Monthly Archives: February 2017

Required Use of the JW Modifier

By Karen Greco, Clinical Consultant

Effective Jan. 1, 2017, CMS required providers to use the modifier JW on claims to report the wasted portion of a drug or biological from a single-use vial (or single-use package) that is eligible for payment under the discarded drug policy. The modifier should only be used for drugs in single-dose or single-use packaging. This policy mandates that the discarded amount of drugs or biologics be appropriately recorded in the patient’s medical record.

When the claim is submitted, submit the first line with the drug and amount given. Submit a second line with the drug and include the JW modifier plus what was discarded.

For example, a single-use vial of a drug that contains 100 units has 95 units administered to the patient and 5 units discarded. The 95-unit dose is billed on one line and the 5-unit, discarded dose is billed on a separate line with the JW modifier. Both lines will be processed for payment.

This policy applies to providers and suppliers who buy and bill drugs and is intended to track discarded amounts of drugs that occur as a result of the preparation of a drug dose for administration to a beneficiary. The JW modifier requirement also applies to critical access hospitals (CAHs) because drugs are separately payable in the CAH setting.

The JW modifier does not apply to drugs or biologicals administered in a rural health clinic (RHC) or a federally qualified health center (FQHC). Drugs and biologicals administered in RHCs and FQHCs are generally not separately payable under Part B. Instead, their payment is included in the RHC’s all-inclusive rate or the FQHC’s prospective payment system rate for the patient’s visit. Exceptions are the influenza, pneumococcal and Hepatitis B vaccines, which are paid separately at cost through an RHC’s or FQHC’s cost report and not via a claim.

RAC AUDIT ALERT

By: Wayne van Halem, President

Well, the RAC is back. We knew it was coming, but what we didn’t know – until now – is where they will begin focusing their audit efforts. In the last couple of weeks, the new national DMEPOS and home health and hospice RAC, Performant Recovery, announced what they will be reviewing.

For our home health and hospice clients, there are no issues identified yet. We don’t expect it to stay that way, but nothing has been published yet. Unfortunately for our DMEPOS clients, we can’t say the same. There have been seven issues identified for review. This includes four complex reviews and three automated reviews.

As a brief reminder, an automated review means there is no human interaction. It is an edit in the system that is run and overpayment demand letter generated. The automated reviews announced are:

Nebulizers: Claim with diagnosis codes that are not supported for coverage in the LCD will be recouped.

Inpatient claims: This is not a new issue and not surprising, but the RAC will compare DMEPOS claim data with Part A claim data and recoup any claims paid while the patient was in an inpatient facility. A complex review is much more comprehensive and involves the RAC requesting documentation and performing a complete review. They have identified the following codes for complex review and the reason for it:

High frequency chest wall oscillation – Potential incorrect billing occurred when claims for high frequency chest wall oscillation devices were billed without an indication supporting medical necessity as described in the Nationwide Local Coverage Determination (LCD) L33785 and prior MAC LCDs L27042, L12934, L12870, L12739, all retired 9/30/2015 L12870 and related article (A25231).

Tracheotomy suction catheters, suction pumps, catheters and other related supplies/equipment:  Overpayments were previously identified where claims for pumps, suction catheters and related supplies/equipment were not in accordance with billing requirements outlined in the LCDs.

Group II support surfaces without correct diagnosis of condition: Documentation will be reviewed to determine if Group 2 support surfaces meet Medicare coverage criteria, meet applicable coding guidelines and/or are medically reasonable and necessary.

Osteogenesis stimulators: The RAC will review and deny claims for these items if they do not meet the indications of coverage and/or medical necessity guidelines in the LCD.

As always, please remember that The van Halem Group has both proactive and reactive RAC audit protection services available to suppliers and providers. Please contact us for more information at (404) 343-1815 or http://www.vanhalemgroup.com/contact-us.

Bundling Information for Mobility Equipment, Wheelchair Seating and Wheelchair Accessories

By: Kim Turner, RN – Clinical Consultant

Although the major manufacturers of complex rehab mobility equipment consider the Medicare policies and equipment specifications for manual and power mobility equipment, the manufacturers’ order forms do not always align with the wheelchair options and accessories that can or cannot be billed separately with the initial issue of the mobility device. Often, a manufacturer will list a separate cost for a wheelchair option and/or accessory that is actually considered bundled in the Medicare allowance (payment) for other equipment.

The following is a list of the most common wheelchair options and accessories that The van Halem Group has recognized as being billed incorrectly with separate costs and HCPCs with the INITIAL ISSUE/BILLING of the mobility device:

Power Mobility (PWC)

  • Joystick (standard, non-expandable remote joystick) – No separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided with the initial issue of a power wheelchair.
  • Battery charger (single mode) is included in the Medicare allowance for the power mobility device.
  • Complete set of tires and casters (any type) is included in the Medicare allowance for the power mobility device.
  • Legrests – There is no separate billing/payment if fixed, swingaway or detachable, non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.
  • Footrests/foot platform – There is no separate billing/payment if fixed, swingaway or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.
  • Armrests – There is no separate billing/payment if fixed, swingaway or detachable, non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.
  • Power adaptable frame is included in the power assist (E0986).
  • E-motion treaded tire style is included in the power assist (E0986).

Wheelchair Seating and Positioning Accessories

  • Custom fabricated seating (back E2617 and seat E2909) is all inclusive. Billing the K0108 for seating components of the back and/or seat is not allowed.
  • The Medicare allowance for the positioning back (E2620) includes the cost for lateral trunk pads (E0956) and any type of mounting hardware (E1028).
  • With the initial issue of the wheelchair seat cushion (example, E2622) or back (example, E2620), the cost for a cushion COVER is included in the allowance for the seat cushion. E2619 can be billed for a replacement cushion cover.
  • There is no separate payment for a solid insert (E0992) that is used with a seat or back cushion because a solid base is included in the allowance for a wheelchair seat or back cushion.
  • Use code E2231 for a solid support base that is used with a manual wheelchair. A solid support base is included in the allowance for the power wheelchair codes. There should be no separate billing with power wheelchairs.

Manual Mobility

  • Wheel lock assembly (E2206) is included in the Medicare allowance for the manual wheelchair base wheelchair.
  • Any seat to floor height is included in the Medicare allowance for the manual wheelchair base.
  • All types of rear propulsion wheels are included in Medicare allowance for the manual wheelchair base.
  • All types of front casters.
  • A sling seat, seat pan which can accommodate a wheelchair seat cushion or a seat frame structured in such a way as to be capable of accepting a seating system.
  • A sling back, other seat back support which can accommodate a wheelchair back cushion or a back frame structured in such a way as to be capable of accepting a back system
  • Standard fixed, swing away or detachable legrests and footrests.
  • Fixed height, non-adjustable armrests. Adjustable height armrests may be billed separately.

Wheelchair Options and Accessories

  • Cost for the tray strap and tray buckets are included in the Medicare allowance for a tray (E0950).
  • A seat belt (E0978) included in the basic equipment package for the power wheelchair. A seat belt may be billed on a power wheelchair base for replacement only.
  • The Medicare allowance for the tray (E0950) includes the cost for any type of mounting hardware. The E1028 cannot be billed with the E0950.
  • A mini-cup switch, blue/green/red/yellow switches included in the allowance for the single or multiple through drive electronic upgrades (E2310 or E2311).

DMEPOS Competitive Bidding Round 2019 Announced

Breaking News: CMS Announces Temporary Delay of Round 2019

Notice from CMS:
“The Centers for Medicare & Medicaid Services (CMS) has decided to temporarily delay moving forward with the next steps of the Round 2019 Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program to allow the new administration further opportunity to review the program. As a result, CMS has removed all information that was released on January 31, 2017, including information on the CMS.gov website and the Competitive Bidding Implementation Contractor (CBIC) website. Please continue to monitor the CMS.gov and CBIC websites for updates.”

This is great news for DME providers as the new administrations has a fresh perspective on these regulations and programs.

VGM will have more commentary and analysis in the coming days.


Original Story (02/07/2017) —–

The Centers for Medicare & Medicaid Services (CMS) announced plans to consolidate all rounds and areas included in the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program into a single round of competition: Round 2019.

The Round 1 2017, Round 2 Recompete and National Mail-Order Recompete contract periods for all product categories will continue through Dec. 31, 2018. Round 2019 contracts are scheduled to be effective for a three-year period from Jan. 1, 2019, through Dec. 31, 2021.

Round 2019 Product Categories

The 11 product categories included in Round 2019 are listed below. New for Round 2019 is the insulin pumps and supplies product category, which will be bid in the national CBA.

  1. Continuous Positive Airway Pressure (CPAP) Devices and Related Accessories (Capped Rental)
    • This product category is only bid in the following five CBAs: Ann Arbor, Mich.; Cedar Rapids, Iowa; Huntsville, Ala.; Salinas, Calif.; Winston-Salem, N.C.
  2. Continuous Positive Airway Pressure (CPAP) Devices and Related Accessories (Non-Capped Rental)
    • This product category is only bid in the following five CBAs: Des Moines-West Des Moines, Iowa; Hickory-Lenoir-Morganton, N.C.; Lansing-East Lansing, Mich.; Mobile, Ala.; Santa Maria-Santa Barbara, Calif.
  3. Enteral Nutrients, Equipment and Supplies
  4. General Home Equipment and Related Supplies and Accessories
    • Includes hospital beds and related accessories, group 1 and 2 support surfaces, commode chairs, patient lifts and seat lifts
  5. Insulin Pumps and Supplies
    • Includes in the national CBA which includes all parts of the U.S., including the 50 states, D.C., Puerto Rico, the U.S. Virgin Islands, Guam, and American Samoa.
  6. Mail-Order Diabetes Testing Supplies
  7. Nebulizers and Related Supplies
  8. Negative Pressure Wound Therapy (NPWT) Pumps and Related Supplies and Accessories
  9. Respiratory Equipment and Related Supplies and Accessories
    • Includes oxygen, oxygen equipment and supplies; continuous positive airway pressure (CPAP) devices and respiratory assist devices (RADs) and related supplies and accessories
  10. Standard Mobility Equipment and Related Accessories
    • Includes walkers, standard power and manual wheelchairs, scooters and related accessories
  11. Transcutaneous Electrical Nerve Stimulation (TENS) Devices and Supplies

A list of the specific items in each product category is available on the CBIC website (www.dmecompetitivebid.com).

Implementation of 10 New CBAs for CPAP Devices and Related Accessories

As noted above, CMS is adding 10 new CBAs specific to the CPAP devices and related accessories product category. No other product category will be subject to competitive bidding in these 10 new CBAs for Round 2019.

In five of the 10 new CBAs – Des Moines-West Des Moines, Iowa; Hickory-Lenoir-Morganton, N.C.; Lansing-East Lansing, Mich.; Mobile, Ala.; Santa Maria-Santa Barbara, Calif. – payment will be made on a bundled, non-capped monthly rental basis, with one monthly rental payment for the CPAP device, related accessories and services for each month of use. No separate payments will be made to suppliers in these CBAs for replacement of equipment, accessories, supplies, repair or maintenance and servicing, including miscellaneous items. Suppliers bidding in these five CBAs will submit bids for a single HCPCS code, K0400.

In the remaining five new CBAs – Ann Arbor, Mich.; Cedar Rapids, Iowa; Huntsville, Ala.; Salinas, Calif.; Winston-Salem, N.C. – payment will be made using the same payment rules for CPAP devices and related accessories in all other existing CBAs. In other words, payment in the remaining five new CBAs will be made for the CPAP device on a capped monthly rental basis, with separate payment on a purchase or rental basis for humidifiers used in conjunction with the CPAP device. Separate payment will also be made for the purchase of essential accessories (such as tubing and masks) and for repair of a beneficiary-owned CPAP device. Suppliers bidding in these five CBAs will submit separate bids to furnish CPAP devices and replacement of related accessories to beneficiaries with a permanent residence in the CBA.

Round 2019: Important Dates

To ensure that suppliers have ample time to prepare for the competition, CMS has announced the following next steps for the program:

January 31, 2017

  • CMS begins pre-bidding supplier awareness program

Spring 2017 (target)

  • CMS announces bidding timeline
  • CMS begins bidder education program
  • Bidder registration period to obtain user ID and passwords begins

Summer 2017 (target)

  • Bidding begins

A Quick Look at ABNs

By: Abrielle Uritz, RN, CPC – Clinical Consultant

An Advanced Beneficiary Notice of Non-Coverage, better known as an ABN, is a written notice that must be issued to a Medicare fee-for-service beneficiary before furnishing items or services that are usually covered by Medicare but that are not expected to be paid. ABNs should not be obtained for items or services that are never covered by Medicare, for example, dentures, cosmetic surgery and hearing aids.

In order to be valid, an ABN must include the supplier/provider’s name, address and phone number; the beneficiary’s name; items or services in question; an estimate of the costs; and the reason Medicare may not pay. Also, the beneficiary must choose one of the options and sign and date the form. The reason Medicare may not pay should not be general statements. For example, an appropriate reason would be “the beneficiary does not have the required diagnosis to qualify for this item;” an inappropriate reason would be “Medicare may not pay for this item.”

Some common issues that may cause an ABN to be invalid include illegible handwriting, when the beneficiary signs after the date of service, and an invalid reason Medicare may not pay. The option boxes must not be pre-checked on the form. If it is apparent that the option box was pre-filled, this can be a cause for denial. If someone other than the beneficiary is signing the ABN, the printed name and relationship to the beneficiary should be included.

Key points to remember when completing an ABN include:

  • Section C of the ABN form is optional.
  • An identifier, such as a medical record number or date of birth, may be used; however, Medicare numbers, Health Insurance Claim Numbers (HICNs), or Social Security numbers must not be used and can be a cause for denial.
  • Health care providers/suppliers should not issue ABNs on a routine basis (in the instance where a reasonable basis for denial is not present).