item.These are denoted as BP, BR and BU.

Region A urges all suppliers to reviewChapter 5.3, Modifiers, in the Region ADMERC Supplier Manual for thorough in-struction on the usage of modifiers.Additionally, you may choose to reviewSupplier Notices 98-16 and 98-22 for ad-ditional information on modifiers. Pleasenote, each of the above references isavailable through our web site,www.medicare-link.com.



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Contractor Updating of the International Classificationof Diseases, Ninth Revision, Clinical Modification(ICD-9-CM)

Beginning October 1, 2000, providers may begin using the updated ICD-9-CM codesfor claims submitted on or after October 1; the updated diagnostic codes must be

used for professional services billed on or after January 1, 2001.

The DMERC is required to accept both old and new ICD-9-CM codes for claims receivedOctober 1 through December 31, 2000. This grace period gives providers sufficient timeto obtain and integrate the latest version of the ICD-9-CM codes into their billingsystem. It is important for providers to use the most recent version of the ICD-9-CMcoding book and to code to the highest level of specificity.

ICD-9-CM books can be obtained from:American Medical Association 1-800-621-8335Channel Publishing 1-800-248-2882Medicode 1-800-999-4600Any medical bookstore

Announcements from the Professional Relations Unit

The Professional Relations Unit is pleased to announce the following newappointments:

Laurie Kulak has assumed the responsi-bilities of Ombudsman for the states ofMaine, New Hampshire, Rhode Island,and Vermont. Laurie’s Product/ProcessFocus Group (P/PFG) is the Respiratorycategory. Laurie has six years of experi-ence as a Respiratory Care Practitioneralong with experience in training, imple-menting policy and procedure, andutilization.

Mary Jo George Rouè has replaced DavidFiorini as the Ombudsman for the statesof Connecticut and Massachusetts. MaryJo’s P/PFG category is the Orthotics andProsthetics category. Mary Jo has anextensive background in health servicesadministration, holding variouspositions in the healthcare industry.Mary Jo’s experience includes being re-sponsible for agency and providerrelations offering healthcare-relatededucation and administration of variousprograms.

David Fiorini has assumed the position ofBeneficiary Ombudsman for Region A;his state territory will be announced at alater date.

Jean Gober has replaced Paul Komishockas the Ombudsman for the states ofDelaware and New Jersey. Jean’s P/PFGcategory is the Specialized DME category.Jean has been associated with theDMERC for one year as a CustomerService Representative in ProviderServices. Jean also has a history of experi-ence in the health care industry, includingbilling for physician services andproviding onsite education in diagnosticlaboratory testing.

Marion Gaynor will assume the positionof the DMERC Congressional Liaison.Marion has been associated with theDMERC for seven years primarily in theCorrespondence Unit. The effective datefor Marion’s new position has yet to bedetermined.



Please join us in welcomingthe new team members of theProfessional Relations Unit.

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DMERCs to Attend Medtrade Show

The four Durable Medical Equipment Regional Carriers (DMERCs) will attend theMedtrade 2000 Exposition and Conference being held October 3 –5, 2000 in Orlando,

Florida. All four Regions will again share booth space and present at the DMERCVendor Conference on October 5, 2000. This joint effort by the DMERCs gives thesupplier community an opportunity to interact with all four DMERCs in one location.Please visit the DMERCs at booth 3854.

SADMERC

These articles were submitted by the SADMERC. Any questions regarding these articles shouldbe directed to the SADMERC.

Differences in FeeSchedule and Non-FeeSchedule Items

The Statistical Analysis DurableMedical Regional Carrier ’s

(SADMERC) primary responsibility is toassist suppliers with coding requests forthe four Durable Medical EquipmentRegional Carriers (DMERC). SADMERCalso provides suppliers with Medicare al-lowances for codes in the DMEPOS FeeSchedule.

The SADMERC cannot answer pricingquestions for codes that are individuallyconsidered, priced by reasonable charge,or which have no fee schedule amount es-tablished. Examples of non-fee scheduleitems include:

• Drugs

• Therapeutic Shoes for Diabetics

• Enteral and Parenteral Nutrition

• Miscellaneous Codes (E1399, L2999,L3999, K0108 etc.)

Requestors of pricing for non-feeschedule codes will be referred to theirDMERC for pricing information.

SADMERC WebsiteTraining

The SADMERC added a new tutorialto their website. This instruction

provides the user with information aboutthe SADMERC. It will guide suppliers,the DMERCs, and any other HCPCS codeusers on the functions of the SADMERC.Please visit the SADMERC at thefollowing address:

http://www.pgba.com./palmetto/main.nsf/allframesets/oth_sadm.html



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Supplier Notices

The information contained in the Supplier Notices was accurate at the time of original publication.Some of the contents may have since been updated or changed.

Correction: Coding ofClinitron Beds

Supplier Notice 2000-20

June 12, 2000

The correct HCPCs code for billing theClinitron At-Home and the Clinitron Elexisis E0194. Since September 1999, theDMERC has published these productswithin the Group II Support Surface Classi-fication List in the Appendices section ofthe Region A DMERC Supplier Manual asE0193.

Please note: The E0194 is a Group IIISupport Surface; the DMERC does notinclude Group III codes in the Appendicessection of the supplier manual. The Ap-pendices section of the June 2000 suppliermanual revision #14 has been updated toreflect this correction. Please be sure toupdate your manuals when you receivethis revision.

The DMERC apologizes for any inconve-nience this may have caused.

Delay in Third QuarterRelease


June 30, 2000

Due to a HCFA delay, the CY 2000 thirdquarter Common Working File (CWF) andMedicare Claims Processing StandardSystems release is targeted for implementa-tion on August 14, 2000. Because of the delayof the 3rd quarter release, we are advisingsuppliers of the following:

Oral Anticancer Drugs (June 2000 DMEMedicare News, page 5) Update:

As previously published in the March 2000newsletter, suppliers should continue to billusing the J8999 code for busulfan andtemozolomide. Include the name of thedrug, the NDC code, and the numberdispensed in the HAO record of an elec-tronic claim and attached to a hard copyclaim.

Effective for claims received on or afterAugust 14, 2000, suppliers should bill forthese oral anticancer drugs using the in-structions published on page five of the June2000 DMERC Medicare News.



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Year 2000 Fee Revisions for L2405, L2415, L2425 and L2430


August 3, 2000

It was brought to our attention that the fee for code L2430 wasestablished using the wholesale and not the retail price list. Inexamining this code we decided to review the other sequenceof “Addition to knee joint” codes. The base fees for codesL2405, L2415 and L2425 were initially gap-filled by theprevious local carriers. The result of this review increasedbase fees for codes L2405 and L2430. The current fees forcodes L2415 and L2425 were found to actually reflect the costof a pair of joints instead of per each joint, as described by thecodes listed below. Therefore, the base fees for these twocodes will decrease.

The Region A DMERC revised the year 2000 fees for all fourcodes for claims with dates of service January 1, 2000 andafter that are processed on or after July 1, 2000. The revisedfees for these codes were developed using available pricelists.

L2405 Addition to knee joint, drop lock, each joint

L2415 Addition to knee joint, cam lock (Swiss, French,bail types) each joint.

L2425 Addition to knee joint, disc or dial lock for adjust-able knee flexion, each joint.

L2430 Addition to knee joint, ratchet lock for active andprogressive knee extension, each joint

The chart below reflects the revised base fees including thefinal fees implemented on July 1, 2000.

Note: Inclusion or exclusion of an allowable amount for anitem or service does not imply Medicare coverage.

Code State Current Revised RevisedBase Fee Base Fee 2000 Fee

L2405 CT $20.00 $54.94 $64.69DE $29.69 $54.94 $64.69MA $19.32 $54.94 $64.69ME $19.63 $54.94 $64.69NH $18.81 $54.94 $64.69NJ $29.69 $54.94 $64.69NY $36.25 $54.94 $64.69PA $30.11 $54.94 $64.69RI $19.53 $54.94 $64.69VT $19.04 $54.94 $64.69







If you have any questions regarding these changes, pleasesend them to:

United HealthCare Medicare Region AMedicare ReimbursementPO Box 6800Wilkes-Barre, Pennsylvania 18773



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Facial Prosthesis Fee Schedule


August 3, 2000

Listed below are year 2000 fee schedules for the facial prostheses codes. When a replacement prosthesis is fabricated startingwith a new impression/moulage, use the KM modifier. When a replacement prosthesis is fabricated using a previous mastermodel, use the KN modifier. When a replacement involves a new impression/moulage (KM) rather than use of a previousmaster model (KN), the reason for the new impression/moulage must be clearly documented in the supplier’s records and beavailable to the DMERC on request. Please refer to your Region A DMERC Supplier Manual, Chapter 16, for the Facial Prosthe-ses policy.

K0440 K0441 K0442 K0443 K0444 K0445 K0446 K0447

CT 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99DE 1509.26 1819.16 2044.01 2289.28 2534.56 1769.32 1635.20 838.06MA 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99ME 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99NH 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99NJ 1645.99 1983.94 2229.14 2496.64 2764.13 1737.57 1783.31 913.95NY 1645.99 1983.94 2229.14 2496.64 2764.13 1737.57 1783.31 913.95PA 1509.26 1819.16 2044.01 2289.28 2534.56 1769.32 1635.20 838.06RI 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99VT 1584.77 1910.25 2146.34 2403.92 2661.46 1673.19 1717.08 879.99

K0440KM K0441KM K0442KM K0443KM K0444KM K0445KM K0446KM K0447KM


K0440KN K0441KN K0442KN K0443KN K0444KN K0445KN K0446KN K0447KN




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DMERC Medicare News

United HealthCare Insurance Company • P.O. Box 6800 • Wilkes-Barre, PA 18773-6800

Suppliers: This newsletter should be directed to your billing manager.

Bulk RateU.S. POSTAGE

PAIDHartford, Conn.Permit No. 2320

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Written Statements of Intent (SOI)

Documents