I am excited about becoming a part of the VGM Blog so we can be an open communication for everyone within the DME community.
If you have an issue please post and I will attempt to address within this format.
Tags: audits, Power Wheelchairs
Ron Bendell
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Stay up to date with VGM’s latest offerings and what we are working on for you. I’ll keep you posted on industry issues. I value your feedback!
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John Gallagher
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Stay informed on the latest developments concerning Competitive Bidding and it’s affect on both the consumers and the HME industry.
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Mark Higley
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Inaccuracies in Medicare payments cost the consumer and the HME industry millions of dollars in time and profit. Learn about the latest steps being taken correct these issues.
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Kelly Turner
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Competitive bidding is happening in your area now or in the near future. Learn how you can become an advocate for local HME users and dealers.
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Peggy Walker
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Compliance in the HME industry can make or break an HME provider and its affects are felt by everyone. Peggy Walker shares news, tips and insight into this important topic.
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Blog Home / Compliance / Hello I’m Peggy Walker –Welcome to the VGM Compliance Blog
we are having trouble getting our doctors to document enough information for the Semi-Electric beds. We know this is a target. Is there a problem with down codeing the bed. If we only bill a manual but place a semi, because no one puts out manual beds in our area. We have like alot have put out and billed alot of Semi beds. We have been tring to train our referrals to document what is required. is it wrong to do the down code? Any help in this matter would be appriciated!
downcoding is acceptable but make sure you have documentation as to why a hospital bed is needed over a standard bed.
Bill the code that you are providing with the RRKHKXGL modifier and put in narrative why you did the free upgrade and what you actually provided.
Invsemielectprovfreeupgradeallkeepin stock
Peggy
Peggy,
I have a patient who was prescribed a portable and a stationary Non-invasive vent. Medicare is denying the portable. R. Hosp told us to bill both the same day, I have a Letter of Medical Necessity from the physician along with a confirmation from the company who provided the wheelchair for the patient. Can you tell me what else I need to do to appeal this denial?
Yes you need to appeal and explain the portable is for the chair but plainly show that the stationary can’t be placed on the chair.
Explanation of down coding – Remember the referral sources have to justify ANY bed. The basic bed has to state why a standard would not meet needs then work your way up to the one the patient “NEEDS” the if you decide you are only going to keep semi electric beds in stock all you have to do is bill the bed the patient MEETS criteria for (NEEDS) with E0250 (or which ever base it is) then RRKHKXGL modifier and in the narrative field state what you actually provided and why.
If you get a quote and it lists K0005 as the code for the chair can you use E1220 – custom configuration as an alternative code?
Please answer only – do not publish. I am concerned with a billing error that I can’t quite put my finger on. I do not believe you can do this. I feel that you can only bill what the chair is sadmerc’d at. Please answer ASAP
You have to bill the Item to Medicare as it is coded by the DMEPDAC (no longer SADMERC) Some Medicaids still accept this code but if they also accept the K0005 and it is coded as a K0005 than that is what you should be it as.
We are having some difficulty determining the Zip Code requirements for the new 5010 transaction. We are unable to get clear difinitive answers. Do our Dr, Facility, referral, Insurances all have to have 9 digit. We have over 300 Dr’s in our system, 210 different Insurance Co’s, several hundred facility (Referal Sources). We have 4 branch office for each of these items. Do we need to change them all. Our facilities are actually our referral sources such as ABC Hospice.
Once 5010 is up and active you will be required to have the full 9 digit postal codes (that is what the conversion states) There is a lot of information that even CMS does not have up and running and some conversions that were supposed to be ready by January for the 2013 updates have already been delayed till June so a lot of the pharmacies – and other part A areas are not going to have these up in a lot of the different areas. My suggestion that you start implementing these on all addresses now. They may delay but you will be ready.
i need to bill for a replacement foam mattress E0272 for a patient owned hospital bed; initial billing date for bed was july of 2010. i reviewed LCD and didn’t see any useful lifetime. is it ok to bill for a replacement so soon. if i can, i assume it will be rbkx???
by the way…did the allowable for a seat lift mechanism that is incorporated in the chair E0627 change from $345.46 to $345.11???
Look on the dmepdac.com and check the pricing – I do not know what state you are in so can’t check.
Peggy
E0272NURBKX but you have a good chance of denial since it is not greater than 5 years old. They are even denying the wheels on wheelchairs as not greater than 5 years old. I suggest getting an ABN and billing with NURBGA – this will deny since you can’t use the KX with the GA — poor way to do for the patient but she can appeal.
Peggy
Hi Peggy,
I have a 8 year old DME company using Brightree going into the oxygen business for the first time. what resourses are out there to help us setup shop?? product setup in brightree, cmn requirements, sales training, what procducts to carry etc.
thanks
Billing and Reimbursement I can help you with. Brightree set up is gonna be from your support team at Brightree — Product suggestion will be Respironics — and or Invacare — both can help with products to carry.
The manufacturers sales reps will help with sales but I can help train your staff with billing and reimbursement issues. It is important that you have a good training program up front for your sales reps for them to discuss with the referral sources.
We can set up a conference call when I am in house and handle that — there is a minimal fee per hour for these.
Peggy
Hi Peggy, Is a home eval required in writing for a standard manual wheelchair?
by the way…did the allowable for a seat lift mechanism that is incorporated in the chair E0627 change from $345.46 to $345.11 FOR NEW YORK STATE??? I tried looking on dmepdac.com with no luck..
A home evaluation for manual can be simply a question and answer that your staff has with the beneficiary or caregiver when discussing needs over the phone. This should be noted on your order intake. It is always a good thing to do a follow up call to make sure any equipment is meeting the patient needs. This allows continued contact and gives you a chance to discuss other needs as well as prevents patient complaints.
Peggy
Pricing for E0627 in NY state 2012 is $353.39 go to dmepdac.com than put the code in the pricing block hit enter then go to all states and page down to New York and enter will show the new allowable.
When having a client sign the authorization for consent for DME, if the client is only able to use an “X” or initials for signature, do we need to have a witness sign also to prove it is authentic?
If there is someone there to authenticate you should have a witness and have their full name, date and relationship to patient. If not your delivery person can print patient name below and then sign and date (legibly) but you should know which patients these are and get permission from someone or if this is the only way patient knows how to sign put a note in chart that he/she is illiterate and cant sign his name.
Peggy
customer came in to get forearm crutches which he just received a year ago. i did have them sign a waiver. how do i bill? do i bill with an RB modifier and/or a narrative that indicates “beyond repair”..not sure. thank you
I’m drawing a blank on this question that should be simple:) if somebody received a cane last year and now needs a walker; will medicare deny as same or similar. i’m thinking because it is an upgrade in equipment and a downgrade in health that it shouldnt deny. can you please clarify. thanks again..
You are correct but make sure you have documentation of change in condition.
Peggy
Did you do an ABN and state it may deny as same/similar? If not you will get a CO denial instead of PR ad you will not be able to collect from beneficiary. This type of claim should always be done non-assigned if you are a non-participating provider so you can collect the money up front. You will bill with NUGA modifier and when it denies you can collect from patient.
You need to know what happened to orginal crutches (were they lost? stolen?) and documentation of need.
With it only being one year these will deny as duplicate.
Peggy
Me again:) with urological supplies customer used to only be able to get a one month supply at a time. I heard this has changed to allow customer to get a 3 month supply at a time same as with ostomy supplies. please clarify. thank you.
I could not find this anywhere but definately not in a facility.
L3670 does this need any modifiers, cannot find an LCD. i did find that the code was recently brought back:)
Jane an L3670 is canvas and webbing material – Orthotics are not covered unless they are rigid.
These do not require modfiers unless you are going to bill for the client and use a GY modifier for non-covered (non assigned) if you are doing this assigned you will need to give an ABN and use the GA modifier to get a PR ( Patient responsibility) denial
HI PEGGY:) WHY WON’T AN “S” CODE (S8424RT) GO THROUGH MEDICARE FRONT END? ALL I WANT IS A DENIAL SO THE 2NDRY WILL PAY. I TRIED GY AND GA WITHOUT SUCCESS. CAN YOU HELP WITH THIS? THANK YOU.
Because this is not a DME code you can use the A9270 as non covered code.
Peggy
I feel like I use this as my own personal Blog:) I thank you for all of your insight. Here is my next question: E1810, I was surprised to find out is a capped rental. I see there is a KX modifier required but was surprised there wasn’t a specific dx associated with this. Do you have any advice for billing with this code to avoid denials?
Exactly what are you providing and why?
I see no statue provided so I dd not see it was a capped rental?
transport wheelchair purchased last year, now wants a scooter. is this considered an upgrade of will this deny as same similar. i will of course get the abn:)
If the patient has a documented change in condition and no longer can self propel the manual wheelchair WITHIN the home they would upgrade to the manual chair or scooter that is Medically necessary. This will depend on the medical necessity documentation that you have. If you are using an ABN why? Does the patient not meet the necessity for a scooter? Remember when you use and ABN you can’t use a KX so you might just as well collect the money up front because it will deny. You may not be able to collect the money after the fact. If you use an ABN you use the GA modifier and this will deny the claim if a KX is required anyway.
Peggy
this questions was for a transport wheelchair not a manual. thank you
after you answer the transport wheelchair question can you please elaborate of why kx and ga cannot be used together. pt can qualify for a scooter but may have same similar on file…right:(
GA means Medical necessity has not been met
KX means all documentation required is in patients’ medical record – for power it means all documenation for Medical necessity is in your file
A transport wheelchair is a manual wheelchair.
cant ga mean over quantity allowed
how can a transport w/c be manual when the pt isnt manually propelling:(
Because someone has to push it or propel it — a transport chair falls under national coverage decision and is only covered if given “in lieu of” a standard manual wheelchair. The patient meets criteria for a standard manual wheelchair but the patient or the family chooses the transport chair instead of the heavier standard weight manual wheelchair. This is usually because the care giver can’t push the heavier manual wheelchair through out the home and they can manage the lighter weight transport chair.
If they are being given just so the patient can be pushed around outside the home for physician visits; shopping ect then they are not covered and an ABN should be used.
Peg
GA means possible medical necessity on file. Over the quanity is a Medical Necessity denial.
Peggy
for example, can the kx be used for catheter because the customer meets criteria and the ga will signify over quantity. in this instance i would use both kx and ga… am i wrong…
next question:) i am billing an E1399NU to medicare for a denial to allow us to bill the secondary insurance which has pre authorized. i keep getting a front end denial. i have tried just a nuga, just a nugy and nothing is working. and, yes, i did put the make, model in the rx narrative.
No modifier required for an E1399
You can’t put them both on same line.
As long as you separate the GA for the over quanity amount and the KX for meets it is OK
E1810 dynamic adjustable knee extension/flexion device is catagorized as a capped rental. how are the modifiers added to bill this correctly if customer has met the criteria.. could it possibly be E1810RRKHRTLTKX. i asked a question previously about this but the response was unclear
If it is capped rental you bill exactly as you would any other capped rental item and if KX is required you use the KX but you can’t bill more the 4 modifiers on a claim so you use the 99 in the fourth place and put all modifiers in the narrative field.
this item is not in the capped rental category but in the O & P category on the DMEPDAC site.
Peggy
I have a client who is currently in skilled care with COPD. He is looking to go home on a BIPAP. The arterial blood gas results that we have were done on the 3rd and discharge looks to be on the 14th of this month. Is there a time frame for the results to be used? Do they need to be closer to discharge from skilled care?
No it is OK as is the two days prior to discharge relates to Oxygen only as far as testing goes for these. You need to have a statement as to why a C-pap was ruled out.
what can a podiatrist prescribe? can they prescribe L2114 low tide cam walker?
Anything that relates to their treatment of the foot. This is a fracture orthosis , tibial fracture orthosis. This would probably be beyond his scope of practice but you would have to ck the rules within your state.
Do you know what the Medicare policy is regarding private pay nursing homes. If a patient is in such a facility, can we still bill Medicare for services, especially if Medicare does not show the patient as being in a nursing home?
The place of service would still be 32 or 31 and this would be a non-covered place of service.
THE PODIATRIST QUESTION didnt have anything to do with the E1810
Long Description: DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL
Date of service requested: January 01, 2012
HCPCS code fee schedule category: Capped Rental Items
Beneficiary State of Residence Modifier Modifier Fee Effective dates:
From To
NY RR $124.75 01/01/2012 12/31/2012
THIS REFERRED TO A PREVIOUS QUESTION WHEN YOU ASKED WHY I THOUGHT IT WAS A CAPPED RENTAL…
Can anybody help me bill this item? i keep getting front end denials. Code: E1810, which is a capped rental dynamic adjustable knee extension/flexion device, includes soft interface material; bilateral.
Date of service requested: January 01, 2012
HCPCS code fee schedule category: Capped Rental Items
Beneficiary State of Residence Modifier Modifier Fee Effective dates:
From To
NY RR $124.75 01/01/2012 12/31/2012
Your search for
HCPCS Code: E1810
Long Description: DYNAMIC ADJUSTABLE KNEE EXTENSION / FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL
Additional Search Terminology: None
Medicare Statute: Not Available
Here is what the DMEPDAC says about this code and does not state it is capped rental but how are you billing the item and in what place of service?
HOME
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ok so, medicare allows(20) A4425 open end reusable pouches per month or (60) A4419 closed end disposible pouches per month. how do we handle it when a customer wants to combine the open and closed end for one month?
is this question clear?
Peggy,
I have a medicare cpap patient that failed the 12 week trial period. and was re-eval by MD and did a repeat sleep test in facility based setting(type 1) and qualified for cpap again.
I want to know if I can start the billing as a new set up. If so, will Medicare pay for the heated humidifier again, since it was a purchased the first time. let me know, Thanks, Joe
Yes you can restart but the humidifier would deny as same similar
call me and lets discuss
Peggy
Peggy,
We have a medicare part B patient moving from Region C to Region D. What does the patient need to do in order to get our DMERC to pay for HME? We are going to supply 02, with no break in service, and with 27 month’s left on the cap’d rental. What do we need to get in order to get paid? Thanks,Joe
The patient has to change his address with Medicare — you will need a copy of original CMN and a revised CMN but just keep the revised CMN in your files – this is just to show change in supplier. You just start billing on your date of delivery as long as that date is not in same month the other supplier has billed.