The Latest in Billing & Reimbursement from Ronda Buhrmester: December 2022

Published in Member Communities on December 07, 2022

RondaBy Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement, VGM & Associates

Read below for several billing & reimbursement-specific updates regarding the enrollment contractor, CMNs and DIFs being eliminated, the new oxygen LCD, updated language to continued medical need, sleep studies related to supply chain and recall issues, and updating patient demographics and insurance

Enrollment Contractor - Know Who Your Contactor is For Your PTAN! 

CMS announced changes with the DMEPOS enrollment contractor using the Mississippi River as a guide to show the two Jurisdictions for these contractors. For states west of the Mississippi River, the contractor is Palmetto GBA. Palmetto has been the enrollment contractor for the entire country for DMEPOS for years.   

Novitas Solutions has been awarded the contract for all states east of the Mississippi River. As with any new contractor, we will expect a learning curve.   

In addition to the contractor announcement, CMS has changed the name from “National Supplier Clearinghouse” to “National Provider Enrollment” contractors.  The new acronym is NPE. More specifically, NPE West is Palmetto GBA and NPE East is Novitas Solutions. This change went into effect Nov. 7, 2022.   

If you are sending any updates to the NPE contractor, you will also need to update the general liability insurance certificate holder regardless of your location. Also, start expecting to receive revalidation notices by the end of 2022 that will be due for 2023.  

For more information on these changes, please take a listen to this podcast I was able to partake in with my colleague Kelly Grahovac with the van Halem Group. 

For any enrollment-related issues, please let me know so I can address them accordingly. 

The CMS CMNs and DIFs Are Being Eliminated January 2023! 

Effective January 1, 2023, the CMS CMNs for oxygen, TENS units, seat lift mechanisms, bone stimulators, and pneumatic compression devices are being eliminated. In addition to the DIFs, the enteral, parental, and external infusion pumps are being eliminated.   

The coverage criteria outlined within the medical policy (LCDs) are still required. Obtaining medical records from the referring practitioner are vital for being successful during an audit and to protect the company. Medical records include the treating/referring practitioner and supporting medical documentation such as a nurse, RT, PT, OT, and other practitioner patient notes including any supporting test results. 

The Program Integrity Manual (PIM) clearly states that a CMN and DIF are not part of the medical record, which means these CMS forms are strictly claims processing tools.  

By having the CMS CMNs eliminated, the claim will process in a more timely manner because there is no wait for a treating practitioner to complete the form.   

Please note if a CMN is attached to a claim with a date of service on or after January 1, 2023, the claim will be rejected. This means the claim will not process because it’s a front-end rejection. Be sure to  monitor the front-end rejections on a daily basis to avoid disruptions on payments. 

With the CMN and DIF elimination, the respective medical policies have been updated. Be sure to review those policies for more information.

It’s Here – the NEW Oxygen LCD is Available! 

The new oxygen LCD and related policy article is available on both DME MACs websites. It’s important to become familiar with these changes that are being implemented January 1, 2023.

A few of the key highlights from the new medical policy are: 

  • Removal of the CMN-484 (initial, recert, and revised) 
  • Removal of alternative treatment language 
  • Changing chronic stable state language to “time of need” 
  • Allowing for both acute and chronic conditions 
  • Coverage criteria by Group (Group I, Group II, Group III, Group IV) 
  • Continued documentation after initial coverage for each group 
  • New modifiers (N1, N2, N3) as related to each Group 

No worries, we already hosted one webinar that you can check out and has been recorded. This webinar had over 600 people attend, so be sure to check out the recording! And, we are hosting an additional webinar about this topic on Dec. 15, so register here.

Continued Medical Need – The Language Got an Update! 

To begin, let’s start with the reasoning behind continued medical need as it can be found in the Standard Documentation Requirement Policy attached to every LCD. 

For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this timeframe. Entries in the beneficiary’s medical record must have been created prior to, or at the time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable coverage policy.

For ongoing supplies and rented DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiary’s medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review.  

For some items, the initial justification for medical need establishes that the condition necessitating the item is permanent. As a result, once the benefit category is met (or continues to be met), ongoing documentation of medical need is not required. Refer to the LCD-related Policy Articles for clarification regarding exceptions to ongoing justification for continued medical need. 

Regarding the updates, the information bolded below are the updates going into effect January 1, 2023: 

Any of the following may serve as documentation justifying continued medical need: 

  • A recent order/prescription by the treating practitioner for refills of supplies
  • A recent order/prescription by the treating practitioner for repairs; 
  • A recent change in an order/prescription; 
  • A properly completed CMN or DIF obtained prior to DOS 01/01/2023, with an appropriate length of need specified; 
  • Timely documentation in the beneficiary’s medical record showing usage of the item; 
  • Timely documentation is a record in the preceding 12 months 

In summary, continued medical need for a repair for any DMEPOS item can be obtain with timely documentation in the medical record or an order, as long as it’s within the preceding 12 months. For the documentation within the medical record, this is not about the patient going to an in-person visit with the treating practitioner. It can be a phone call into the treating practitioner who is documenting the medical need. It can also be a supporting documentation from the nurse, PT, OT, RT, etc. that has identified the continued medical need. However, the treating practitioner does need to review and sign off on these notes. 

Sleep Studies Related to Supply Chain and Recall Issues

For those suppliers that live in the sleep world, we all know that when a patient gets a diagnostic sleep study performed for the very first time, the clock starts ticking. When a sleep study has identified the patient has OSA, that patient has 12 months from the date of the sleep study to get a CPAP machine. Insert all the issues with supply chain allocations and recalls, we have been faced with delays in getting machines. After many discussions with the medical directors at both DME MACs, we have good news. 

Here is the response we received regarding this issue: 

During the PHE, if there is documentation from the treating practitioner that states the beneficiary’s medical condition has not changed since the previous sleep study and the evaluation by the treating physician is within a year of the DOS for initial issue of a CPAP, then DME MACs will accept this documentation in lieu of a repeat sleep study to meet the timely documentation requirement. The DME MACs would expect to only see this used in cases where a PAP device has truly not been available for the beneficiary due to supply chain and recall. 

We all recognize the supply chain and recall issues will go beyond the PHE. However, it’s still a win for our industry. 

A few key takeaways: 

  • Make sure the treating practitioner has justified within the medical record the condition has not changed and need still exists. This must be done within the preceding 12 months (timely documentation requirement). 
  • Make sure it is only related to supply chain and/or recall. 
  • No CR modifier, no claim narrative! 
  • This is only effective during the PHE. Once the PHE is terminated, further guidance will need to come from CMS. 
  • Document, document, document if this situation arises with one of your patients. 

New Year – Update Patient Demographics and Insurance 

With the new year approaching, this is a good reminder to make sure all your staff is getting the most recent information from patients. Just as we are asked when checking in for a doctor’s appointment, lab work, or any other testing, the DME industry must do the same. In all honesty, this should be done on a regular basis. 

  • What is your current insurance? Get copies of the card. 
  • What street do you live on? 
  • What are the last four numbers of your phone number to best reach out? 

The key is asking the questions so it makes the patient think and respond with the most recent and correct information.   

For any questions, please reach out to me, Ronda Buhrmester, via email at [email protected] or by calling 217-493-5440.


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