Monthly Archives: January 2017

DME MACs Local Coverage Determination (LCD) Format Change

If you are a supplier that dispenses DMEPOS to Medicare beneficiaries, then you know Medicare requires certain documentation to meet coverage criteria. This coverage criterion is necessary to determine if DME is reasonable and necessary for each beneficiary.

The requirements are located in every LCD on each jurisdiction’s website. In 2011, the DME MACs added the DOCUMENTATION REQUIREMENTS section because of the frequency at which providers were supplying incomplete or missing documentation, needed to determine medical necessity for each beneficiary and lower the improper payment rate. Since this time, minor changes within these requirements have required a tremendous effort and administrative burden to keep each LCD updated.

In a recent Joint DME MAC Publication, CMS said it will be changing the format of these LCDs during their annual LCD review. The GENERAL DOCUMENTATION REQUIREMENTS section for all LCDs will be moved to their related Policy Article for reference. The GENERAL DOCUMENTATION REQUIREMENTS section contains standardized requirements, which provide detailed information on each key payment rule. In addition, the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section, which also appears within each LCD, will be moved to their respective Policy Article. The POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section contains coverage criteria specific to that piece of DME, which is required for payment purposes.

These changes will take place in early January 2017 and will not add any new or remove any existing Medicare documentation requirements. When these changes are implemented, you will need to access all three documents: the LCD, the Policy Article and the new Standard Documentation Requirements.

CMS release changes to High Liter-Flow O2 payments

CMS has released its updated manual for payment for oxygen volume adjustments and portable oxygen equipment. Change Request (CR) 9848, effective April 1 with implementation date April 3, provides instructions and a summary of changes for processing claims for oxygen and oxygen equipment under the Medicare Part B benefit for durable medical equipment.

The background provides information on when the fee schedule amount is increased based on conditions listed.

It also includes two informational modifiers to indicate the beneficiary has been prescribed high-liter flow oxygen and has a qualifying test on a minimum of 4 liters/minute.

  • QF-used with portable equipment
  • QG-used with stationary equipment

Claims processing scenarios are also provided.

What you should know

After April 1:

  • When a patient has stationary and portable equipment, suppliers should bill both stationary (HCPCS E0424, E0439, E1390 or E1391) and portable (E0431, E0433. E0434, E1392 or K0738) using the QF modifier. The stationary unit will be paid at standard rates, and the portable equipment will be paid at the higher fee schedule rate of the volume adjustment (50 percent of stationary) or portable add-on rental rate. The QF modifier will require the portable oxygen to be billed in order to receive the maximum reimbursement rate under this new guidance.
  • When a patient has only stationary equipment, suppliers should bill stationary (E0424, E0439, E1390 or E1391) using the QG modifier. The stationary unit will be paid at 150 percent of standard rates. The QG modifier is to be used for patients who have only stationary equipment. If this is guidance is not followed, the claim will be returned as unprocessable.

Click here for a complete summary of changes.

For more information, contact a member of the van Halem Group at 404-343-1815 or email [email protected].