Monthly Archives: April 2017

Audit Alert: NPWT

Performant Recovery, National RAC for DME, Home Health and Hospice has released another issue to the approved issues log. Negative Pressure Wound Therapy (NPWT) pumps are under complex review, effective April 28, 2017. Claims will be reviewed for potential incorrect billing when medical necessity, as outlined in the LCD, was not established. Visit Performant Recovery’s website to review this and all other approved issues.

Improvements to the Adjudication Process of Serial Claims

A major win for DME Suppliers was announced yesterday, as CMS released information regarding improvements to the adjudication process of serial claims. Effective April 7, 2017, CMS has implemented changes to improve the processing and adjudication of recurring (monthly) claims for capped rental and certain inexpensive and routinely purchased (IRP) items.

Prior to April 2017, if a monthly rental claim was denied and then appealed separately, then the claim was adjudicated independently and without reference to the other claims in the series. As a result, one month could pay while claims for other months in the rental period remained denied and pending at various other levels of appeal. Industry leaders have been working hard to get CMS to see the light and make changes that would get all monthly claims in the rental period adjusted and paid following an effectuation for any month. CMS listened and has directed the DME MACs to change their processes for adjudicating serial claims!

What does that mean?

Once the reason for denial for one claim in a series is resolved at any appeal level, the DME MACs will identify other claims in the same series that were denied for the same or similar reasons, and take that determination into consideration when adjudicating such claims.

The DME MACs will also communicate the favorable decision(s) to the DME QIC and the Office of Medicare Hearings and Appeals (OMHA) to consider when adjudicating related appeals pending at those levels.

CMS has also instructed the DME MACs to update the Certificate of Medical Necessity (CMN) in the ViPS Medicare System (VMS), when appropriate, to reflect when a favorable decision has been rendered for a serial claim, allowing future claims in the same series to pay without requiring suppliers to continually resubmit evidence.

Finally, CMS instructed the DME MACs to perform data analysis of all favorable serial claim appeal decisions made over the past 3 years, in an effort to capture all currently pending appeals in the series that could be included in this initiative. Suppliers do not need to take any action and should not reach out to the DME MAC within their jurisdiction to request that their appeal be considered for this initiative.

Will this help me?

Going forward, any claim in a series that denies but is then paid will result in adjustments for payment to other denied months in the series. Remember, the data analysis only applies to recurring (serial) claims for capped rental items and certain IRP items adjudicated during the past three years. For a complete listing of HCPCS codes that are included in this initiative please see the list published in MedLearn Matters article SE17010.

Bottom Line

This is a major win for the DME Industry! With 51% of DME claims comprising the ALJ Appeals backlog this new initiative will most certainly help reduce that number! More importantly, this new process will alleviate the burden on suppliers billing monthly rentals.

Attention Suppliers with CERT Reviews related to DME MAC Jurisdiction D (Noridian)!

On April 26, 2017, Noridian sent the following notice to ListServ subscribers:

Notice – Some Jurisdiction D Demand Letters incorrectly identified Performant Recovery as the claim review contractor

Noridian Jurisdiction D mailed 3,647 initial demand letters during the period of March 15, 2017 through April 21, 2017 that incorrectly identified Performant Recovery (the Jurisdiction D Recovery Auditor) as the contractor who reviewed the claim. While these demand letters stated that suppliers could contact Nordian with any questions about the demand letter, they included an incorrect paragraph stating that suppliers could also contact Performant (and provided contact information) to discuss the demand letter. This paragraph was incorrect since Performant was not the review contractor.

Suppliers should call JD Customer Service: 877-320-0390 (M – F, 8 a.m. – 6 p.m. CT) with any questions about these incorrect demand letters. Please note Noridian Customer Service can always be contacted with any questions on a JD demand letter, no matter who was identified as the reviewing contractor in the letter.

Noridian apologizes for this error. Please call JD Customer Service: 877-320-0390 (M – F, 8 a.m. – 6 p.m. CT) with any questions about this listserv message.

The CERT contractor reviews claims on a post-payment basis to ensure appropriate coverage and billing guidelines were applied, both by the Supplier and the DME MAC. Improperly paid claims compile the DMEPOS error rate. As a reminder, it is imperative that you respond to CERT requests in an attempt to reduce the error rate by showing your compliance with Medicare rules and regulations. For more information about CERT, visit the Noridian JD website here.

If you have been audited by the CERT, or other audit contractors, The van Halem Group can help. We offer a variety of services to assist you in various stages of the audit process. Visit the Products and Services section of our website to learn more!

NCART and Complex Rehab Capitol Hill Day This Week- April 26 & 27, 2017

By Kay Koch, OTR/L, ATP

This week the National Coalition for Assistive and Rehab Technology (NCART) and the National Registry of Rehabilitation Technology Suppliers (NRRTS) are partnering to hold the 2017 National CRT Leadership and Advocacy Conference. The Conference will be held April 26-27 at the Hyatt Regency Crystal City in Arlington, VA. On April 27th the attendees will be visiting representatives on Capitol Hill.

NCART is a national association of suppliers and manufacturers of Complex Rehab Technology (CRT) products and services that are used by individuals with significant disabilities and medical conditions.

NRRTS is a professional association supporting individuals who provide Complex Rehab Technology wheelchairs and seated positioning systems for people of all ages and diagnoses who have postural or mobility deficits. These professionals offer quality care and service using specialized knowledge, training, experience and skills to match the consumers’ needs to appropriate equipment.

The National Registry of Rehabilitation Technology Suppliers ( NRRTS) was incorporated in 1992 by a group of rehabilitation technology suppliers (RTSs) committed to raising the standards of their profession and ensuring consumers receive quality, cost-effective, individualized and function-enhancing equipment. NRRTS currently has Registrants in all 50 states.

Even if you don’t attend The 2017 National CRT Leadership and Advocacy Conference this week, you may contact your representative any day of the week – Regardless of who you are; consumer; supplier; clinician, or manufacturer – you have a stake in what happens on Capitol Hill and in your State Houses and in the offices of State and Federal regulators. Consider being an active advocate to assure that consumers with significant disabilities and health issues receive the Complex Rehab Technology they need to help assure their health, function and quality of life.

Making a call to your Member of Congress, local representative or Governor’s office takes a few minutes.

Complex Rehab Technology (CRT) needs to be separately recognized in order to improve and protect access for people with disabilities who rely on this unique equipment for their medical and functional needs. Legislation has been reintroduced in the House of Representatives (H.R. 750) to establish a separate benefit category for CRT and a Senate companion bill will be reintroduced shortly. Email your Members of Congress asking them to cosponsor the bill and help get it passed this year.  Call your representative and ask for their support.

Additional Resources*:

2017 Cosponsors by State
H.R. 750 Position Paper
2016 Cosponsors by State


Legislation has also been re-introduced in the House of Representatives (H.R. 1361) and the Senate (S.486) to permanently prevent the inappropriate application of competitive bid pricing to accessories used with Complex Rehab Wheelchairs. Congress must pass these bills before June 30 to stop these cuts and to protect people with disabilities. Email  your Members of Congress and ask them to cosponsor these bills and ensure passage before June 30,2017.

Additional Resources*:

2017 Cosponsors by State
H.R. 1361 / S. 486 Position Paper
2016 Cosponsors by State
171 HCPCS Codes


*From NCART.uswebsite

Audit Alerts

DME contractors perform pre- and post-payment reviews on a continual basis. Through data analysis, the medical review department determines the codes they will review and then sends Additional Documentation Request (ADR) letters to suppliers that bill those codes. The following list includes those codes currently being reviewed amongst all four DME jurisdictions.

  • Positive Airway Pressure (PAP) (HCPCS E0601)
  • Ankle-Foot/Knee-Ankle-Foot Orthosis (HCPCS L1970, L4360, L4361)
  • Spinal Orthoses (HCPCS L0648, L0650)
  • Knee Orthoses (HCPCS L1832, L1833)
  • Therapeutic Shoes for Persons with Diabetes (HCPCS A5500)
  • Urological Supplies (HCPCS A4351, A4352, A4353)
  • Manual Wheelchairs (K0001 – K0004)
  • Hospital Beds (E0260)
  • Oxygen and Oxygen Equipment (E1390, E0431, E0434, E0439)
  • Pressure Reducing Support Services (E0277)
  • Immunosuppressive Drugs (J7507, J7517, J7518)

Performant Recovery, the National Home Health and Hospice and DMEPOS Recovery Audit Contractor (RAC) has posted the following CMS approved issues to their website:

  • Multiple DME Rentals in One Month (approved 3/31/2017)
  • Chest Wall Oscillation Devices (2/8/2017)
  • Tracheotomy suction catheters, suction pumps, catheters and other supplies (2/8/2017)
  • Nebulizers (2/2/2017), (4/14/2017)
  • DME billed while inpatient (2/16/2017)
  • Osteogenesis stimulators (2/14/2017)
  • Automated Excessive Units of Spring Powered Devices Billed for >1 in a 6 Month Period (1/5/2017)
  • CPM Billed without Total Knee Replacement (2/2/2017)
  • Group 2 Support Surfaces Without Correct Diagnosis of Condition (2/15/2017)
  • Glucose Monitor When Billed With Same Date of Services as Glucose Monitor Supplies (Unbundling) (1/5/2017)
  • Hospital Beds with Mattresses Billed with Group I or Group II Support Mattresses (4/12/2017)
  • L5845 with Incompatible Codes (4/12/2017)

Beneficiary Upgrade and Advanced Beneficiary Notice (ABN)

By Kim Turner, RN – Clinical Consultant

An upgrade is an item with features that go beyond what is medically necessary. DME upgrades involve situations in which the upgraded item or component has a different HCPCS code than the item that will be covered by Medicare.

An option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational activities is non-covered.

An ABN cannot be used to charge beneficiaries for premium quality services described as “excess components” and an ABN cannot be used to shift liability for an item or service that is described on the ABN as being “better” or “higher quality” but do not exceed the HCPCS code description.

The upgrade item must be within the range of items or services that are medically appropriate for the beneficiary’s medical condition and the purpose of the physician’s order. ABNs may not be used to substitute a different item or service that is not medically appropriate for the beneficiary’s medical condition for the original item or service. The upgraded item must still meet the intended medical purpose of the item the physician ordered.

Use of an ABN to furnish an upgraded item or service, with the beneficiary being personally responsible for the difference between the costs of the standard and upgraded item or service, does not change coverage or payment rules, statutory provisions, or manual instructions for the particular benefit involved.

You must bill two line items for upgraded DMEPOS items where the beneficiary requests an upgrade.

You must bill both lines on the same claim in the following order:

Claim Line 1: Bill the appropriate HCPCS code for the upgraded item that you actually provided to the beneficiary with the dollar amount of the upgraded item. If you have a properly obtained ABN on file signed by the beneficiary, use the GA modifier. If you did not properly obtain an ABN signed by the beneficiary, use the GZ modifier.

Claim Line 2: Bill the appropriate HCPCS code for the reasonable and necessary item with the actual charge for the item. Use the GK modifier.


Claim line 1 K0884 NU KH BP GA  ( with a properly signed ABN on file)   

Claim line 2 K0861 NU KH BP GK KX    

Definition of Modifiers

GA – Waiver of Liability Statement on file (expected to be denied as not reasonable and necessary, ABN on file)

GZ – Item or Service not Reasonable or Necessary (expected to be denied as not reasonable and necessary, no ABN on file)

Do’s and Don’ts: Amending a signed and dated Legal Document

By: Nancy Conant, Clinical Consultant

Are you finding yourself challenged explaining how to properly amend the record to a therapist or practitioner, particularly when the document has been previously signed?


The proper way to amend a Licensed Certified Medical Professional Specialty Evaluation and Face to Face Mobility Examination is to strictly adhere to CMS’s established recordkeeping principles.  An addendum to a legal document needs to be added as soon as possible and contain all clarification information intended to support medical necessity.  When amending a LCMP Specialty Evaluation and Face to Face, there are fundamental standards you can recommend the therapist and/or the practitioner follow:

  • Clearly identify the date of the original date of the LCMP/LMN or F2F. Example:  Addendum to the LMN/F2F dated 3/16/17
  • Include the beneficiary’s name
  • The author must clearly sign and date the addendum
  • For Power Mobility Devices, a practitioner must sign/date/concur

When a significant amount of information is to be added to a previously signed/dated LCMP/LMN or Face to Face that clarifies coverage criteria and/or accessory justification, the best way to keep the validity of the current LCMP/LMN/F2F and the date sequence of other required documentation intact is to prepare a separate document for the addendum.  Most addendums are prepared to clarify information already entered in the medical documentation provided in the review.  These clarifying addendums do not change the completion date of the F2F, therefore, a new 7EO, F2F, or DPD is generally not needed if the addendum is executed correctly and timely.


  • Therapists/Practitioners often make the mistake of adding the addendum information to the existing documentation as if they were creating the document for the first time. This is tantamount to altering a legal document and is not acceptable practice.  This is a source of Medicare denial.
  • Do not re-sign an original document that has already been signed unless you provide an explanation for re-signing the document. Forcing the dates is not acceptable practice.
  • Back dating a record is not acceptable practice
  • Pre/Post-dating an addendum or record is not acceptable practice

In summary, LCMP/LMN and Face to Face addendums that have been properly amended will be considered by the Medicare reviewer when determining coverage criteria has been met for certain DME products.

DMEPOS Order Requirements for Changing Suppliers

Effective April 24, 2017, MACs to accept timely orders and medical documentation (so long as it meets Medicare requirements), regardless of whether the supplier received the documentation directly from the beneficiary’s eligible practitioner or from another, transferring supplier.

Be aware that a new order is required in the following situations:

  • There is a change in the order for the accessory, supply, drug, and so forth.
  • On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy.
  • When an item is replaced.
  • When there is a change in the supplier, if the recipient supplier did not obtain a valid order for the DMEPOS item from the transferring supplier.

This change permits the MACs to accept timely orders and medical documentation, regardless of whether the supplier received the documentation directly from the beneficiary’s eligible practitioner or from a transferring supplier. This change is applicable to all suppliers.

Refill Requests: What to Include and When to Complete

By: Christina Colegrove, RN,BSN – Clinical Consultant

Here are some things to remember when completing a refill request to avoid denials.  Documentation of a refill request must be either a written document received from the beneficiary or a written record of a phone conversation between the supplier and beneficiary.  The request must include the beneficiary’s name/authorized representative, description of each item being requested and date of refill request.  If consumable supplies are being requested, then the supplier should assess the quantity of each item that the beneficiary has remaining.  The supplier manual mentions, “Vague or nonspecific references to the quantity remaining are not sufficient to demonstrate compliance with the requirement that refills be provided when the current supply on hand is ‘approaching exhaustion’.”  Although an actual count is not necessary, it is recommended.  The record should demonstrate that individual assessment was performed.  Examples of consumable supplies includes surgical dressings or urological supplies.  If non-consumable supplies (items that are not used up but may need periodic replacement) are being requested, then the supplier should assess if the supplies remain functional and provide replacement/refill only when the item(s) are no longer functioning.  The documentation should support the functional condition of the item(s) being refilled and demonstrate the cause of dysfunction which necessitates replacement.  Examples of non-consumable supplies includes PAP or RAD supplies.

Per the Medicare Program Integrity Manual, “Suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary.”  The beneficiary/designee should be contacted no sooner than 14 calendar days prior to the delivery/shipping date.  The supplier must deliver the product no sooner than 10 calendar days prior to the end of usage for the current product.