Monthly Archives: May 2017

Schedule a consultation at Heartland

The van Halem Group (vHG) has announced something new for Heartland attendees this year. Multiple vHG representatives will be on-site and available for personal consultations throughout the day Tuesday through Thursday. Whether you have questions about a specific situation you are experiencing or want to learn how to protect and safeguard your business from compliance issues, now is the time to take advantage of a free consultation!

Scheduling is easy! Just visit the Heartland Scheduling page on our website, and select a day and time that works for you. The Heartland conference is the industry’s premiere education and networking event! Let us help make this year the best one yet! For more details on what you can expect at Heartland this year, visit the VGM Heartland page.

New CMS ABN form available

Effective June 21, 2017, providers must use the most recent version of the Advance Beneficiary Notice (ABN) Form CMS-R-131 with the March 2020 expiration date to deliver a valid ABN. If the new form is not used on/after this date, any new ABN executed on the old form will be considered invalid and would result in provider liability if Medicare denies the claim. Providers may begin using the new ABN Form CMS-R-131 immediately.

For more information and to download the new ABN form, visit the CMS’ Advance Beneficiary Notice of Noncoverage webpage.

RAC Announces it will review Underpayments made on Group 3 Wheelchair options

On May 17, 2017, Performant Recovery, the National DMEPOS RAC announced that it will begin to recover underpayments, or incorrect reductions owed to suppliers, for wheelchair accessories and cushions for Group 3 complex power rehab wheelchairs.

Section 2 of the Patient Access and Medicare Protection Act (PAMPA) mandates that adjustments to the 2016 Medicare fee schedule amounts for certain DME based on information from competitive bidding programs not be applied to wheelchair accessories (including seating systems) and seat and back cushions furnished in connection with Group 3 complex rehabilitative power wheelchairs (codes K0848 – K0864). The change was effective January 1, 2016, however, Medicare was unable to implement changes to the claim processing systems until July 1, 2016. During that time frame, payments were based on adjusted fee schedule amounts. The underpayment recovery will apply to claims for accessories for dates of service 1/1/2016 – 6/30/2016.

DME suppliers rarely experience RAC underpayments, so this is a welcome change. Even better? This review was suggested by The van Halem Group’s own Wayne van Halem! “Many folks don’t know this, but the RACs are funded to find underpayments, in addition to overpayments,” expressed van Halem. “And in this environment, every little bit helps!”



Two New “K” Codes for Therapeutic Continuous Glucose Monitors

By: Christina Colegrove RN, BSN – Clinical Consultant

Change Request (CR) 10013 provides the addition of 2 new “K” codes for therapeutic Continuous Glucose Monitors (CGM) to the Healthcare Common Procedure Coding System (HCPCs).  The effective date is July 1, 2017 and the implementation date is July 3, 2017 for the following 2 codes:

  • K0553: Supply allowance for CGM, includes all supplies and accessories (1 unit of service is equal to 1 month’s supply)
  • K0554: Receiver (Monitor), dedicated, for use with CGM


Continuous glucose monitoring systems are considered therapeutic CGMs/DME if the equipment:

  • Is approved by the Food and Drug Administration (FDA) for use in place of a blood glucose monitor for making diabetes treatment decisions (such as changes in diet or insulin dosage)
  • Is generally not useful to the individual in the absence of illness or injury
  • Is appropriate for use in the home
  • Includes a durable component (component that CMS determines can withstand repeated use with expected lifetime of at least 3 years) that is able to display continuous glucose measurements trends

The addition of K0553 and K0554 will facilitate Durable Medical Equipment (DME) MAC claims processing for therapeutic CGMs.


CGS to begin claim adjustments to reflect competitive bid rates in non-CBAs

CGS announced yesterday that they will begin mass claims adjustments to reflect the revised 2016 DMEPOS fee schedule amounts for certain DME items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DME. CGS will adjust 40,000 claims each day for 24 weeks for Jurisdiction C, and 20,000 claims each day for Jurisdiction B.

Why is this happening? 

Change Request (CR) 9968 provides instructions regarding the implementation of revised 2016 DMEPOS fee schedule amounts based on changes mandated by Section 16007 of the 21st Century Cures Act. These changes relate to the new Chapter 20, Section 20.6 (Phase-In for Competitive Bidding Rates in Areas Not in a Competitive Bid Area) of the “Medicare Claims Processing Manual,” which is part of CR9968.

Legislation requires changes to the July and October 2016 fee schedule amounts for certain items. Section 1834(a)(1)(F)(ii) of the Social Security Act (the Act) mandates adjustments to the fee schedule amounts for certain DME items furnished on or after January 1, 2016, in areas that are not competitive bid areas, based on information from competitive bidding programs for DME.

Section 16007 of the 21st Century Cures Act changes the 2016 fee schedule transition period so that payment based on 50 percent of the adjusted payment amount established using competitive bidding information and 50 percent of the unadjusted fee schedule amount extends from June 30, 2016, to December 31, 2016. Section 16007 also changes from July 1, 2016, to January 1, 2017, the date that payment based on 100 percent of the adjusted payment amounts in non-bid areas is effective.

To supplement Section 16007 for dates of service July 1, 2016, through December 31, 2016, the 50/50 blend fee schedules have been recalculated so that the adjusted portion of the payment blend utilizes July 1, 2016, adjusted fees.

What else?

The KE modifier fee schedules for items bid in the initial Round 1 Competitive Bidding Program (CBP) have been added back to the fee schedule file for this extended phase-in period. The KE modifier was added to the DMEPOS fee schedule file as part of the January 2009 fee schedule update and described items that were bid under the initial Round 1 CBP but were used with non-competitive bid base equipment. Suppliers should submit a request for reopening if their claim for dates of service between July 1, 2016, and December 31, 2016, should have been processed with the KE modifier.

The revised July 1, 2016, through December 31, 2016, DMEPOS and parenteral and enteral nutrition (PEN) fee schedule files will be made available to the DME MACs. The previously posted July 2016 and October 2016 DMEPOS and PEN public use files will be revised to reflect the new fee schedule amounts associated with the extension of the transition period. MACs will accept the KE modifier on the adjusted claims. In addition, for claims that the KE modifier would have been applicable to, the supplier may adjust the claim or notify MACs to adjust the claims after the mass adjustments for the 50/50 fee blend have been completed.


The adjusted claims will not be given any unique code to indicate that the adjustment is related to CR9968. Therefore, Provider Contact Center (PCC) representatives will not be able to tell you if a claim(s) is/are part of the mass adjustment required under CR9968.


For more information, please refer to the following:

MedLearn Matters Article MM9968

CGS Summary Article

Oxygen Therapy and Obstructive Sleep Apnea

By: Christina Colegrove RN, BSN – Clinical Consultant

For beneficiaries who require simultaneous use of home oxygen and PAP therapy, it is important to remember that all of the requirements in both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met.

Home oxygen therapy requires that the beneficiary is tested in a “chronic stable state” which means obstructive sleep apnea (OSA) must be sufficiently treated so the underlying severe lung disease is unmasked. For beneficiaries with OSA, a qualifying oxygen saturation test may only occur during a titration polysomnogram study in which the following criteria are met:
• The titration is conducted over a minimum of two hours; and
• During titration:
o The AHI/RDI is reduced to less than or equal to 10 events/hour; or
o If the initial AHI/RDI was less than 10 event/hour, the titration must demonstrate additional reduction in the AHI/RDI; and
• Nocturnal oximetry for oxygen qualification can only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
• The nocturnal oximetry during the polysomnogram must show an oxygen saturation less than or equal to 88% for 5 minutes (continuous or non-continuous)

When the above criteria are met, the beneficiary is considered to be in a “chronic stable state.” Please note that to be eligible for Medicare coverage and payment for home oxygen for concurrent use with PAP therapy, the beneficiary must still meet all other coverage requirements for oxygen therapy as outlined in the LCD. It is also important to remember that beneficiaries who qualify for oxygen therapy based on testing conducted during a sleep test are only eligible for reimbursement of stationary equipment.

RAC removes L5845 from Approved Issues

After much concern in the O & P world, Performant Recovery has removed the automated review for code L5845 when billed with codes L5610-5616 & L5810-L5826.

The announcement of this review on April 12, 2017 sparked immediate backlash, as the local coverage determination (LCD) and DME MAC websites have never indicated these codes could not be billed together. As of today, May 1, 2017, the issue has been removed from the approved issues on the Performant Recovery website.