Jurisdiction B Connections: December 2014December 2014 Jurisdiction B Connections 5 ANSI Code...

Jurisdiction B Connections December 2014

The Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) processes durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) claims for beneficiaries who reside in the states of Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

The Jurisdiction B Connections is published quarterly in March, June, September and December.

To receive up-to-date information about Medicare and/or changes within the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), National Government Services, Inc. encourages suppliers to sign up for the electronic mailing list, Jurisdiction B DME Email Updates.

CMS Quarterly Provider Update The Centers for Medicare & Medicaid Services (CMS) publishes the Quarterly Provider Update (QPU) at the beginning of each quarter to inform providers and suppliers about the following:

• Regulations and major policies under development during the quarter • Regulations and major policies completed or cancelled • New or revised manual instructions

Think Green and Go Paperless Suppliers should file claims electronically and you are encouraged to sign up for both the electronic remittance advice (ERA) and electronic funds transfer (EFT) to take advantage of the tremendous benefits associated with electronic transactions.

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In This Issue

Medicare Information for All Suppliers APPEALS

Amount in Controversy Increases for 2015............................................................................................... 4

COVERAGE, BILLING AND DENIALS Supplier Responsibility for Filing Claims To Medicare............................................................................... 4 Correct Coding – Cefaly®.......................................................................................................................... 4 CMS-1500 Item 12 and Item 13 Signature Requirements......................................................................... 5 Third Quarter 2014 Top Claim Submission Errors .................................................................................... 5

DOCUMENTATION ACA Requirement for Indicating Receipt Date of Documentation ........................................................... 10

FEE SCHEDULE, PRICING AND OVERPAYMENTS Medicare’s Acceptance of Voluntary Refunds......................................................................................... 11 Notice of New Interest Rates for Medicare Overpayments and Underpayments –

Change Request 8988......................................................................................................................... 11

MEDICAL POLICY Local Coverage Determination and Policy Article Revisions Summary for 10/2/2014 ............................. 11

MISCELLANEOUS SUPPLIER INFORMATION Improved Our Search Function – Your Feedback Counts....................................................................... 12 Obtaining Eligibility Information............................................................................................................... 13 Third Quarter 2014 Supplier Telephone Inquiries ................................................................................... 13 Third Quarter 2014 Supplier Written Inquiries......................................................................................... 17

Drugs/Infusion/Parenteral and Enteral Nutrition DRUGS

Correct Coding – Oral Anticancer Drugs and PDAC’s NDC/HCPCS Crosswalk Listings ........................ 21

Mobility/Respiratory MOBILITY

Submit a Power Mobility Devices Prior Authorization Request................................................................ 22 Current Top Reasons for Nonaffirmed Prior Authorization Requests ...................................................... 23 Reporting a Unique Tracking Number for Power Mobility Device Prior Authorization Requests .............. 23 Tips for Correctly Completing a Detailed Product Description................................................................. 24 Widespread Prepayment Probe Review – Manual Wheelchairs ............................................................. 24

RESPIRATORY Billing Reminder for Secondary Ventilators............................................................................................. 25 Reasonable Useful Lifetime Policies for Oxygen and Oxygen Equipment............................................... 26 Reminder: Revised High Liter Flow Oxygen and Oxygen Equipment Payment and Billing Guidelines.... 27 Oxygen Concentrator–Notification of Widespread Prepayment Probe Review ....................................... 28

December 2014 Jurisdiction B Connections 2

Other Durable Medical Equipment Widespread Prepayment Probe Review – Hospital Beds........................................................................ 29 Coverage Reminder – Negative Pressure Wound Therapy Devices Revised – 10/02/14........................ 30

Orthotics and Prosthetics/Therapeutic Shoes/Lenses ORTHOTICS AND PROSTHETICS

E1825, E1830 and E1831 and Use of Modifiers ..................................................................................... 32

THERAPEUTIC SHOES Documentation Reminder—Therapeutic Shoes...................................................................................... 32

Surgical Dressings/Glucose Monitors/Urological and Ostomy Supplies/Other Supplies UROLOGICAL AND OSTOMY SUPPLIES

Intermittent Catheter Kits (HCPCS A4353)–Prepayment Medical Review Results.................................. 33

Jurisdiction B DME Contact Information Supplemental Resources........................................................................................................................ 37 MLN Connects Provider eNews.............................................................................................................. 37 Medicare Learning Network Matters Articles........................................................................................... 38


Medicare Information for All Suppliers

APPEALS Amount in Controversy Increases for 2015 Effective for Federal District Court requests filed on or after 1/1/2015, the amount in controversy will increase to $1,460. The amount that must remain in controversy for review in Federal District Court requested before 12/31/2014 is $1,430.

The amount that must remain in controversy for Administrative Law Judge (ALJ) hearing requests filed before 12/31/2014 is $140. This amount will increase to $150 for ALJ hearing requests filed on or after 1/1/2015.

The amount in controversy is computed as the actual amount charged for the items and services in question, reduced by:

• any Medicare payments already made or awarded for the items or services; and • any deductible and coinsurance amounts applicable in the particular case.

To meet the amount in controversy, suppliers may combine two or more claims to meet the amount in controversy requirements if:

• the claims were previously considered by the preceding level of appeal; • the request for amount in controversy hearing lists all of the claims to be combined and is filed within

the specified time frame; and • the preceding level of appeals determines that the combined claims involve the delivery of similar or

related services.

For additional information on appeals, you may refer to Chapter 20 of the Jurisdiction B Supplier Manual.

COVERAGE, BILLING AND DENIALS Supplier Responsibility for Filing Claims To Medicare The OBRA of 1989 requires a Medicare supplier to submit a completed claim within one year when furnishing covered items to a Medicare beneficiary. The supplier is relieved of this obligation when furnishing noncovered items, unless the beneficiary requests Medicare payment/determination. If the beneficiary chooses to waive Medicare determination/payment, the supplier is relieved of the responsibility to file claims for covered Medicare items. Should the beneficiary change his/her mind in the future, the supplier would again be responsible for submitting claims for covered items to Medicare. This includes both participating and nonparticipating suppliers.

To read more about the supplier’s responsibility for filing claims to Medicare, please refer to Chapter 12 of the Jurisdiction B Supplier Manual.

Correct Coding – Cefaly®

Joint DME MAC Publication

The Cefaly® device (Cefaly Technology) is a transcutaneous electrical nerve stimulator (TENS) that is applied to the forehead using a self-adhesive electrode positioned bilaterally over the upper branches of


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the trigeminal nerve. The Cefaly® device is intended to stimulate the upper branches of the trigeminal nerve and has received FDA approval for the prophylactic treatment of episodic migraine headache.

Items that serve a prevention or precautionary purpose are noncovered by Medicare. The correct code for Cefaly® is:

A9270 – Noncovered item or service

For questions about correct coding, contact the PDAC 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 located on the PDAC Website.

CMS-1500 Item 12 and Item 13 Signature Requirements In order for a supplier to submit a claim for an item of durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS), a beneficiary or his/her authorized representative must sign and date Item 12 of the CMS-1500 or may sign a statement to be retained in the supplier’s file. When a signature is kept on file, “signature on file” or “SOF” must be indicated in Item 12. The signature authorizes release of medical information necessary to process the claim. It also authorizes payment of benefits to the supplier when the supplier accepts assignment on the claim. This is required for all DMEPOS claims. The authorization is effective indefinitely unless the beneficiary or his/her representative revokes this arrangement.

A beneficiary (or his/her authorized representative) signature in Item 13 allows payment to be issued to the supplier. This is considered assignment of benefits (AOB). An AOB is only valid for the items that are listed within the AOB. Additionally, the signature in Item 13 of the CMS-1500 claim form authorizes payment of mandated Medigap benefits to the participating supplier if required Medigap information is included in Item 9 and its subdivisions. The beneficiary or his/her authorized representative must sign Item 13 or the signature must be on file as a separate authorization. When a signature is kept on file, “signature on file” or “SOF” must be indicated in Item 13. The assignment on file in the participating supplier’s office must be insurer specific. It may state that the authorization applies to all occasions of service until it is revoked.

For additional information about signature requirements for Item 12 and Item 13 of the CMS-1500, please refer to the Jurisdiction B Supplier Manual, Chapter 12.

Related Content • Signature on File Requirements, Chapter 12, Jurisdiction B Supplier Manual

Third Quarter 2014 Top Claim Submission Errors We conducted claim analysis for the third quarter of calendar year 2014 (July–September) of issues related to claim submission errors. Below is a chart listing the top claim submission errors as well as tips on how to reduce errors. The total denied claims for the third quarter was 639,106.


https://www.dmepdac.com/http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/news-alerts/news-articles/news-detail/supplier%20responsibility%20for%20filing%20claims%20to%20medicare/%21ut/p/a1/vVJNc4IwEP0rePCYSfio4jEIpdYi1Y5VuDgBAqZCYCDVsb--odXWHqxtD81p3-bt7su-wBAuYcjJlmVEsJKTvMVhb2XgkaOqQzT2zRuE8NjGBp64ujlX4QKGMGzIlsZluWG0RXFOSf0JZ4478idvF1xUYg0DnjUFTVhMalnFBeWC010XnaTfMd01gPAEkJzWojkmasHkBAkPtV3UPFdVzmit1LSpSt6wiOVM7JW0rJVUhjxT4pywolFEqRxHtIKqmCUwGKAIpQlFQDNRHxhUH4BIIwRERO-retpTtShp2Xe-BQPbc-RSArkUdOZg9KOdfaHovomwcW3Z9vRedy3tQPhmRCA19M8OUVX40PZYDL3VdO7MJPvEI4lOPZLw4JGMPh75u_VckKP_s5zbSxZIC7XaG3qZbEvEGjCelnD5t4-0sGD4qHldRHawKjYz19QLsERPV1WG7Ze0KDC-n4Aw2uNO5xXiOMJH/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpublications%2Fmanuals%2Fsuppliermanual%2Fchapter%2B12%2B-%2Bclaim%2Bsubmissionhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B12%2B-%2BClaim%2BSubmission%2FSignature%2Bon%2BFile%2BRequirements&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B

ANSI Code Category Denial Type July 2014

August 2014

September 2014

3rd Quarter Total

% of Denials

CO-16 Claim/service lacks information which is needed for adjudication.

Return/Reject 28,011 23,397 24,250 75,658 11.18%

CO-4 The procedure code is inconsistent with the modifier used, or a required modifier is missing.

Return/Reject 19,401 19,647 18,602 57,650 8.54%

CO-18 Duplicate Claim Duplicate 16,691 14,735 15,573 46,999 6.96%

OA-24 Payment for charges adjusted. Charges covered under a capitation agreement/ managed care plan.

Eligibility 9,189 8,512 8,156 25,857 3.83%

CO-151 Equipment is the same or similar to equipment already being used.

Same/Similar 7,927 7,518 7,522 22,967 3.40%

CO-176 Payment denied because the prescription is not current.

Return/Reject 6,719 5,576 6,002 18,297 2.71%

CO-173 Payment adjusted because this service was not prescribed by a physician.

Return/Reject 5,080 4,513 4,435 14,028 2.08%

CO-13 The date of death precedes the date of service.

Return/Reject 3,203 2,824 2,897 8,924 1.32%

OA-109 Claim is not covered by this payer or contractor.

Return/Reject 2,561 2,231 2,577 7,269 1.09%

CO-22 Payment adjusted because this care may be covered by another payer per coordination of benefits.

Eligibility 1,976 1,608 1,748 5,332 0.79%


1. CO-16: Claim/service lacks information which is needed for adjudication

Claims were submitted to the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) that contained incomplete or invalid information and cannot be processed as submitted. Please refer to the remark code (REM) on the remittance advice (RA). The REM code advises what information is missing or incomplete on the claim. If the REM field is not complete, you may contact the Provider Contact Center to request additional information regarding the American National Standards Institute (ANSI)-16 rejection. We have received an increase in the volume of claims submitted without a required modifier or with an invalid modifier. You are reminded to use the KX, GA, GZ or GY modifier to indicate whether the coverage criteria are or are not met as outlined in the local medical policy. Since the KX modifier has a differing definition depending on the local coverage determination (LCD) requirements, suppliers should review the LCDs carefully to understand the proper use of the KX, GA, GZ or GY modifiers for each policy. The LCDs and policy articles (PAs) may be accessed through the Medical Policy Center on our website. Claims denied with ANSI-16 are not eligible for an appeal or a reopening. The rejected claim must be resubmitted with the missing/incomplete information.

2. CO-4: The procedure code is inconsistent with the modifier used, or a required modifier is missing

For a complete listing of the HCPCS modifiers, please consult the JB Supplier Manual, Chapter 14 “Level II HCPCS Codes and HCPCS Modifiers.” Additionally, specific instructions regarding modifier usage is located in the JB Supplier Manual, Chapter 15, “DMEPOS Payment Categories.” The LCDs and PAs provide specific instructions for using the informational modifiers listed within the medical policy. Medical policies can be accessed from the Medical Policy Center section of our website.

You may also utilize the DME Coding System (DMECS), to verify if the Healthcare Common Procedure Coding System (HCPCS) code requires a primary pricing modifier. DMECS provides HCPCS coding assistance and national pricing information via searches for HCPCS Level II codes and modifiers, durable medical equipment prosthetics, orthotics and supplies (DMEPOS) items and Centers for Medicare & Medicaid Services (CMS) national fee schedules. To search for HCPCS and modifier coding or to find out more about the DMECS, please visit the Pricing, Data Analysis, and Coding Contractor’s website.

3. CO-18: Duplicate claims

We receive a large quantity of claims that result in duplicate denials. The duplicate claim submission denial is the number-one claims submission error. Generally, claim submission errors are services/items previously processed for the same patient, date of service and HCPCS code.

Suppliers are reminded to allow 14 days for electronically submitted claims and 29 days for hard copy claims before resubmitting a claim to the DME MAC. Suppliers should utilize the Claim Status Inquiry (CSI), NGSConnex or the interactive voice response (IVR) system at 877-299-7900 before resubmitting the claim for payment.

4. OA-24 Payment for charges adjusted. Charges are covered under a capitation agreement/managed care plan

The Jurisdiction B DME MAC records indicate that the beneficiary is enrolled in a Medicare Advantage plan, often referred to as a health maintenance organization (HMO). If the beneficiary elects to receive his or her Medicare benefits through a managed care plan, the beneficiary usually is required to receive all his or her care from doctors, hospitals and other health care providers that are part of the plan. Beneficiaries enrolled in a Medicare HMO will receive an identification card from their Medicare HMO. Beneficiaries, doctors, hospitals, or any other health care provider must contact the HMO for details pertaining to coverage requirements. The DME MACs do not process claims for Medicare HMOs. You must submit their


claim to the appropriate insurance carrier for the specific HMO in which the beneficiary is enrolled. We encourage suppliers to utilize the Customer Care IVR system or CSI for assistance in determining whether the beneficiary is enrolled in a Medicare Advantage Plan/HMO.

By selecting Option 2 from the main menu of the IVR, you will be able to obtain the Medicare HMO number, name, address, telephone number and effective/termination date of the plan. The IVR system is available from 7:00 a.m.–6:00 p.m. eastern time (ET), Monday through Friday and 7:00 a.m.–3:00 p.m. most Saturdays. You may access the IVR system by dialing 877-299-7900. For additional information regarding the IVR unit, you should refer to the IVR guide located on our website.

Online eligibility for all suppliers is also available through the CSI application. The CSI application and manual are available on our website.

5. CO-151: Equipment is the same or similar to equipment already being used

Suppliers should evaluate the patient’s history during the intake process to determine if the same or similar equipment was previously obtained. You may utilize CSI, NGSConnex or the IVR system at 877-299-7900 to determine if the beneficiary’s record indicates they already has the same/similar equipment. If the beneficiary wants the same/similar equipment and agrees to be financially liable, the supplier should have the beneficiary sign an Advance Beneficiary Notice of Noncoverage (ABN) and submit the claim with modifier GA to indicate an ABN is on file. However, if a claim denies because the patient has previously received the same/similar equipment, and the supplier was unaware of the previous purchase, the supplier should refund the beneficiary (if applicable). The supplier may choose to exercise their right to request a redetermination. Redetermination requests may be submitted to the following address:

Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036

You may also fax redetermination requests. You should complete the Medicare DME Redetermination Request Form and fax the redetermination request to 317-595-4737.

You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, you should visit our website or login the NGSConnex application.

6. CO-176: Payment denied because the prescription is not current

We encourage suppliers to review the medical policies, referred to as LCDs, to verify whether or not an initial, revised or recertification CMN is required for a specific item. When submitting claims that require a CMN, you should ensure that all sections of the CMN are completed prior to submitting the claim to the DME MAC. You should submit the CMN with the initial claim only, and wait 24–48 hours before submitting any subsequent claims. The LCDs and related PAs can be found in the Medical Policy Center on our website.

However, if a claim denies because the patient has previously received same/similar equipment, and you was unaware of the previous purchase, you should refund the beneficiary or exercise his/her appeal rights and request a redetermination. Redetermination requests may be submitted to the following address:


Jurisdiction B DME MAC Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036


You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, you should visit our website or login to the NGSConnex application.

7. CO-173 Payment adjusted because this service was not prescribed by a physician

We encourage suppliers to review medical policies to verify whether or not the items or services routinely provided to Medicare beneficiaries require an initial, revised or recertification CMN. When submitting claims that require a CMN, you should ensure that all sections of the CMN are completed prior to claim submission to the DME MAC. You should submit the CMN with the initial claim only and wait 24-48 hours before submitting any subsequent claims. The medical policies are located within the Medical Policy Center on our website.

8. CO-13 The date of death precedes the date of service

Medicare Part B coverage was not valid when the patient received this item and/or service. Expenses were incurred after coverage was terminated, prior to coverage, date of death precedes the date of service or Medicare was unable to identify the patient as an insured. You should contact the beneficiary to whom they are providing service, to determine whether the beneficiary is still using the supplier’s equipment. We also recommended that suppliers check their patients’ Health Insurance Claim card and Medicare records for valid coverage dates and for correct patient information prior to claim submission.

9. OA-109: Claim is not covered by this payer or contractor

This denial is given when the wrong payer or contractor has been billed. The most common reason for this denial is when the supplier submits a claim with an incorrect beneficiary address resulting in the claim being sent to the incorrect DME MAC. This ANSI is also received when the date of service on the supplier’s claim overlaps a beneficiary’s inpatient stay in a hospital or a skilled nursing facility. Verify the beneficiary’s eligibility via NGSConnex or the IVR system. Once eligibility has been verified, resubmit the claim to the appropriate payer or contractor. In cases where the inpatient dates are incorrect, you are encouraged to work with the beneficiary, the caregiver and/or the facility to get the date of discharge correct. Once the discharge dates have been corrected, you may resubmit their claim to the DME MAC for payment. Prior to resubmission, NGSConnex and/or the IVR should be checked again to confirm the correction has been made to the discharge dates.

10. CO-22: Payment adjusted because this care may be covered by another payer per coordination of benefits

Our records indicate that Medicare is the secondary payer. When Medicare is the secondary payer, you must send the claim to the primary payer first and then submit the claim to Medicare with a copy of the primary payer’s explanation of benefits (EOB) notice. When claims are submitted to Medicare as primary and another insurer is actually the primary payer, claims will be denied with the following explanation: “Our records show that Medicare is your secondary payer. This claim must be sent to your primary insurer first. Resubmit this claim with a copy of the primary payment notice.” You must send these claims to the correct


payer/contractor and then resubmit the claim to Medicare with a copy of the primary payment notice or the EOBs. If the beneficiary’s Medicare Secondary Payer (MSP) records are outdated, suppliers should advise the beneficiary to contact the Benefits Coordination and Recovery Center at 855-798-2627 to have his/her MSP control file updated.

Related Content • CSI Information • Claim Status Inquiry Manual • IVR System • IVR User Guide • DMEPOS HCPCS Jurisdiction List, Chapter 14, JB Supplier Manual • Inexpensive or Other Routinely Purchased DME, Chapter 15, JB Supplier Manual • Medical Policy Center • Medicare DME Redetermination Request Form • NGSConnex Information • NGSConnex Website • Pricing, Data Analysis, and Coding Contractor’s Website

DOCUMENTATION ACA Requirement for Indicating Receipt Date ofDocumentation Joint DME MAC Publication

With the implementation of ACA Section 6407, there are LCDs and related PAs that require suppliers to receive clinical documentation and orders within a specific period of time. According to these LCDs, “A date stamp or equivalent must be used to document receipt date.” Documentation of the receipt date is a key requirement of these policies to demonstrate compliance with the statutory timeliness requirement.

Questions have arisen from suppliers about what methods are acceptable for documenting a receipt date. The DME MACs do not specify what method may be used to indicate date of receipt; however, there must be some indicator or notation on the documents that they were received by the supplier within the required time period. Some commonly accepted methods are hard-copy date stamps, hand-written dates, facsimile headers and electronic receipt dates. Regardless of the method used, it must be clear to contractor staff reviewing the claim that the date received meets the requirements in the applicable LCD.

A cautionary note about utilizing facsimile headers to document receipt date: Suppliers often rely on a fax header that includes a date and time indicator as an alternative to a date stamp. However, there are often multiple facsimile header lines that are the result of documents being faxed back and forth between the supplier and treating physician. Consequently, it is often difficult to determine the actual date of receipt of the documents by the supplier.

Suppliers should review their process for documenting the date of receipt of the documentation related to policies that requirement a receipt date. Suppliers must ensure that all documents clearly indicate the date that the documents were received. Suppliers who rely on fax header information should be especially vigilant to make sure that the receipt date is clearly indicated to avoid claim denials.


http://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2FTask%2B1_DME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FElectronic%2BData%2BInterchange%2FElectronic%2BData%2BInterchange%2B-%2BCSI%2FIndex%2Bfor%2BClaim%2BStatus%2BInquiry%2BManual&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K0SRC0AK6R2V911006&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/wcm/connect/90be9740-152f-4db5-bc9d-323ce257d06f/906_dme_ivr_user_guide_052813.pdf?MOD=AJPEREShttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B14%2B-%2BLevel%2BII%2BHCPCS%2BCodes%2Band%2BHCPCS%2BModifiers%2FDME_DMEPOS%2BHCPCS%2BJurisdiction%2BList&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B15%2B-%2BDurable%2BMedical%2BEquipment%252C%2BProsthetics%252C%2BOrthotics%252C%2Band%2BSupplies%2BPayment%2BCategories%2FInexpensive%2Bor%2BOther%2BRoutinely%2BPurchased%2BDME&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/wcm/connect/dd57b5a6-51c0-4f51-bf2b-9d0f760594e9/305_dme_redetermination_0812.pdf?MOD=AJPEREShttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/0614%20first%20quarter%202014%20supplier%20telephone%20inquiries/%21ut/p/a1/xVLJTsMwEP2VXHqM7CaOmx6jllR0RS0VjS_IcZzUVeosdhDw9TgFBAe6QA_4YPnNvBnPzBtAwAYQSZ9ERrUoJM1bTPAjHK8GQeghCGd9CG8DvApHI-giHxlCdJywmDvn4h8AAYRJXeotiGSm9jwRjNacFVJzqTvwm60DyybOzbMtTnXgrqmFMq4WWrFlQiRnHz6Iu8hKRa20VTW01ry2HGhMqinLXBikec7LbSG5JWTViFpw1ZZS0ownXIlMHhATCYgY6rm0z1wbuYiZy09tH_axjbppgin3HRzHn4M4cgJ43SDD3pVCeBcJcUbKd8KJFk9maHs4_YUHItNF74uwGIVDQ-hOPWe9vL8bYrD6pSzjC-bm1LPBLGu111tbyLQAmz-tj0kldlVFArPR7fo-a7D575Uen9Ps5_5jqrh1vBhQ7td7f5dOJlO8vEnnc5vEL-7rNHgDagP_Uw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontent%2Fngsmedicare%2Fresources%2Fconnexhttp://www.ngsconnex.com/https://www.dmepdac.com/dmecs/index.html

FEE SCHEDULE, PRICING AND OVERPAYMENTS Medicare’s Acceptance of Voluntary Refunds The acceptance of a voluntary refund as repayment for the claims specified in no way affects or limits the rights of the federal government, or any of its agencies or agents, to pursue any appropriate criminal, civil or administrative remedies arising from or relating to these or any other claims.

Notice of New Interest Rates for Medicare Overpaymentsand Underpayments – Change Request 8988 Effective 10/20/2014, the new interest rate for Medicare overpayments and underpayments is 10.75 percent.

The interest rates on overpayments and underpayments is determined in accordance with regulations promulgated by the Secretary of the Treasury and is the higher of the private consumer rate or the current value of funds rate prevailing on the date of final determination. Interest accrues from the date of the initial request for refund and is assessed for each 30-day period, or portion thereof, that payment is delayed after the initial refund request.

Interest assessed for both late payments and installment payments is computed as simple interest using a 360-day year. Simple interest is interest that is paid on the original principal balance and after each payment interest accrues on the remaining unpaid principal balance. Interest charges will not be prorated on a daily basis for overdue payments received during the month (e.g., 10, 15 or 20 days late). Interest is assessed for the full 30-day period. The interest rate on each of the final determinations will be the rate in effect on the date the determination is made.

Period Rate Interest January 17, 2013 – April 16, 2013 10.625% April 17, 2013 – July 16, 2013 10.125% July 17, 2013 – October 17, 2013 10.375% October 18, 2013 – January 20, 2014 10.125% January 21, 2014 – April 16, 2014 10.25% April 17, 2014 – July 17, 2014 10.125% July 18, 2014 – October 19, 2014 9.625% October 20, 2014 10.75%

MEDICAL POLICY Local Coverage Determination and Policy Article RevisionsSummary for 10/2/2014 Outlined below are the principal changes to Durable Medical Equipment Medicare Administrative Contractor (DME MAC) local coverage determination (LCDs) and policy articles (PAs) that have been revised and posted. Please review the entire LCDs and related PAs for complete information.


External Infusion Pumps LCD Revision Effective Date: 11/01/2014

DOCUMENTATION REQUIREMENTS: Removed: Suggested form for inotrope information

Knee Orthoses LCD Revision Effective Date: 10/01/2014

COVERAGE INDICATIONS, LIMITATIONS, and/or MEDICAL NECESSITY: Added: Codes K0901 and K0902 to Prefabricated Knee Orthoses section Added: Base Codes K0901 and K0902 to Addition Codes tables Added: Codes K0901 and K0902 to the requirement (1) for custom fabricated knee orthosis with an adjustable flexion and extension joint HCPCS CODES: Added: Codes K0901 and K0902 ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY: Added: Codes K0901 and K0902 to Group 4 Codes

Policy Article Revision Effective Date: 10/01/2014

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:| Added: Codes K0901 and K0902 to Correct coding of prefabricated knee orthoses Added: Reasonable Useful Lifetime for codes K0901 and K0902 CODING GUIDELINES: Added: Codes K0901 and K0902 to coding guidelines Added: Base Codes K0901 and K0902 to Addition Codes table

Therapeutic Shoes for Persons with Diabetes Policy Article Revision Effective Date: 11/01/2014

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES: Revised: Criterion 5 (in-person fitting requirement)

Note: The information contained in this article is only a summary of revisions to the LCDs and PA. For complete information on any topic, review the LCD and/or PA located in the Medical Policy Center.

MISCELLANEOUS SUPPLIER INFORMATION Improved Our Search Function – Your Feedback Counts Did you know that your feedback is invaluable to us? In addition to revamping our website based on your feedback, we also improved our Google search engine to better define content based on policy, topic and task. What does this mean to you? As you use the


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newly enhanced search feature, you will notice that the search results are more relative to the search term you entered and we’ve added suggested links that will be presented based on your search criteria.

Since our search is powered by Google below are some common search tricks and tips that can help further refine your search experience.

• To match an exact phrase, use quotes around the phrase – Example: “Power Mobility Device”

• If you precede a word with + that word is required to be on the page. – Example: +Order

• If you precede a word with - that word is required to not be on the page. – Example: -Requirements

• You can use these uppercase words in your search: AND, OR, NOT. These words MUST be in capital letters. This will allow you to require words and exclude others. – Example: Oxygen AND Recertification NOT Order

Are you able to more easily find the content you were searching for? Did the above examples help narrow your search? Share your thoughts with us if you like the changes we made to the NGSMedicare.com search function.

Feedback has a direct impact on your user experience, so make a positive impact by telling us what you think about our improved search capabilities. Next time you are on the newly redesigned site, remember to complete the Foresee Website Survey when it is presented to you.

Obtaining Eligibility Information You are reminded that the Medicare Program has a 12-month claim filing limit. This allows you to submit your claims to us for consideration of payment up to 365 days after the date of service.

To protect the privacy of Medicare beneficiaries, we disclose Medicare beneficiaries’ PII and PHI only when appropriate. The appropriateness to disclose this information is determined by the date of service that is entered when accessing eligibility information via the IVR. If you enter a date of service via the eligibility option (touch-tone 2) on the IVR that is beyond the 12-month timely filing, we will be unable to provide eligibility information since the date of service is past Medicare’s claim timely filing limit.

If you have a claim that has denied due to a Part A claim on file (inpatient, skilled nursing, home health, etc.), you are able to receive the Part A claim information via the Claims option on the IVR. After authentication elements have been verified via the Claims option (touch-tone 1), you may say “claims details” or touch-tone 4. You will receive discharge information which includes the admission date, discharge, and if applicable, the NPI of the facility.

Please note these guidelines are also applicable when using NGSConnex.

Related Content • Jurisdiction B DME MAC IVR User Guide • NGSConnex Quick Steps

Third Quarter 2014 Supplier Telephone Inquiries We have included a review of the top telephone inquiries for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) for the third quarter of calendar year 2014 (July–September). The Provider Outreach and Education Team works closely with the Provider Contact Center (PCC) to develop educational materials to ensure the supplier community is knowledgeable on the top telephone inquiries.


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The National Government Services Provider Contact Center received 55,671 telephone inquiries for the third quarter of 2014. Following is a list of the top ten Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) supplier telephone inquiries for the third quarter.

1. Entitlement – Same/Similar (7,441)

Claims submitted for items that are the same or similar to equipment already being used by the beneficiary will deny with American National Standards Institute (ANSI) code CO-151 (equipment is the same or similar to equipment already being used). To avoid this denial, you should evaluate the patient’s history during the intake process to determine if the same, or similar equipment, was previously obtained by the patient. You may utilize NGSConnex, Claim Status Inquiry (CSI) or the interactive voice response (IVR) system at 877-299-7900 to determine if the beneficiary’s record indicates he or she already has the same or similar equipment. If the beneficiary wants the equipment even though they already own or rent the same or similar equipment, and he or she agrees to be financially liable, the supplier should have the beneficiary sign an Advance Beneficiary Notice of Noncoverage (ABN) accepting financial responsibility for the item since it will not be covered by Medicare. You would then submit the claim with the GA modifier to indicate an ABN is on file. However, if a claim denies because the patient has previously received the same/similar equipment, and you were unaware of the previous purchase, you should refund the beneficiary (if applicable). The supplier may choose to exercise his/her right to request a redetermination. Redetermination requests may be submitted to the following address:



You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, suppliers should login to the NGSConnex application.

2. Claim Denials – Medical Necessity (4,798)

Suppliers are encouraged to consult the local coverage determinations (LCD) and policy articles for individual medical policy coverage criteria, which are located on the National Government Services website. For medical necessity denials, you are given the option to submit the claim along with supporting documentation as an appeal request. You may submit redetermination requests to the following address:



You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to NGSConnex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGSConnex, suppliers should login to the NGSConnex application.


3. Coding – Modifiers (2,747)

Claims submitted to the Medicare Program with invalid or incorrect Healthcare Common Procedure Coding System (HCPCS) and modifier combinations will result in a denial due to the claim lacking the information which is needed for complete adjudication with ANSI code CO‐16. Claims denied CO‐16 are not eligible for a redetermination or reopening request. This is because an initial claim determination could not be made with the coding information submitted. All CO‐16 denials must be resubmitted with the complete and correct coding.

For a complete listing of the HCPCS modifiers, please consult the Jurisdiction B (JB) Supplier Manual, Chapter 14. Special coverage guidelines are published in each individual medical policy. The LCDs and policy articles (PAs) provide specific instructions for using the informational modifiers listed within the medical policy. The LCDs and policy articles may be accessed through the Medical Policy Center on our website.

You may also utilize the Durable Medical Equipment Coding System (DMECS) to verify if the HCPCS code requires a primary pricing modifier. DMECS provides HCPCS coding assistance and national pricing information via searches for HCPCS Level II codes and modifiers, DMEPOS items and Centers for Medicare & Medicaid Services (CMS) national fee schedules.

4. Claim Denials – Contractual Obligation Not Met (3,552)

Some claims submitted to the DME MAC reject because the provider did not comply with his or her Medicare contractual obligation. For example, the claim was presented with missing information (other than codes or modifiers), the billing was not timely, etc. You should reference the JB Supplier Manual, Chapter 12 for instructions on claim completion as well as claim filing time limits and other helpful information.

5. Claim Denials – Claim Overlap (3,261)

Some claims submitted to the DME MAC will be denied when the beneficiary was in a home health agency (HHA) episode, inpatient hospital stay, or a skilled nursing facility (SNF) Part A stay on the date of service on the supplier’s claim. This is because payment for certain DMEPOS items are included in the reimbursement for the HHA, hospital or SNF Part A stay under the consolidated billing rules. You may not submit claims to Medicare for certain items provided to a beneficiary when the DMEPOS item the beneficiary received is covered under the HHA benefit, inpatient hospital benefit, or SNF benefit, nor may the supplier bill the patient for those items.

When a supplier’s claim overlaps another supplier’s claim for the same or similar dates of service or billing periods due to an error in another supplier’s billing, you may contact the Provider Contact Center for assistance at 866-590-6727. You must be prepared to provide his/her name, National Provider Identifier (NPI), Provider Transaction Access Number (PTAN), last five-digits of the Tax Identification Number (TIN), beneficiary name, Health Insurance Claim Number (HICN) and date of service for postclaim information, or date of birth for preclaim information.

6. Claim Status – Payment/Explanation/Calculation (2,813)

DMEPOS items and/or services are paid based on three payment methodologies: (1) fee schedules, (2) reasonable charge and (3) drugs and biologicals. Most DME payments are based on a fee schedule. A standard fee is established for each DMEPOS item by state.

The Medicare Pricing, Data Analysis, and Coding (PDAC) Contractor can assist DMEPOS suppliers with locating fee schedule allowable for a particular product by state. In addition, the PDAC is responsible for determining the appropriate HCPCS code to use when submitting DMEPOS claims to Medicare,


processing coding verification applications, assigning existing HCPCS codes to products and maintaining a national drug code (NDC)/HCPCS code crosswalk applicable to DME billing.

7. Claim Denials – Certification Requirements (2,598)

This denial is given when a claim is submitted with an outdated prescription, Certificate of Medical Necessity (CMN) or DME Information Form (DIF). You should utilize CSI, NGSConnex or the IVR system at 877-299-7900 to verify if the item was previously provided or is on file with Medicare. If the item is on file, CSI, NGSConnex and the IVR will provide the previous supplier’s name and telephone number. You are encouraged to work with the beneficiary to ensure that equipment and supplies are only provided when they are medically necessary. In this situation, the new supplier would need to validate the discontinuance of the first piece of equipment and determine if a break in billing or break in need has occurred. Claims that deny for this reason must be resubmitted with a current prescription, CMN or DIF.

8. Claim Denials – Local Coverage Determination (2,077)

Verify your claim status by utilizing the IVR system, NGSConnex or CSI. Verify your claim was submitted to the correct DME MAC. More information regarding claim filing jurisdiction can be found in the JB Supplier Manual, Chapter 11. If the claim is not on file and you submitted a paper claim, please resubmit the claim. If the claim is not on file and you submitted an electronic claim, contact your software vendor.

9. Claim Denials – Statutory Exclusion (2,023)

Section 1861(s) of the Social Security Act defines medical services that are covered by Medicare, which in turn are implemented through federal regulations, Medicare manuals, instructions from the CMS and decisions by the individual DME MACs that administer the Medicare Program in each jurisdiction. Services that are not included in those definitions or instructions are not covered by Medicare. CMS has provided instructions regarding the general exclusions from Medicare coverage in the CMS Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage.”

Suppliers are encouraged to review the Jurisdiction B Supplier Manual, Chapter 17 for an overview of denial categories billed to Medicare. Special coverage guidelines are published in individual medical policies which can be found in the Medical Policy Center on our website. In addition, the LCDs and PAs both provide specific instructions when an item or service indicated in the LCD and PA are deemed to be excluded from coverage.

10. Claim Denials – Provider Number (1,756)

A supplier’s enrollment in the Medicare Program must be current in order for claims to process and be considered for payment. To ensure you are enrolled and your enrollment is up to date, you should contact the National Supplier Clearinghouse. Medicare will also deny DMEPOS claims if the ordering/referring physician is not identified, not enrolled in Provider Enrollment, Chain and Ownership System (PECOS), or not of a specialty type that may order/refer the service/item being billed. You may reference the Ordering/Referring Physician Checklist for Durable Medical Equipment, Prosthetic, Orthotic, and Supplies Suppliers checklist on our website for assistance.

Related Content • Benefit and Denial Categories, Chapter 17, JB Supplier Manual • Claim Filing Jurisdiction, Chapter 11, JB Supplier Manual • Claim Submission, Chapter 12, JB Supplier Manual


• CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, “General Exclusions from Coverage”

• CSI Information • DMECS • IVR System • Level II HCPCS Codes and HCPCS Modifiers, Chapter 14, JB Supplier Manual • Medical Policy Center • Medicare DME Redetermination Request Form • National Supplier Clearinghouse • NGSConnex Information • NGSConnex Website • Pricing, Data Analysis, and Coding Contractor’s Website • Revised: Ordering/Referring Physician Checklist for Durable Medical Equipment, Prosthetic, Orthotic,

and Supplies Suppliers

Third Quarter 2014 Supplier Written Inquiries We have included a review of the top supplier written inquiries for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) for the third quarter of calendar year 2014 (July–September). The National Government Services Written Correspondence Unit received 4,539 written inquires for the third quarter. Following is a list of the top ten Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) supplier written inquiries for the third quarter.

1. Claim Denials – Coding Errors including Modifiers (1,063)

Claims submitted to the Medicare Program with invalid or incorrect Healthcare Common Procedure Coding System (HCPCS) and modifier combinations will result in a denial due to the claim lacking the information which is needed for complete adjudication with American National Standards Institute (ANSI) code CO‐16. Claims denied CO‐16 are not eligible for a redetermination or reopening request. This is because an initial claim determination could not be made with the coding information submitted. All CO‐16 denials must be resubmitted with the complete and correct coding.

For a complete listing of the HCPCS modifiers, please consult the Jurisdiction B (JB) Supplier Manual, Chapter 14. Additionally, specific instructions regarding modifier usage is located in the JB Supplier Manual, Chapter 15 “DMEPOS Payment Categories.” For specific instructions on using the informational modifiers listed within the medical policy, please go the Medical Policy Center located on our website.

You may also utilize the DME Coding System (DMECS) to verify if the HCPCS code requires a primary pricing modifier. DMECS provides HCPCS coding assistance and national pricing information via searches for HCPCS Level II codes and modifiers, DMEPOS items and Centers for Medicare & Medicaid Services (CMS) national fee schedules.

2. Claim Denials – DMEPOS Issues (599)

Maintenance and Servicing

Medicare covers maintenance and servicing of some DME items depending upon the situation and the benefit category into which the item falls. For detailed information on the coverage and billing of maintenance and servicing, refer to the JB Supplier Manual, Chapter 15.


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.htmlhttp://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.htmlhttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/0614%20first%20quarter%202014%20supplier%20telephone%20inquiries/%21ut/p/a1/xVLJTsMwEP2VXHqM7CaOmx6jllR0RS0VjS_IcZzUVeosdhDw9TgFBAe6QA_4YPnNvBnPzBtAwAYQSZ9ERrUoJM1bTPAjHK8GQeghCGd9CG8DvApHI-giHxlCdJywmDvn4h8AAYRJXeotiGSm9jwRjNacFVJzqTvwm60DyybOzbMtTnXgrqmFMq4WWrFlQiRnHz6Iu8hKRa20VTW01ry2HGhMqinLXBikec7LbSG5JWTViFpw1ZZS0ownXIlMHhATCYgY6rm0z1wbuYiZy09tH_axjbppgin3HRzHn4M4cgJ43SDD3pVCeBcJcUbKd8KJFk9maHs4_YUHItNF74uwGIVDQ-hOPWe9vL8bYrD6pSzjC-bm1LPBLGu111tbyLQAmz-tj0kldlVFArPR7fo-a7D575Uen9Ps5_5jqrh1vBhQ7td7f5dOJlO8vEnnc5vEL-7rNHgDagP_Uw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontent%2Fngsmedicare%2Fclaims%2Felectronic%2Bdata%2Binterchange%2Fenrollment%2Binformationformshttps://www.dmepdac.com/dmecs/index.htmlhttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/0614%20first%20quarter%202014%20supplier%20telephone%20inquiries/%21ut/p/a1/xVLJTsMwEP2VXHqM7CaOmx6jllR0RS0VjS_IcZzUVeosdhDw9TgFBAe6QA_4YPnNvBnPzBtAwAYQSZ9ERrUoJM1bTPAjHK8GQeghCGd9CG8DvApHI-giHxlCdJywmDvn4h8AAYRJXeotiGSm9jwRjNacFVJzqTvwm60DyybOzbMtTnXgrqmFMq4WWrFlQiRnHz6Iu8hKRa20VTW01ry2HGhMqinLXBikec7LbSG5JWTViFpw1ZZS0ownXIlMHhATCYgY6rm0z1wbuYiZy09tH_axjbppgin3HRzHn4M4cgJ43SDD3pVCeBcJcUbKd8KJFk9maHs4_YUHItNF74uwGIVDQ-hOPWe9vL8bYrD6pSzjC-bm1LPBLGu111tbyLQAmz-tj0kldlVFArPR7fo-a7D575Uen9Ps5_5jqrh1vBhQ7td7f5dOJlO8vEnnc5vEL-7rNHgDagP_Uw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontent%2Fngsmedicare%2Fresources%2Fcontact%2Bus%2Finteractive%2Bvoice%2Bresponse%2Bsystem%2B%25282%2529http://www.ngsmedicare.com/ngs/wcm/connect/bd8a6e004592ce0191d7b9855ca2ccfc/305_dme_redetermination_0812.pdf?MOD=AJPEREShttp://www.palmettogba.com/nschttp://www.ngsconnex.com/https://www.dmepdac.com/dmecs/index.htmlhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FNews-And-Alerts%2FNews-Articles%2FContent%2FRevised%2BOrdering%2BReferring%2BPhysician%2BChecklist%2Bfor%2BDurable%2BMedical%2BEquipment%252C%2BProsthetic%252C%2BOrthotic%252C%2Band%2BSupplies%2BSuppliers&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FNews-And-Alerts%2FNews-Articles%2FContent%2FRevised%2BOrdering%2BReferring%2BPhysician%2BChecklist%2Bfor%2BDurable%2BMedical%2BEquipment%252C%2BProsthetic%252C%2BOrthotic%252C%2Band%2BSupplies%2BSuppliers&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20B

Break in Need/Break in Service

Under the Medicare Part B Program, monthly rental payments may be made for certain DME that is provided to a beneficiary for a period of continuous use. If there is an interruption in the use/medical need for capped rental equipment, a parenteral and enteral nutrition (PEN) pump, or oxygen equipment that is greater than 60 days plus the days remaining in the month the use ceases, the period of continuous use leading up to the break ends and a new period of continuous use begins when the beneficiary again has a medical need for the equipment. (For oxygen equipment, a new period of continuous use may begin following a break in need that is greater than 60 days plus the days remaining in the last paid rental month, only when that break in need occurs during the 36-month payment period.) Suppliers must provide break-in-need (BIN)/break-in-service (BIS) information on claims following a break in need to identify that a new capped rental period is beginning. A physician’s order, new initial Certificate of Medical Necessity (CMN), if applicable, new testing, if applicable, and all medical necessity criteria must be met as outlined in the local coverage determination (LCD).

Suppliers who have an Administrative Simplification Compliance Act (ASCA) waiver on file should utilize the Jurisdiction B DME MAC Break-in-Service Form and submit it with their CMS-1500 claim form.

For suppliers submitting claims electronically, the BIS information is reported in the Note (NTE) segment in the order and format as follows:

Order:

1. The abbreviation “BIS” for break in service/break in need

2. The “pick up” date and the “delivery” date

3. The beneficiary’s previous International Classification of Diseases, Clinical Modification, 9th Revision (ICD-9-CM) diagnosis code and the new ICD-9-CM diagnosis code

The “pick up” date refers to the date the new and/or previous supplier removes the piece of equipment from the patient’s home. The “delivery” date will be the most recent date the new item was delivered.

Format: BIS MMDDYY MMDDYY ICD-9 ICD-9

For detailed information pertaining to interruptions in a period of continuous use (break in need/break in service), refer to the JB Supplier Manual, Chapter 15.

3. General Information – Issue Not Identified/Incomplete Information (543)

You are reminded to include as much detail as possible when submitting a written inquiry to the Jurisdiction B DME MAC Written Correspondence Department. When submitting an inquiry in writing, the following information should be included:

• Beneficiary’s name • Medicare Health Insurance Claim Number (HICN) • Service date(s) • Service/supply rendered • Charges for the supply/service • Outline of the problem or questions (be specific) • Copy of the original remittance, if applicable


All written inquiries should be mailed to the following address:

National Government Services, Inc. Jurisdiction B DME MAC Correspondence P.O. Box 6036 Indianapolis, IN 46206-6036

4. Claim Denials – Medical Necessity (369)

You should refer to each individual medical policy to verify coverage criteria for an item and/or service. The medical policies can be found on our website. For medical necessity denials, you are given the option to submit the claim along with supporting documentation as an appeal request. You may submit redetermination requests to the following address:

DME MAC Redeterminations P.O. Box 6036 Indianapolis, IN 46206-6036


You also have the option to submit redetermination requests via a secure Internet portal called NGSConnex. Access to Connex only requires users to have the Internet and an email address. There are no costs associated with using this application. For additional information regarding NGS Connex, suppliers should login to the NGSConnex application.

5. RTP/Unprocessable – Missing/Invalid Diagnosis (326)

The diagnosis code is required when submitting a claim to Medicare and is reported on the Medicare CMS1500 paper claim in Item 21 or the corresponding segment of the electronic claim format. It is the supplier’s responsibility to code the diagnosis to the highest specified ICD-9-CM code. If you are unable to determine the highest level of specificity, you are encouraged to contact the ordering physician. If claims received are not coded to the highest level of specificity, the claim will be returned to the supplier as unprocessable. You must correct the diagnosis code and resubmit the claim.

The diagnosis pointer is also required and must be reported in Item 24e of the 1500 paper claim form or the corresponding segment of the electronic claim format. In Item 24e (or the corresponding segment of the electronic format), the supplier must indicate the number that corresponds to the diagnosis code reported in Item 21 that supports the need for the item being billed on that line. You must enter only one number 1, 2, 3 or 4 in item 24e.

6. Claim Status – Claim Status (282)

The Jurisdiction B DME MAC telecommunications system is equipped with an interactive voice response system. You can obtain claim status information from the interactive voice response (IVR) system from 7:00 a.m. to 6:00 p.m. eastern time (ET), Monday through Friday, and 7:00 a.m. to 3:00 p.m. ET most Saturdays by calling 877-299-7900. For additional information regarding the IVR unit, suppliers should refer to the IVR user guide.

All suppliers submitting claims electronically or on paper are eligible for Claim Status Inquiry (CSI). This applies to participating and nonparticipating suppliers. With access to CSI, submitters can view the status of all claims as they appear in the DME MAC claims processing system. This includes paid, denied, and pending claims.


NGSConnex is a web application aimed at suppliers and offering access to a wide array of Medicare information. This application will help answer questions, address Medicare issues, assist in solving problems and will guide suppliers to business forms. NGSConnex is a free service available to all Jurisdiction B DME MAC suppliers.

A Rules of Behavior Document, Quick Steps Job Aid and NGSConnex training materials are available on the NGSConnex website. These documents should be reviewed prior to registering in this application.

7. Claim Denials – Duplicate (235)

The Jurisdiction B DME MAC receives a large quantity of claims that result in duplicate denials. The duplicate claim submission is often the number one claims submission error. Generally claim submission errors are services/items previously processed for the same patient, date of service and HCPCS code.

You are reminded to allow 14 days for electronically submitted claims and 29 days for hard copy claims before resubmitting a claim to the DME MAC. You should utilize CSI, NGSConnex or the IVR system at 877-299-7900 before resubmitting the claim for payment.

If you received a duplicate claim denial for an item that is not an actual duplicate item, you may request an appeal. Submit supporting documentation along with your appeal request, within 120 days from the date of the initial determination, to the following address:

National Government Services, Inc. P.O. Box 6036 Indianapolis, IN 46206-6036

You may also utilize NGSConnex to submit an appeal. More information regarding NGSConnex is available on the National Government Services website.

For additional information regarding steps to take to avoid duplicate denials, please review the article titled “How To Prevent Duplicate Claim Denials” on our website.

8. Return to Provider Unprocessable – Submitted to Incorrect Program (191)

The traditional fee-for-service Medicare Program consists of two parts: Part A, hospital insurance and Part B, medical insurance. Medicare Part A helps cover inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Part B covers doctors’ services, outpatient care, some of the services of physical and occupational therapists, some home health care and medically necessary DMEPOS. Suppliers should refer to the CMS Internet-Only Manual (IOM) Publications for Medicare coverage criteria requirements of items and services specific for each Medicare Program. The CMS IOM Publications are located on the CMS website.

9. Claim Denials – Frequency/Dollar Amount Limitation (155)

You should refer to each individual local medical policy to verify coverage criteria for an item and/or service. When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, you must obtain information supporting the medical necessity for the higher utilization. This information must be retained in your file and be available to the Jurisdiction B DME MAC upon request. Medical policies can be accessed from the Medical Policy Center section of our website.

For medical necessity denials, suppliers are given the option to request a redetermination by submitting supporting documentation along with the request. You may file your redetermination within 120 days from the date of the initial determination to the following address:


National Government Services, Inc. P.O. Box 6036 Indianapolis, IN 46206-6036

You may also utilize NGSConnex to submit an appeal. More information regarding NGSConnex is available on our website.

10. DMEPOS Competitive Bidding Program – Claim Denials (93)

Claims submitted to Medicare that are part of the Competitive Bidding Program need to be billed correctly or they will result in a claim denial. For information regarding the Competitive Bidding Program, refer to the JB Supplier Manual, Chapter 3. For information regarding Competitive Bidding modifiers, refer to the JB Supplier Manual, Chapter 14. For assistance in determining the appropriate use of the KE or KY modifiers with base codes for noncompetitively bid based items for Round 2 Competitive Bid, you can utilize the KE/KY Code Search Tool that is available on our website.

Related Content • CMS Website for IOMs • DMEPOS Payment Categories, Chapter 15, JB Supplier Manual • How To Prevent Duplicate Claim Denials • Jurisdiction B DME MAC Break-in-Service Form • Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor Provider Interactive

Voice Response User Guide • KE/KY Code Search Tool • Level II HCPCS Codes and HCPCS Modifiers, Chapter 14, JB Supplier Manual • Medical Policy Center • Medicare DMEPOS Competitive Bidding Program, Chapter 3, JB Supplier Manual • Medicare DME Redetermination Request Form • NGSConnex Information • NGSConnex Website

Drugs/Infusion/Parenteral and Enteral Nutrition

DRUGS Correct Coding – Oral Anticancer Drugs and PDAC’sNDC/HCPCS Crosswalk Listings Joint DME MAC Publication

Occasionally pharmaceutical manufacturers release drugs with national drug code (NDCs) and they do not immediately appear on the NDC/Healthcare Common Procedure Coding System (HCPCS) crosswalk list maintained by the Pricing, Data Analysis and Coding Contractor (PDAC) (see article from April 2013 entitled “Oral Anti-Cancer Drugs – Coding and Billing Change”). This recently happened when Roxane Laboratories, Inc., a manufacturer of oral cyclophosphamide, discontinued their tablet forms of the drug and substituted capsules. Initially the capsule forms of the drug (NDC 00054-0382-25 for the 25 mg strength and NDC 00054-0383-25 for the 50 mg strength) were not on the NDC/HCPCS crosswalk list. This list has now been updated to reflect the new dosage forms and NDC numbers for Roxane’s cyclophosphamide.


http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.htmlhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B15%2B-%2BDurable%2BMedical%2BEquipment%252C%2BProsthetics%252C%2BOrthotics%252C%2Band%2BSupplies%2BPayment%2BCategories%2FDMEPOS%2BPayment%2BCategories%2BOverview&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FClaim%2BSubmission%2BArticles%2Band%2BModifier%2BTips%2FHow%2Bto%2BPrevent%2BDuplicate%2BClaim%2BDenials&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/wcm/connect/5c586df2-b1bc-4b7e-8a75-e4d66949e0ec/263_0309_dmemac_bisform_508.pdf?MOD=AJPEREShttp://www.ngsmedicare.com/ngs/wcm/connect/90be9740-152f-4db5-bc9d-323ce257d06f/906_dme_ivr_user_guide_052813.pdf?MOD=AJPEREShttp://www.ngsmedicare.com/ngs/wcm/connect/90be9740-152f-4db5-bc9d-323ce257d06f/906_dme_ivr_user_guide_052813.pdf?MOD=AJPEREShttp://authornew.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0K8N200AC30AF6N04E5&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B14%2B-%2BLevel%2BII%2BHCPCS%2BCodes%2Band%2BHCPCS%2BModifiers%2FStructure%2Bof%2BHCPCS%2BCodes&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://authornew.ngsmedicare.com/ngs/poc/ngsmedicare?uri=wcm:path:&page=Z6_4AIE11C0KOD170AK4P0HTO0G95&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/poc/ngsmedicare?1dmy&urile=wcm%3apath%3a%2FNGSMedicareContentNEW%2FNGSMedicareNEW%2FPublications%2FManuals%2FSupplierManual%2FChapter%2B3%2FOverview&LOB=DME&LOC=All%20States&ngsLOC=All%20States&ngsLOB=DME&jurisdiction=Jurisdiction%20Bhttp://www.ngsmedicare.com/ngs/wcm/connect/bd8a6e004592ce0191d7b9855ca2ccfc/305_dme_redetermination_0812.pdf?MOD=AJPEREShttp://www.ngsconnex.com/

If a supplier bills an oral anticancer drug with an NDC number that is not on the NDC/HCPCS crosswalk list, the claim will receive a front-end reject by Common Electronic Data Interchange (CEDI). To avoid this situation, suppliers should follow the instructions in the Coding Guidelines section of the oral anticancer drugs related policy article which states:

A list of valid NDC numbers called the “NDC/HCPCS Crosswalk” for covered oral anticancer drugs can be found on the Pricing, Data Analysis and Coding (PDAC) Contractor web site. Until a newNDC number is added to the list, suppliers must submit claims using code J8999.

Until a new NDC number is added to the list in the monthly update, suppliers have two options:

1. Hold claim submission until the NDC/HCPCS Crosswalk reflects the monthly update of covered OACDs; or,

2. Submit claims using code J8999.

Claims submitted using code J8999 must include the name of the drug, the manufacturer, the NDC number, the dosage strength of each drug form (e.g., capsule, tablet, suppository, liquid) and the number of tablets or capsules dispensed. This information must be entered in the narrative field of an electronic claim (NTE 2300 or NTE 2400 of an electronic claim) or Item 19 of a paper claim.

The NDC/HCPCS Crosswalk files can be found on the PDAC website.

Related Content • Oral Anticancer Drugs – Coding and Billing Change • Oral Anticancer Drugs – Policy Article – Effective March 2014 (A47234) • NDC/HCPCS Crosswalk

Mobility/Respiratory

MOBILITY Submit a Power Mobility Devices Prior AuthorizationRequest Suppliers who furnish PMD to fee-for-service Medicare beneficiaries residing in Illinois, Indiana, Kentucky, Michigan or Ohio (residence is based on the address reported to Social Security) may submit a PMD PAR to National Government Services. The request must include the following information to be a valid:

• PMD PAR coversheet • Seven-element order • Face-to-face examination • Detailed product description • Specialty evaluation (if required by medical policy) • Other relevant medical documentation


http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/oral%20anticancer%20drugs/correct%20coding%20-%20oral%20anticancer%20drugs%20and%20pdacs%20ndc%20hcpcs%20crosswalk%20listings/%21ut/p/a1/3VPbToNAEP2V9qGPZHdhufRxgS3FtksvEAovZOXS0JSLWjX69dKqTbRBbDQxcV92Z_bMZM6ZGRCCNQhL_pBv-D6vSr472KESYWJThAw4cbQxhGRiEkyYJVlYagBBO8BZwUvjJUeDBI9001zMJUsXu-J9EILQN2aRNXV0Mo0Mh7l07YJgAJm1mqVJHvPb1KjKfVruGfU_uI_2vNrl8dP73aPJfXxk33OrOo_vBtCc0ajlEwQOCG_ER_d6c6ijjvMEBDBDQzXVYkGRkCxgVUMCT2AqaMM0gykfSpgrb7xhyyHwW7w7lP8EMChppDWZwsgIOVA-A5xrfwR8UWTQsFBbyzQgWF0oS0dC8TXhod8Ljy4b9N-1_leJof9CDMqoGSID2yoej0XHVX86ApZn00YpfeJNPSjaFr444VXnLs1PS-wT_fSuC88rtG02VZY0Y0zggSbJ9fY5K4qoMUNK-v0X0Fj9oA%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Fpolicy%2Beducation%2Btopics%2Foral%2Banticancer%2Bdrugs%2Foral%2Banti-cancer%2Bdrugs%2B-%2Bcoding%2Band%2Bbilling%2Bchangehttp://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-education/oral%20anticancer%20drugs/correct%20coding%20-%20oral%20anticancer%20drugs%20and%20pdacs%20ndc%20hcpcs%20crosswalk%20listings/%21ut/p/a1/3VPbToNAEP2V9qGPZHdhufRxgS3FtksvEAovZOXS0JSLWjX69dKqTbRBbDQxcV92Z_bMZM6ZGRCCNQhL_pBv-D6vSr472KESYWJThAw4cbQxhGRiEkyYJVlYagBBO8BZwUvjJUeDBI9001zMJUsXu-J9EILQN2aRNXV0Mo0Mh7l07YJgAJm1mqVJHvPb1KjKfVruGfU_uI_2vNrl8dP73aPJfXxk33OrOo_vBtCc0ajlEwQOCG_ER_d6c6ijjvMEBDBDQzXVYkGRkCxgVUMCT2AqaMM0gykfSpgrb7xhyyHwW7w7lP8EMChppDWZwsgIOVA-A5xrfwR8UWTQsFBbyzQgWF0oS0dC8TXhod8Ljy4b9N-1_leJof9CDMqoGSID2yoej0XHVX86ApZn00YpfeJNPSjaFr444VXnLs1PS-wT_fSuC88rtG02VZY0Y0zggSbJ9fY5K4qoMUNK-v0X0Fj9oA%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpolicy%2Flcds%2Band%2Bpolicy%2Barticles%2B-%2Bmpc%2Bcontent%2Fa47234_futurehttps://www.dmepdac.com/crosswalk/index.html

You can submit your PMD PAR via NGSConnex, fax, mail or esMD:

NGSConnex Fax Mail esMD http://www.NGSConnex.com

Instructions on how to submit Prior Authorization Requests for PMD using Connex are found in the Quick Steps Job Aid on the NGSConnex home page.

317-841-4414 National Government Services, Inc. Attn: Medical Review - PMD Prior Authorization Request P.O. Box 7018 Indianapolis, IN 46207-7018

Electronic Submission of Medical Documentation (esMD)—Additional information located in Chapter 6 of the JB Supplier Manual.

Current Top Reasons for Nonaffirmed Prior Authorization Requests 1. The F2F examination and other medical records submitted for review contain conflicting information. 2. The seven-element order contains an invalid date of the F2F examination. 3. The F2F examination received was insufficient and did not contain enough information to satisfy the

requirements Medicare has established for the PMD. a. Key areas of the F2F examination that lack the necessary Medicare requirements for PMDs

include: i. The F2F examination indicates there is a physical or mental deficit that is not explained that may

prevent the safe use of the PMD. ii. The F2F examination does not indicate that the beneficiary has the physical and/or mental

capability to safely operate the PMD being requested. iii. The F2F examination does not indicate that the beneficiary's limitation of upper extremity

function is insufficient to self-propel an optimally-configured manual wheelchair in the home in order to perform MRADLs.

iv. The F2F examination does not indicate the beneficiary is able to safely transfer to and from the power mobility device.

v. The F2F examination does not indicate the beneficiary is able to operate the tiller steering system of the power mobility device.

vi. The F2F examination does not indicate the beneficiary's mobility limitations that would establish significant impairment to participate in MRADLs within their home.

4. The documentation does not include a signed and dated attestation by the supplier or LCMP stating they have no financial relationship with the supplier.

Reporting a Unique Tracking Number for Power MobilityDevice Prior Authorization Requests If you receive an affirmed decision on a PMD PAR, you are required to submit the UTN on the claim.

• The UTN is located on the decision letter sent by National Government Services. • For paper claims, the UTN is reported in Item 23 of the CMS-1500 paper claim form. • For electronic claims, the unique tracking number is submitted at either loop 2300 REF02 (REF01= G1)

or loop 2400 REF02 (REF01 = G1). • For electronic submitters, if you are unsure where these loops are, please contact your software

vendor. • Failure to submit the UTN on the claim in the appropriate field may result in a delay of processing the

claim.


http://www.ngsconnex.com/http://www.ngsconnex.com/http://www.ngsconnex.com/http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/complianceandaudits/medical-review/medical-review-focus-areas/medical-review-focus-areas-detail/dme_submit%20a%20pmd%20par/%21ut/p/a1/vVLJbsIwFPwVX3KM7MQhDcewFtqwhLIkF2QcAy7EsRIDar--DqCWSqW0UlWfPPZ43njegzGcwViQPV8RxTNBtiWO3bnjd5qWVUcP7W6ngvzRYDieOKGFhi6cwhjGBdkzmmUbzkpEt4zkHzBstjv93vFCKKnWMBKrImUJpyTXr4RiQgl2MNDF8RHTLJVbTgRlgIgEkF3CVWGgE2cLcrbnJe0zBsuM7gqgNUgBip2UWa64WBkoSdm82C1SrgABMk2AJHlpSlKewGiBMcK27ZqO41VNJ3Ft0_MQMxNq4YpnIUxZtWQ_9mswagRNHUykg0FXlo9-lNslpY_7HvKdVq3RGA5wu2afCd-UiLSHu6tFAgRHv_zgDUH7JDitB_PhuBlq9kXjNbpsvIbnxuvde2p_asf6ZzvdWz3VM2HnQT1YaVmi1iYXywzOvhy8aQvGEzswEDlAmW7CtodTc4aeK3L_-uT79-m8F_g-W3gvePMGEx6cCw%21%21/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?1dmy&urile=wcm%3apath%3a%2Fngsmedicarecontentnew%2Fngsmedicarenew%2Fpublications%2Fmanuals%2Fsuppliermanual%2Fchapter%2B6

National Government Services, the Jurisdiction B DME MAC have been processing PMD PARs for beneficiaries residing in Illinois, Indiana, Kentucky, Michigan and Ohio.

Tips for Correctly Completing a Detailed ProductDescription PMD PAR submitted with incorrect DPD will result in a nonaffirmed decision.

If you submit an incorrect DPD with your claim, it may deny as not medically necessary.

Below are common errors we see on returned DPDs and tips on how to avoid these errors.

A. The DPD is signed and dated prior to the face-to-face examination and/or the seven-element order.

• For a DPD to be considered valid, the face-to-face examination must be completed prior to the signature and signature date on the DPD.

• The DPD must also be dated on or after the seven-element order was received by the supplier.

B. The DPD is signed and dated by a physician other than the treating physician.

• The DPD requires a signature and signature date from the treating physician. • This typically refers to the physician who completed the seven-element order. • A different physician other than the ordering physician may sign and date the DPD only if the

ordering physician has a significant absence, such as a lengthy sick leave or maternity leave, etc. • The alternative physician signing the DPD should have access to the medical records that will

support the PMD. • Also, a rationale should be provided along with the PMD PAR if a different physician is signing the

DPD.

C. The PMD on the DPD is considered an upgrade.

• When a beneficiary meets the coverage criteria stated in the medical policy but requests a different PMD, then suppliers are able to provide a different PMD as an upgrade.

• The DPD should have the PMD that is being delivered to the beneficiary, not the PMD that meets coverage criteria.

• The medical records should support the PMD that the beneficiary meets per coverage criteria. • It is suggested that the PMD PAR clearly advise that the request contains an upgrade situation by

specifying the HCPCS code of the PMD being requested for PAR and the HCPCS code of the PMD that will be delivered.

Note: Medicare only makes reimbursement for items that meets Medicare’s coverage criteria. Suppliers may refer to Chapter 10 of the Jurisdiction B Supplier Manual for information on situations that involve upgrades.

National Government Services, the Jurisdiction B DME MAC, has been processing PMD PARs for beneficiaries with residence in Illinois, Indiana, Kentucky, Michigan and Ohio.

Widespread Prepayment Probe Review – ManualWheelchairs Jurisdiction B will be initiating a widespread prepayment probe review of manual wheelchair bases (E1161, and K0001–K0009 except K0005) billed with accessories.


During 2013, data analysis has shown an increase in submitted charges for manual wheelchair bases and accessories submitted to Jurisdiction B. Data analysis identified this area as having a high CERT error rate with an increase in claims and submitted charges in Jurisdiction B.

Suppliers will receive an ADR letter for the following information:

• A copy of the DWO signed and dated by the treating physician. For items with initial DOS 1/1/2014, the detailed written order must include the physician’s NPI and be signed and dated by the physician prior to dispensing per ACA 6407.

• A dispensing order, if the DWO is signed and dated after the DOS for those items not requiring a WOPD.

• For all claims, documentation indicating the general coverage criteria has been met as well as additional criteria for specific manual wheelchairs as stated in LCD L27014.

• For subsequent month’s claims, a copy of the medical records that contain information supporting the continued medical necessity of the manual wheelchair.

• Documentation of proof of delivery. • If there is an ABN on file, please submit the ABN with the requested documentation.

It is important for you to be familiar with the documentation requirements and utilization parameters as outlined in the LCD for manual wheelchair bases (L27014) and the LCD for wheelchair options/accessories (L27223). Please ensure when submitting additional documentation, that all medical necessity documentation is current for date of service. Your responses should also be submitted timely. You can review the LCD on our website. You may also find useful information and articles on our Policy Education page.

Related Content • LCD for Manual Wheelchair Bases (L27014) • LCD for Wheelchair Options/Accessories (L27223) • Policy Education Topics

RESPIRATORY Billing Reminder for Secondary Ventilators We continue to see a high number of reopenings for secondary ventilators. Patients may qualify for both a primary ventilator and a secondary ventilator in certain situations. Below are examples of when a patient will qualify:

• A patient requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., positive pressure ventilator with a nasal mask) during the rest of the day.

• A patient who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and requires a stationary ventilator of the same type for use while in bed. Without two pieces of equipment the patient may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.

As a reminder, Medicare does not pay separately for backup equipment but Medicare will make a separate payment for a second piece of equipment if it is required to serve a different purpose that is determined by the patient’s medical needs.


http://www.ngsmedicare.c

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