EDITION 40 ∙ SUMMER 2017 - CGS Medicare€¦ · for dates of service July 1, 2016, through...

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

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.


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.


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

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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


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.


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.

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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!

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Attention myCGS Users: Change to EIDM Password Requirements

- CGS Publication


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


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

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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).

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COVERAGE & BILLING

Items Provided on a Recurring Basis and Request for Refill Requirements – Annual Reminder

- DME MAC Joint Publication

Published March 16, 2017


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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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).

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Correct Coding and Coverage – Braces Constructed Primarily of Elastic or Other Fabric Materials - Revised


Published March 16, 2017


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



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).


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


Correct Coding – Interferential Current (IFC) Therapy Devices


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/.

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DME Information Forms (DIFs) Usage for Enteral and Parenteral Nutrition and External Infusion Pumps - Revised


Publication Date: April 6, 2017


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



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


Billing Instructions – Continuous Glucose Monitors


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


Continuous Glucose Monitors – Frequently Asked Questions


Published May 4, 2017


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



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.


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.


“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?


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.

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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


Updated Advance Beneficiary Notice – Required for Use June 21, 2017



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


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


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


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/


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


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/


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

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