DMERC MEDICARE ADVISORY

Transcription

1 Palmetto GBA DMERC MEDICARE ADVISORY Durable Medical Equipment Regional Carrier PO Box Columbia SC Winter 2003 Issue 47 Page IN THIS ISSUE Cervical Traction Devices Comprehensive Error Rate Testing Fee Updates 2003 Fourth Quarter Drug Fee Update Fourth Quarter Oral Anti-Cancer Drug Fees DMEPOS Fee Schedule and Reasonable Charge Updates Region C Reasonable Charge Payment Limits: Therapeutic Shoes and Inserts HIPPA CMS Webcast Presentation: Free HIPPA Training Contingency Plan for HIPPA Transaction and Code Sets Supplemental ANSI 276/277 v4010a Home Health Consolidated Billing: 2004 Update Billing Code Lists Home Health Consolidated Billing Correction for HCPCS Code A Medicare Secondary Payer: Individuals Not Subject to the Limitation on Payment Streamlining of Claims Crossover Process Medical Affairs Bulletins Classification of Walkers and Gait Trainers Completion of Medicare Certificates of Medical Necessity Face Down Positioning Devices Home Dialysis Supplies & Equipment: HCPCS Code Changes & Modifier AX Requirement on New HCPCS Codes ICD-9 Coding Issues Knee Orthoses: Locking Mechanisms Knee Orthoses: New HCPCS Code and Clarification of HCPCS Codes L1832 and L Negative Pressure Wound Therapy Pumps Notification of Product Changes to the SADMERC Orthoses: Coding Classification Orthoses: of Components..117 RAD & CPAP Policy Revisions Repairs/ Chart Refractive Lenses Local Medical Review Policy: New and Revised HCPCS Codes Respiratory Assist Device/Ventilator: Coding Clarification Saline and Water: HCPCS Code Changes Surgical Dressings Containing Silver Wheelchair Options and Accessories Appeal Reminders DMEPOS Information Resource EDI Technical Support Update Financial Control Numbers (FCNs) NSC Supplier Standards Ombudsman Addresses & Territories Online Event Enrollment Online Workshop Schedule Quarterly Provider Update Region C Directory Register on the Palmetto GBA Web Site Review Request Guideline Reminders Team Tips CERVICAL TRACTION DEVICES A draft LMRP for Cervical Traction Devices (L14074) is available for comments on the Palmetto GBA Web site until December 19, 2003 at the following location: WHEELCHAIR OPTIONS AND ACCESSORIES The 2004 HCPCS Update contains many new HCPCS codes for wheelchair options and accessories which are effective for dates of service on or after January 1, A revision of the LMRP on Wheelchair Options and Accessories incorporating the changes is included on the Palmetto GBA web site. The Revision History section of the policy lists the HCPCS codes that were changed. A number of HCPCS codes will also be discontinued effective January 1, Under the stan- HOME HEALTH CONSOLIDATED BILLING CODE LISTS INSIDE MEDICARE Palmetto GBA Alabama Arkansas Colorado Florida Georgia Kentucky Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee Texas Virgin Islands Comments and suggestions are welcome. Please direct them to Communications Specialists in the Professional Relations Department at the address listed above.

2 Page 116 WHEELCHAIR OPTIONS AND ACCESSORIES cont. Winter 2003 DMERC Medicare Advisory dard grace period, these HCPCS codes will continue to be accepted on claims with dates of service on or after 1/1/04 that are received by 3/31/04. Claim lines with these HCPCS codes with dates of service on or after 1/1/04 that are received on or after 4/1/04 will be rejected as invalid coding. The discontinued HCPCS codes should continue to be used for claims with dates of service prior to 1/1/04 regardless of the date of claim submission. Detailed definitions for many of the new HCPCS codes are included in the Coding Guidelines section of the policy. The definitions are meant to be broadly inclusive. All related components are included in the codes and should generally not be billed separately unless specifically allowed in the definition or description of a HCPCS code. If the supplier chooses to bill separately for an included component, HCPCS code A9900 (miscellaneous DME supply, accessory and/or service component of another HCPCS code) must be used and will be denied as not separately payable. If an included component is billed with the miscellaneous HCPCS code K0108, that claim line will be rejected as incorrect coding. Although the new HCPCS codes are only valid for dates of service on or after January 1, 2004, suppliers are encouraged to use the new categorization of accessories on claims for K0108 with dates of service in 2002 and Suppliers could use the narrative description of the new HCPCS code and/or enter the new HCPCS codes along with the narrative description of the item billed using K0108. This will result in more consistent processing and pricing of these accessories. The new HCPCS codes revise the definition of nonstandard seat frame dimensions for adult manual and power wheelchairs. HCPCS codes E2201-E2204 and E2340-E2343 define nonstandard seat width and/or seat depth as being 20 inches or greater. As a result of this, effective for dates of service on or after 1/1/04, the definitions of standard seat widths and depths for adult wheelchair bases in the Manual Wheelchairs and Motorized/Power Wheelchairs LMRPs are being revised. The new definitions are as follows: Seat width: inches Seat depth: inches Wheelchairs with seat widths and/or depths of 14 inches or less should be billed using HCPCS codes E1231-E1238 for pediatric manual wheelchairs or HCPCS code K0014 for pediatric power wheelchairs. New codes E1019 and E1021 are invalid for claim submission to the DMERC. Suppliers should contact the SADMERC with any questions concerning the correct coding of these items. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

3 Winter 2003 DMERC Medicare Advisory Page 117 COMPLETION OF MEDICARE CERTIFICATES OF MEDICAL NECESSITY Dear Physician: Certificates of Medical Necessity, commonly known as CMNs, are documents used by the DMERCs to assist in gathering information about the medical necessity of an item. It is your responsibility to determine both the medical need for, and the utilization of, all healthcare services. Suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) are your partners in caring for your patient. They will not receive payment for their services until you return the completed, signed and dated CMN. If you have ordered equipment or supplies as part of your patient's treatment plan, completing the CMN accurately and in a timely manner helps insure that your treatment plan will be carried out. Moreover, your cooperation is a legal requirement as outlined in the Social Security Act, the law governing Medicare. Section 1842(p)(4) of the Act provides that: [i]n case of an item or service ordered by a physician or a practitioner but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner. Remember, everyone has tight cashflow these days - help your DMEPOS supplier continue to provide good service to your patients by prompt completion and return of the CMN. ORTHOSES of Components Clarification The allowance for a prefabricated orthosis includes all components provided at the time of initial issue including, but not limited to, soft interfaces, straps, closures, etc. of components of covered orthoses are covered if the original component is no longer functional due to wear and cannot be repaired. components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered. Some replacement items have unique HCPCS codes. For example, replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with HCPCS codes L4392 and L4394, respectively. One unit of service of the replacement interface HCPCS code is covered no more often than once every 6 months. components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L1499, L2999, or L3999, whichever is applicable. The claim must include a description of the component provided, the reason for replacement, and the HCPCS code or narrative description of the base orthosis. Note: HCPCS codes L4040-L4055 do not describe replacement soft interfaces used with contracture orthoses. Questions concerning the coding of specific items should be directed to the SADMERC. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

4 Page 118 ORTHOSES Coding Clarification Winter 2003 DMERC Medicare Advisory Orthoses are described by base HCPCS codes that represent either prefabricated or custom fabricated braces. There are also HCPCS codes that describe variations or modifications of base orthoses. These usually begin with the phrase "Addition to." Use of and payment for the variation/addition codes are limited to custom fabricated orthoses. If these add-on codes are billed with prefabricated orthoses, they will be denied as incorrect coding. Questions concerning whether specific HCPCS codes describe prefabricated or custom fabricated orthoses or additions to orthoses should be directed to the SADMERC. RESPIRATORY ASSIST DEVICE/ VENTILATOR Coding Clarification Any product presented to the SADMERC for coding as a respiratory assist device (RAD) will be coded to the product's highest capabilities. However, coverage by the DMERCs will be determined by what is ordered and how the device is used. Similar principles would also apply to coding and coverage of a ventilator. For details on billing these items, please see the Winter 2001 Medicare Advisory article entitled "New Procedures to Use the ABN Form for DMEPOS Upgrades" (page 84-85). ICD-9 CODING ISSUES The SADMERC is not responsible for issuing diagnosis codes such as ICD-9 codes for diagnosis. Please contact the physician or consult the ICD-9 reference book for these codes. Surgical Dressings Containing Silver If surgical dressings are impregnated with or otherwise incorporate drugs, coding of the dressing is based on the other materials and features of the product without regard to the drug. This principle is applied to the coding of dressings containing silver. If the other material meets the definition of a dressing (e.g., gauze, foam), the product must be billed using one of those HCPCS codes. If the other material serves only to deliver silver to the wound and does not meet the definition of a dressing, the product must be billed with HCPCS code A9270, noncovered item or service. HCPCS code A4649 must not be used for silver-containing dressings. Questions concerning the coding of specific products should be directed to the SADMERC. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

5 Winter 2003 DMERC Medicare Advisory Page 119 NOTIFICATION OF PRODUCT CHANGES TO THE SADMERC The SADMERC maintains current and accurate product information. It is therefore necessary that if there are any of the following changes to products, which have gone through the formal Coding Verification Review process and received a written determination, the manufacturer or the distributor is responsible for the notification process. When a product has been discontinued, the SADMERC must be notified in writing of the discontinuance and the effective date of the discontinuance. When a change in the product name occurs, the manufacturer or the distributor must notify the SADMERC of the name change and verify that the product itself has not been altered. If a manufacturer has sold the product line to another company, this information must be submitted to the SADMERC, along with appropriate documentation that the acquisition has been accomplished. If any of the components of a product have been changed, the product must be submitted to the SADMERC for a new verification review to ensure that the product still meets the definition and characteristics of the existing HCPCS code. If the product change alters the product in such a way that it no longer meets the existing HCPCS code, then the SADMERC will determine and assign a current HCPCS code. For questions, contact the SADMERC Product Review at FACE DOWN POSITIONING DEVICES Following vitrectomy and certain other eye surgery procedures, patients are instructed to position themselves with their face down through most of the day. There are certain devices that facilitate this positioning. Examples (not all-inclusive) are a face cushion that is attached to a frame that can rest on a table or be positioned on a bed or a cushion pad that is attached to a chair-like device. CMS has confirmed that these devices are statutorily noncovered because they do not fall within a Medicare benefit category. The reasons are that they are considered "precautionary devices" and also the equipment can be used for purposes other than the treatment of an illness or injury. The denial is a noncoverage denial, not a medical necessity denial. The face cushion and frame should be coded as A9270 for dates of service prior to January 1, 2004 and as E0190 (positioning cushion/pillow/wedge, any shape or size) for dates of service on or after January 1, The chair-like device should be coded as A9270. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

6 Page 120 Winter 2003 DMERC Medicare Advisory CLASSIFICATION OF WALKERS AND GAIT TRAINERS A gait trainer is a term used to describe certain devices that are used to support a patient during ambulation. CMS has determined that gait trainers serve the same purpose as walkers. Therefore, when billing Medicare for a gait trainer, the appropriate walker HCPCS code E0130, E0135, E0140 E0141, E0143, E0144, E0147, E0148 or E0149 must be used. If a gait trainer has a feature described by one of the walker attachment HCPCS codes (E0154-E0157) that code may be separately billed. Other unique features of gait trainers are not separately payable and may not be billed with HCPCS code E1399. If a supplier chooses to bill separately for a feature of a gait trainer that is not described by a specific HCPCS code, then HCPCS code A9900 (miscellaneous DME supply, accessory, and/or service component of another HCPCS code) must be used and the claim line will be denied as not separately payable. RAD & CPAP POLICY REVISIONS HCPCS Codes Effective for dates of service on or after January 1, 2004, the following permanent codes replace temporary codes in the Continuous Positive Airway Pressure (CPAP) Devices and Respiratory Assist Devices (RAD) local medical review policies (LMRP): Policy Group New HCPCS Code Replaces RAD E0470 K0532 RAD E0471 K0533 RAD E0472 K0534 CPAP & RAD E0561 K0268 CPAP & RAD E0562 K0531 The K HCPCS codes will be discontinued for dates of service on or after January 1, Under the standard grace period, HCPCS codes K0532, K0533, K0534, K0268 and K0531 will continue to be accepted on claims with dates of service on or after January 1, 2004 that are received by March 31, Claim lines for HCPCS codes K0532, K0533, K0534, K0268 and K0531 with dates of service on or after January 1, 2004 that are received after March 31, 2004 will be returned as unprocessable or denied as incorrectly coded. The K HCPCS codes should continue to be used on claims for dates of service prior to January 1, 2004, regardless of the date of claim submission. In addition, effective for dates of service on or after January 1, 2004, the following new HCPCS code is created: A7046 water chamber for humidifier, used with positive airway pressure device, each These codes are incorporated in revisions of the RAD and CPAP LMRP that are posted on the Palmetto GBA web site. Definitions: In the LMRP for CPAP and RAD, the Other Comments section currently specifies that the diagnosis of obstructive sleep apnea requires This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

7 Winter 2003 DMERC Medicare Advisory Page 121 RAD & CPAP POLICY REVISIONS HCPCS Codes cont. that the apnea-hypopnea index (AHI) be calculated based on a minimum of two hours of sleep without the use of a positive airway pressure device. The LMRPs are revised, effective January 1, 2004, to delete the requirement that the polysomnogram demonstrate two hours of recorded sleep and will read as follows: The apnea-hypopnea index (AHI) is defined as the average number of episodes of apneas and hypopneas per hour and must be based on a minimum of two hours of recording time without the use of a positive airway pressure device, reported by polysomnogram. The AHI may not be extrapolated or projected. These revisions are made as a result of comments and suggestions from the clinical community in sleep medicine. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

8 Page 122 HOME DIALYSIS SUPPLIES & EQUIPMENT HCPCS Code Changes & Modifier AX Requirement on New HCPCS Codes Winter 2003 DMERC Medicare Advisory Effective for dates of service on or after January 1, 2004, the following HCPCS code changes; revisions and deletions are implemented for the Home Dialysis Supplies and Equipment local medical review policy (LMRP): New HCPCS codes that require AX Modifier A4216 A4217 A4248 Sterile Water/Saline, 10 ML Sterile Water/Saline, 500 ML Chlorhexidine Containing Antiseptic, 1 ML Providers are reminded that the AX modifier must be used when specified items are furnished in conjunction with home dialysis supplies and equipment. Please refer to the Home Dialysis Supplies & Equipment local medical review policy. New HCPCS codes that do not require AX Modifier A4728 Dialysate Solution, Non-dextrose Containing, 500 ML A4671 Disposable Cycler Set Used with Cycler Dialysis Machine, Each A4672 Drainage Extension Line, Sterile, for Dialysis, Each A4673 Extension Line With Easy Lock Connectors, Used with Dialysis A4674 Chemicals/Antiseptics Solution Used To Clean/Sterilize Dialysis Equipment, Per 8 OZ E1634 Peritoneal Dialysis Clamps, Each Deleted HCPCS codes A4712 Sterile Saline or Water 30 CC Vial K0610 Peritoneal Dialysis Clamps, Each K0611 Disposable Cycler Set Used for Dialysis, Each K0612 Drainage Extension Line, Sterile for Dialysis, Each K0613 Extension Line with Easy Lock Connectors, Used with Dialysis K0614 Chemicals/Antiseptics Solution Used to Clean/Sterilize Dialysis Equipment, Per 8 Oz Under the standard grace period, the deleted HCPCS codes (A4712, K0610, K0611, K0612, K0613 and K0614) will continue to be accepted on claims with dates of service on or after January 1, 2004 that are received by March 31, Claims billed with dates of service on or after January 1, 2004 that are received on or after April 1, 2004 will be denied or rejected as invalid coding, HCPCS codes A4712, K0610, K0611, K0612, K0613 and K0614 should continue to be used on claims with dates of service prior to January 1, 2004, regardless of the date of claim submission. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

9 Winter 2003 DMERC Medicare Advisory Page 123 SALINE AND WATER HCPCS Code Changes The following codes will be discontinued effective January 1, The table shows the LMRP in which in each HCPCS code is currently included: Policy A4214 A4319 A4323 A4712 A7019 A7020 Sterile saline or water, 30 cc vial Suction Pumps Sterile water irrigation solution, 1000 ml Sterile saline irrigation solution, 1000 ml Water, sterile, for injection, per 10 ml Saline solution, per 10 ml, metered dose dispenser, for use with inhalation drugs Sterile water or sterile saline, 1000 ml, used with large volume nebulizer Urological Supplies Suction Pumps Urological Supplies Home Dialysis Supplies and Equipment Nebulizers Nebulizers Under the standard grace period, these HCPCS codes will continue to be accepted on claims with dates of service on or after 1/1/04 that are received by 3/31/04. Claim lines with these HCPCS codes with dates of service on or after 1/1/04 that are received on or after 4/1/04 will be rejected or denied as invalid coding. These codes should continue to be used for claims with dates of service prior to 1/1/04 regardless of the date of claim submission. Effective for date of service on or after January 1, 2004, the following new HCPCS codes have been established for sterile saline or water for uses other than infusion: A4216 Sterile water/saline, 10 ml A4217 Sterile water/saline, 500ml When HCPCS code A4216 or A4217 is used as a dialysis supply, the AX modifier must be added to the code. When HCPCS code A4217 is used as a urological supply, the AU modifier must be added to the HCPCS code. These modifiers are not used when HCPCS code A4216 or A4217 is used as a suction pump or nebulizer supply. The following HCPCS codes, which are included in the Nebulizers policy, remain valid: A7018 Water, distilled, used with large volume nebulizer, 1000 ml J7051 Sterile saline or water, up to 5 cc The code changes will be incorporated into the relevant LMRPs in a future Supplier Manual update. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

10 Page 124 KNEE ORTHOSES New HCPCS Code and Clarification of Codes L1832 and L1845 Winter 2003 DMERC Medicare Advisory Effective for dates of service on or after January 1, 2004, a new HCPCS code has been established for a knee orthosis: L1831 Knee orthosis, locking joint(s), positional orthosis, prefabricated, includes fitting and adjustment This HCPCS code describes a knee orthosis which has double uprights and a locking joint for positioning the knee. This joint locks the knee into a particular position either in flexion or extension. This orthosis is designed for a patient who is nonambulatory. It is typically used to treat a flexion contracture of the knee. It is important to distinguish this HCPCS code from two other existing HCPCS codes for knee orthoses, L1832 and L1845 HCPCS code L1832 describes a prefabricated knee orthosis that has double uprights and adjustable flexion and extension joints. An adjustable flexion and extension joint is one which enables the practitioner to set limits on flexion and extension but allows the patient free motion of the knee within those limits. The joints can be unicentric or polycentric. Medial-lateral control of the knee is accomplished by way of the solid metal (or similar material) structure of the double uprights. It may have condylar pads. This orthosis is designed for a patient who can bear weight on the knee and is capable of some ambulation. It is typically used for early rehabilitation following knee surgery. HCPCS code L1845 describes a prefabricated knee orthosis that has double uprights, condylar pads, and an adjustable flexion and extension joint (as described above) and provides both medial-lateral and rotation control. The joint can be unicentric or polycentric. The function of the joint is to control flexion and extension of the knee joint. Medial-lateral control of the knee is accomplished by the solid metal (or similar material) structure of the double uprights. Rotation control is accomplished by the combination of (1) solid metal (or similar material) in the anterior portion of the thigh and calf cuffs and (2) the condylar pads. Rotation of the knee joint occurs during weight bearing and ambulation. This orthosis is designed for a patient who is fully ambulatory. KNEE ORTHOSES Locking Mechanisms Effective for dates of service on or after January 1, 2004, the description of HCPCS code L2405 is revised as follows: L2405 Addition to knee joint, lock; drop, stance or swing phase, each joint This code includes not only simple drop locks that the patient must lift to unlock the knee but also includes other manual locks, including but not limited to the Becker G-Knee and Becker Load Response Knee, as well as locks that automatically unlock in response to the patient's gait, including but not limited to the Basko (Fillauer) Swing Phase Lock, Becker UTX knee joint, Becker E-Knee, Horton Stance Control Orthotic Knee Joint, and Otto Bock Free Walk knee joint. HCPCS code L2999 must not be used to code these knee joints. If it is, the claim line will be rejected or denied as incorrect coding. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

11 Winter 2003 DMERC Medicare Advisory Page 125 REFRACTIVE LENSES LOCAL MEDICAL REVIEW POLICY Effective for dates of service on or after January 1, 2004, the following HCPCS code changes will apply to the Refractive Lenses LMRP: New and Revised HCPCS Codes Deleted Code V2116 V2117 V2216 V2217 V2316 V2317 V2740 V2741 V2742 V2743 Crosswalk to New Code V2121 (Lenticular lens, per lens, single) V2221 (Lenticular lens, per lens, bifocal) V2321 (Lenticular lens, per lens, trifocal) V2745 (Addition to lens, tint, any color, solid, gradient or equal, glass, plastic or equal, excludes photochromatic, any lens material, per lens) The following HCPCS codes will be discontinued effective for dates of service on or after January 1, 2004: V2116, V2117, V2216, V2217, V2316, V2317, V V2743. Under the standard grace period, these codes will continue to be accepted on claims with dates of service on or after January 1, 2004 that are received by March 31, Claim lines with these HCPCS codes with dates of service on or after January 1, 2004 that are received on or after April 1, 2004 will be returned as unprocessable or denied as incorrectly coded. These HCPCS codes should continue to be used for claims with dates of service prior to January 1, 2004 regardless of the date of claim submission. New HCPCS codes Effective for dates of service on or after January 1, 2004, the following new HCPCS codes are included in the Refractive Lenses LMRP: V V V V V V V V Eye glass case Mirror coating, any type, solid, gradient or equal, any lens material, per lens Polarization, any lens material, per lens Lens, index 1.54 to 1.65 plastic or 1.60 to 1.79 glass, excludes polycarbonate, per lens Lens, index greater than or equal to 1.66 plastic or greater than or equal to 1.80 glass, excludes polycar bonate, per lens Lens, polycarbonate or equal, any index, per lens Specialty occupational multifocal lens, per lens Vision supply, accessory and/or service component of another HCPCS vision code A revision of the LMRP on Refractive Lenses is posted on the Palmetto GBA web site. Refer to that policy for information concerning definitions, coverage criteria, and special documentation requirements for the new HCPCS codes. Suppliers are reminded that the establishment of a unique HCPCS code for a particular product does not necessarily indicate coverage. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

12 Page 126 NEGATIVE PRESSURE WOUND THERAPY PUMPS Winter 2003 DMERC Medicare Advisory In response to questions concerning the Negative Pressure Wound Therapy Pumps policy and findings on our medical review of claims, we are providing the following clarification to several aspects of the policy. The medical policy says that coverage of an NPWT pump ends if wound healing has failed to occur over the prior month. Healing of a wound is assessed by comparing measured wound volumes. It is therefore important that the length, width, and depth of the wound be recorded during each evaluation performed to document continued medical necessity for the NPWT pump. If any one of these values is not recorded, then healing of the wound will not have been adequately documented and coverage for that wound will end. Changes in undermining or tunneling around the wound will not be considered in the determination of wound healing because the dimensions cannot be quantitated and because it is expected that changes in measured wound volume will correlate with other aspects of wound healing. If healing of a wound fails to occur in a particular month, there will be no further coverage for that wound - even if treatment with the pump continues and subsequent improvement occurs. If healing of a wound fails to occur in a particular month, the KX modifier must not be added to claims for any subsequent months for use of the pump on that particular wound. (If other wounds are being treated and improvement is continuing in one or more of those wounds, the KX modifier may continue to be used.) If it is determined on review that claims were paid after a month in which no improvement occurred, overpayments will be collected. NPWT pumps are used to initiate the healing of wounds. It is not necessary to continue using a pump until a wound is completely healed. For example, if the depth of a wound is less than 0.5 cm, then it would generally not be appropriate to continue use of the device. Also, if improvement of a wound has steadily occurred during four months treatment with the pump, then continued use of the pump on that wound would very rarely be medically necessary. An exception might be a very large open sternotomy or abdominal wound which had improved but was still quite large after four months of treatment. If multiple wounds are being treated and there is no improvement in one wound but improvement is noted in the other wound(s), then coverage could continue for those wounds. The four month time frame for coverage would apply to each wound being treated. If treatment of a new wound was started after treatment for an initial wound was begun, this would not generally not start a new capped rental period for the device. However, it may extend the total months in which we cover the device - if there was continual improvement of the wound(s) being treated. A new capped rental period would only begin if the device had not been used on any wound for at least 2 months and treatment was then begun on a completely new wound which met coverage criteria. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

13 Winter 2003 DMERC Medicare Advisory Page 127 REPAIRS / REPLACEMENT CHART The accompanying chart on repairs and replacements indicates when original or new suppliers need new CMNs or orders, or when the original CMN or order will be adequate for repairing or replacing DME. Repair before or after 5 years N/A because covered by rental or M/S Repair before 5 years N/A because covered by rental Repair before or after 5 years Doc of why repair, but no order for actual repair; Repair up to $Rplcmnt CAPPED RENTAL (Rented) EQUIPMENT/DURABLE ACCESSORIES Original Item Requires CMN Original Item Requires Only Order before 5 years (for wear) N/A because covered by rental or M/S INEXPENSIVE/ROUTINELY PURCHASED (IRP) (Rented) EQUIPMENT/DURABLE ACCESSORIES Original Item Requires CMN Original Item Requires Only Order before 5 years (for wear) N/A because covered by rental before 5 years (for loss or damage) N/A because covered by rental after 5 years N/A because not rented for 5 years Repair before or after 5 years N/A because covered by rental before 5 years (for wear) N/A because covered by rental before 5 years (for loss or damage) N/A because covered by rental CAPPED RENTAL (Purchased) OR IRP (Purchased) EQUIPMENT/DURABLE ACCESSORIES Original Item Requires CMN Original Item Requires Only Order before 5 years (for wear) N/A - Only Cover Repair before 5 years (for loss or damage) N-CMN plus doc of why replcmnt nec before 5 years (for loss or damage) N-CMN and doc of why replacement after 5 years N-CMN after 5 years N-CMN Repair before or after 5 years N/A because covered by rental or M/S Repair before or after 5 years Doc of why repair, but no order for actual repair; Repair up to $Rplcmnt before 5 years (for wear) N/A because covered by rental or M/S before 5 years (for wear) N/A - Only Cover Repair before 5 years (for loss or damage) N-ORD plus doc of why replcmnt nec before 5 years (for loss or damage) N-ORD and doc of why replacement after 5 years N-ORD after 5 years N/A because not rented for 5 years after 5 years N - ORD ACCESSORIES FOR DME Requiring More Frequent Same Supplier or New Supplier Original Item Requires CMN Original Item Requires only Order Repair before or after 5 years before 5 years Repair before or after 5 years before 5 years Doc of why repair, but no order for actual repair; Repair up to $Rplcmnt O-CMN or N-CMN stating frequency of replacement; Frequency of replacement at discretion of DMERC Doc of why repair, but no order for actual repair; Repair up to $Rplcmnt O-ORD or N-ORD stating frequency of replacement; Frequency of replacement at discretion of DMERC N-CMN = New Initial CMN; O-CMN = Original CMN; N-ORD = New Order; O-ORD = Original Order; "Doc" = Statement submitted by supplier Same requirements apply regardless of whether the same supplier or a new supplier is providing the repair or replacement Bulletins issued after October 1, 1999 are available at no cost from our Web site at

14 Page 128 HOME HEALTH CONSOLIDATED BILLING CORRECTION FOR HCPCS CODE A4421 Winter 2003 DMERC Medicare Advisory In an article entitled "Home Health Consolidated Billing: HCPCS Code Update" published in the Autumn 2003 DMERC Medicare Advisory, we published information contained in Program Memorandum AB which, among other changes, removed HCPCS code A4421 (Ostomy supply, misc.) from the list of supply HCPCS codes subject to home health consolidated billing effective for dates of service on or after October 1, Removing HCPCS code A4421 was an error, and the HCPCS code will not be deleted from home health consolidated billing enforcement. For a complete list of HCPCS codes subject to home health consolidated billing, please see the home health consolidated billing master code list at The 2004 Update Billing Code Lists is available on page 134 in this Advisory. No change has been made to the following three non-routine supply HCPCS codes, which were added to the list of HCPCS codes subject to consolidated billing, effective October 1, K0614 Chem/antiseptic solution, 8 oz. K0620 Tubular elastic dressing K0621 Gauze, non-impreg pack strip STREAMLINING OF CLAIMS CROSSOVER PROCESS The Centers for Medicare & Medicaid Services (CMS) has decided to streamline the claims crossover process to better serve our customers. Insurer entities that are eligible to receive Medicare paid claims data directly from CMS for purposes of calculating their secondary liability will no longer have to sign separate agreements with individual Medicare intermediaries and carriers. Likewise, they will not need to prepare and send separate eligibility files that include eligibility information for each insured beneficiary to individual contractors nor receive numerous claims crossover files. The CMS will consolidate the claims crossover function under one contractor, the Medicare Coordination of Benefits Contractor (COBC), and trading partners will execute national Coordination of Benefit Agreements (COBAs) with and send COB eligibility files to the COBC. The effort to consolidate the claims crossover function will be implemented via a phased-in approach to begin in January Completion of the consolidation is expected in April Today, Medicare contractors access their claims history or other internal files to determine whether specific claims have been crossed over and to whom. Under CMS' Coordination of Benefits Agreement (COBA) process, contractors will no longer have this information from their claims histories or internal files, since the claim selection inclusion or exclusion logic that determines whether a claim will or will not cross will now be applied at the Coordination of Benefits Contractor (COBC). To avoid potential customer service problems, the COBC will send CWF a claim extract file that contains details about specific claims that the COBC either crossed over or suppressed from the crossover file. The CWF will receive and process the extract file and display the appropriate code indicating whether a claim was crossed over. In addition, CWF will display the COBA Identification Number (ID) associated with each claim and crossover occurrence. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

15 Winter 2003 DMERC Medicare Advisory Page FOURTH QUARTER DRUG FEE UPDATE The allowance for drugs is based on the National Average Wholesale Price (AWP) for all sources of the pharmaceutical. If more than one available source of a drug exists, 95% of the median of the national wholesale generic prices is used, unless a brand AWP is lower. If a generic source of a drug does not exist, 95% of the brand product with the lowest AWP is used to calculate the allowance. HCPCS FEE CODE J0285 $10.28 J0287 $21.85 J0288 $15.20 J0289 $35.80 J0895 $15.63 J1170 $1.49 J1250 $4.74 J1325 $12.64 J1455 $13.07 J1570 $35.25 J1815 $0.10 J1817 $2.80 J2175 $0.56 J2260 $51.58 J2270 $0.71 J2271 $11.07 J2275 $4.39 J2545 $50.77 J2920 $2.11 J2930 $3.24 J3010 $0.93 J7051 $0.14 J7500 $1.24 J7501 $59.84 J7502 $5.23 J7506 $0.02 J7507 $3.50 J7508 $17.48 J7509 $0.54 J7510 $0.03 J7513 $ J7515 $1.31 J7517 $2.81 J7520 $7.07 The following drug allowables are effective October 1, 2003 and are subject to change on a quarterly basis. The fee changes are bolded. HCPCS FEE CODE J7525 $ J7608KO $6.33 J7608KP $6.33 J7608KQ $5.97 J7622KO $0.65 J7622KP $0.65 J7622KQ $0.08 J7624KO IC* J7624KP IC* J7624KQ IC* J7626KO $4.51 J7626KP $4.51 J7626KQ $0.06 J7628 IC* J7629KO IC* J7629KP IC* J7629KQ IC* J7631KO $0.36 J7631KP $0.36 J7631KQ $0.29 J7633 $0.06 J7635 $0.37 J7636KO $0.51 J7636KP $0.51 J7636KQ $0.37 J7637 $0.10 J7638KO $0.18 J7638KP $0.18 J7638KQ $0.10 J7639KO $16.67 J7639KP $16.67 J7639KQ $16.62 J7641KO $0.80 J7641KP $0.80 HCPCS FEE CODE J7641KQ $0.51 J7642 $0.56 J7643KO $0.93 J7643KP $0.93 J7643KQ $0.56 J7644KO $3.34 J7644KP $3.34 J7644KQ $3.06 J7648 $0.68 J7649KO $0.71 J7649KP $0.71 J7649KQ $0.68 J7658 IC* J7659KO IC* J7659KP IC* J7659KQ IC* J7668 $0.25 J7669KO $1.10 J7669KP $1.10 J7669KQ $0.25 J7680 IC* J7681KO IC* J7681KP IC* J7681KQ IC* J7682KO $49.27 J7682KP $49.27 J7682KQ IC* J7683 $0.11 J7684KO $0.19 J7684KP $0.19 J7684KQ $0.11 J9000 $12.54 J9040 $ J9065 $61.72 HCPCS FEE CODE J9100 $3.19 J9110 $8.55 J9190 $2.07 J9200 $ J9360 $4.10 J9370 $33.98 J9375 $67.96 J9380 $ Q0163 $0.02 Q0164 $0.57 Q0165 $0.86 Q0166 $44.69 Q0167 $3.28 Q0168 $9.17 Q0169 $0.31 Q0170 $0.02 Q0171 $0.07 Q0172 $0.09 Q0173 $0.50 Q0174 $0.56 Q0175 $0.57 Q0176 $0.93 Q0177 $0.41 Q0178 $0.30 Q0179 $30.42 Q0180 $72.43 Q4075 $0.47 Q4076 $0.62 Q4077 IC* Q9920- $10.00 Q9940 Note: For HCPCS code J7626 (Budesonide), bill one unit per vial of drug regardless of strength. IC-Individual Considered codes. Drugs identified as IC* must include the national drug code (NDC), strength and dosage on the claim for processing. Inclusion or exclusion of an allowable amount for an item or service does not imply Medicare coverage. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

16 Page REGION C REASONABLE CHARGE PAYMENT LIMITS Therapeutic Shoes and Inserts Winter 2003 DMERC Medicare Advisory In July of 1994, a provision for the coverage of therapeutic shoes for individuals with diabetes was included in the Medicare Carriers Manual (Section 2134), (now located at CMS Manual Sytem, Pub.100-2, Medicare Benefit Policy Manual, Chapter 15, Section 140). In this provision, the Centers for Medicare & Medicaid Services (CMS) outlined limitations for reimbursement of therapeutic shoes. The increase of 2.1% for 2004 has been applied to payment limitations for Therapeutic Shoes and Inserts. The 2004 payment limitations for diabetic shoe HCPCS codes follow. HCPCS Code Pricing Limit A5500 $ A5501 $ A5503 $ A5504 $ A5505 $ A5506 $ A5509 $ A5510 $ A5511 $ NOTE: The limitations to allowances listed may not reflect suppliers' allowances. Medicare calculates the allowance for each HCPCS code listed above by selecting the lower of the prevailing charge, the supplier's customary charge (or 50th percentile of customary charges in the absence of a customary charge), the inflation index charge, the CMS limit and the supplier's submitted charge. Suppliers may obtain a profile of their customary charges by writing to: Palmetto GBA - Pricing Unit P.O. Box , AG-311 Columbia, S.C Suppliers should include their National Supplier Clearinghouse 2004 DMEPOS FEE SCHEDULE AND REASONABLE CHARGE UPDATES The 2004 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) update factor is 2.1 percent for all fee schedule items except oxygen and oxygen equipment. The 2004 covered item update factor for oxygen is 0 percent. The 2004 DMEPOS Fee Schedule will apply to all claims with dates of service January 1, 2004 through December 31, The 2004 Inflation Index Charge update for items paid under the reasonable charge methodology is 2.1 percent. Therefore, your payment for reasonable charge items will not exceed 2.1 percent above the reasonable charge payment you received in This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

17 Winter 2003 DMERC Medicare Advisory Page DMEPOS FEE SCHEDULE AND REASONABLE CHARGE UPDATES cont. Therapeutic shoes and dialysis supplies and equipment are the only benefits that continue to be reimbursed under the reasonable charge methodology. Reasonable charge payment limits will be posted under separate cover. The 2004 DMEPOS Fee Schedule allowances will be available on the CMS Web site ( after December 9, 2003 or on the Palmetto GBA Web site in the DMERC Fee Schedule area by the end of December FOURTH QUARTER ORAL ANTI-CANCER DRUG FEES The following drug allowables are effective October 1, 2003, and are subject to change on a quarterly basis. Currently, these drugs meet the requirements for coverage under OBRA '93. Unlike other drugs billable to the DMERC, these oral anti-cancer drugs are not submitted with HCPCS codes. Oral Anti-Cancer drugs are billed using the National Drug Code (NDC) number. The fees are as follows: DRUG NAME STRENGTH 10/01/2003 PER TABLET FEE Busulfan 2 mg 2.08 Capecitabine 150 mg 3.59 Capecitabine 500 mg Cyclophosphamide 25 mg 1.98 Cyclophosphamide 50 mg 3.64 Etoposide 50 mg Melphalan 2 mg 2.50 Methotrexate 2.5 mg 3.36 Methotrexate 5 mg 7.25 Methotrexate 7.5 mg Methotrexate 10 mg Methotrexate 15 mg Temozolomide 5 mg 7.35 Temozolomide 20 mg Temozolomide 100 mg Temozolomide 250 mg Inclusion or exclusion of an allowable amount for an item or service does not imply Medicare coverage. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

18 Page 132 CONTINGENCY PLAN FOR HIPPA TRANSACTION AND CODE SETS HIPAA Winter 2003 DMERC Medicare Advisory After a careful analysis of Medicare provider, submitter and other trading partner HIPAA readiness, Medicare will continue to accept and send standard and non-standard versions and/or formats for any electronic transaction for a limited time period beyond October 16, This is a temporary measure to maintain provider cash flow and minimize operational disruption while trading partners who are not compliant on October 16, 2003 work with Medicare to achieve full compliance. This contingency plan is only for a limited time. Providers who must continue to bill and receive non-compliant formats should test and move into production on the HIPAA required formats as soon as possible or risk possible cash flow problems. CMS WEBCAST PRESENTATIONS Free HIPAA Training The CMS Southern Consortium's Achieving Compliance Together (ACT) Team has developed a series of HIPAA presentations. They can be accessed via the internet and there is no cost to you. To access these presentations, type in the following web address: You can choose any of the following presentations: 1) Message to Providers 2) HIPAA Basics 3) Provider Steps to Getting Paid 4) HIPAA Security 5) CMS Enforcement of T&CS **NEW** 6) 837 for Professional Claims **NEW** 7) 837 for Institutional Claims (Coming Soon) SUPPLEMENTAL ANSI 276/277 V4010A1 GUIDE Palmetto GBA has published the "Supplemental Guide to the ANSI ASC X12N 276/277 version 4010A1 Implementation Guide" on the Palmetto GBA Web site. This manual provides information specific to submitting ANSI 276 claim status requests and retrieving ANSI 277 claim status responses. To download a copy, please go to and click on HIPAA located on the bottom left side. Select Specifications & Technical Information and ANSI 276/277. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.

19 Winter 2003 DMERC Medicare Advisory Page 133 MEDICARE SECONDARY PAYER Individuals Not Subject to the Limitation on Payment The Medicare secondary provision for working aged does not apply to: Individuals enrolled in Part B only; Individuals enrolled in Part A on the basis of a monthly premium. Anyone who is under age 65. (Medicare is secondary to large group health plans that cover at least one employer of 100 or more employees for certain disabled individuals under age 65.); Individuals covered by a health plan other than an GHP as defined above, e.g., one that is purchased by the individual privately, and not as a member of a group, and for which payment is not made through an employer; Employees of employers of fewer than 20 employees who are covered by a single employer plan. Members of multi - employer plans, which have been approved by CMS for the "multi-employer exemption", whom the plan identified as employees of employers with fewer than 20 employees; Retired beneficiaries who are covered by GHPs as a result of past employment and who do not have GHP coverage as the result of their own or a spouse's current employment status; Individuals enrolled in single employer GHPs of employer of fewer than 20 employees; or Members of multi-employer plans whom the plan identified as employees of employers with fewer than 20 employees, provided the plan formally elected (see CMS Manual System Pub Medicare Secondary Payer, Chapter 2, Section 10.4) to exempt the plan from making primary payment for employees and spouses of employees of specifically identified employers with fewer than 20 employees. Domestic partners are given "spousal" coverage by the group health plan. Federal law defines spouse as a person of the opposite sex who is a husband or a wife. Thus a domestic partner cannot be recognized as a spouse. Bulletins issued after October 1, 1999 are available at no cost from our Web site at

20 Page 134 COMPREHENSIVE ERROR RATE TESTING Winter 2003 DMERC Medicare Advisory In order to improve the processing and medical decision-making involved with payment of Medicare claims, CMS began a new program in August This program is called Comprehensive Error Rate Testing (CERT) and was implemented in order to achieve goals of the Government Performance and Results Act of 1993, which sets performance measurements for federal agencies. Under CERT, an independent contractor (AdvanceMed Corporation, a CSC Company in Richmond, Virginia) selects a random sample of claims processed by each Medicare contractor. AdvanceMed's medical review staff (which includes nurses, physicians, and other qualified healthcare practitioners) verifies that contractor decisions regarding the claims were accurate and based on sound policy. CMS uses the AdvanceMed findings to determine underlying reasons for errors in claims payments or denials, and to implement appropriate corrective actions aimed toward improvements in the accuracy of claims and systems of claims processing. How are suppliers impacted by CERT? Suppliers of the sampled claims are asked during the course of the AdvanceMed review to provide additional information (e.g., medical records, certificates of medical necessity, etc.) for AdvanceMed staff to verify delivery of billed services, medical necessity, and appropriateness of claims processing procedures. If contacted, you are provided with the details regarding the needed information and the name of a contact person. It is important that you provide the requested documentation to assist CMS and AdvanceMed in the CERT process. HOME HEALTH CONSOLIDATED BILLING 2004 Update Billing Code Lists The CMS periodically updates the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the Home Health Prospective Payment System (HH PPS). With the exception of therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings, services appearing on this list which are submitted on claims to Medicare contractors will not be paid separately on dates when a beneficiary for whom such a service is being billed is in a home health episode (i.e., under a home health plan of care administered by a home health agency). Medicare will only directly reimburse the primary home health agencies that have opened such episodes during the episode periods. Therapies performed by physicians, supplies incidental to physician services and supplies used in institutional settings are not subject to HH consolidated billing. Medicare contractors include fiscal intermediaries (FIs), carriers, and durable medical equipment regional carriers (DMERCs). The HH consolidated billing code lists are updated annually, to reflect the annual changes to the HCPCS code set itself. Additional updates may occur as frequently as quarterly in order to reflect the creation of temporary HCPCS codes (e.g., 'K' codes) throughout the calendar year. The new coding identified in each update describes the same services that were used to determine the applicable HH PPS payment rates. No additional services will be added by these updates; that is, new updates are required by changes to the coding system, not because the services subject to HH consolidated billing are being redefined. This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.