The Latest in Billing & Reimbursement from Ronda Buhrmester: February 2023

Published in Member Communities on February 01, 2023

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

Read below for several billing & reimbursement-specific updates regarding the oxygen policy updates, a reminder on the enrollment contractor, additional HCPCS codes added to F2F/WOPD required list, and continuous glucose monitor HCPCS codes

Oxygen Policy Updates 

N modifiers for oxygen 

By now, you all have heard about the N modifiers that will be part of the new oxygen policy. The implementation for the N modifiers is April 2023. Until then, follow the policy by still appending the KX modifier to the RR oxygen payment category. When the N modifiers are implemented, the KX will no longer be required. The N modifiers identified the group in which the coverage criteria has been met.  

  • N1 = Group 1  
  • N2 = Group 2 
  • N3 = Group 3 

By appending the appropriate N modifier, it will direct the DME MAC to the corresponding Group of which the coverage criteria has been met (E1390RRN1).  

Until the current oxygen policy has been revised, continue to use the KX modifier. 

Oxygen testing during sleep 

We received clarification on the requirements for testing during sleep. In the past, when a test was performed during sleep, either the overnight oximetry study OR the study done while in the sleep lab for oxygen to be bled into CPAP machine, the requirement was to be at 88% or less for a total of five minutes. This specific requirement has been removed. While all other criteria is still required, including the recording time, there is no longer a need to gather testing for total of  five minutes at 88% or less. The policy has been updated to reflect requirement. 

If you’re interested in learning more, I will be hosting a webinar on Feb. 22 at 11 a.m. CT with Noel Neil, VP of Auditing and Compliance, ACU-Serve Corp, “Post Implementation View of the New Oxygen Policy.” To register, click here

Reminder on 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.   

A revised 855S application is required by March 10, 2023, for new applications, revalidations, or changes. 

Changes to the form include: 

  • Added medical record correspondence address to section 4B2 
  • Revised section 2E: Products and accreditation information to collect whether the supplier fills orders, fabricates, or fits items by contracting with other companies. 

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

Additional HCPCS Codes Added to F2F/WOPD Required List 

On Jan. 14, 2023, CMS released a public notice CMS-6088-N, adding 10 more HCPCS codes to the F2F/WOPD Required List. The effective date for these 10 new HCPCS codes in the brace category is April 2023. 

The new codes include the following for back, knee, and ankle/foot braces: 

  • L0631 
  • L0637 
  • L1843 
  • L1932 
  • L1940 
  • L1951 
  • L1960 
  • L1970 
  • L2005 
  • L2036 

The F2F Encounter/WOPD Required List already includes all HCPCS codes in the PMD product category and seven HCPCS codes effective nationally in 2022. With the 10 new codes, this makes the Required List for F2F/WOPD up to 63 HCPCS codes. 

CMS has a webpage dedicated to information for suppliers. When a code makes the Required F2F/WOPD List, a patient must have a face-to-face encounter with their treating practitioner documenting the medical necessity for the item being prescribed. The medical necessity must meet the coverage criteria outlined within the respective medical policy (LCD).   

In addition, the written order prior to delivery is required and must be completed within six months after the required F2F encounter. The Standard Documentation Requirements Policy includes these details. 

Continuous Glucose Monitor HCPCS Codes Effective January 1, 2023 

On December 28, 2021, CMS published the Medicare DMEPOS final rule (CMS-1738). This rule expanded the classification of DME to a larger group of non-implantable CGMs, regardless of whether the CGMs are non-adjunctive (can alert patients when glucose levels are approaching dangerous  levels, including while they sleep and also replace blood glucose monitors) or adjunctive (can alert patients when glucose levels may be approaching dangerous levels, including while they sleep but don’t replace blood glucose monitors), as long as the CGMs otherwise satisfy the regulatory definition of DME. 

The new HCPCS that are effective January 1, 2023, and have been included in the revised Glucose Monitor medical policy

  • K0553 is cross-walked to A4239 
  • K0554 is cross-walked to E2103 

Effective January 1, 2023, the code descriptors for adjunctive CGM codes A4238 and E2102 are  revised to add “non-implanted” to clarify use with no associated changes to the Class III code/modifier KF fee schedule amounts on the DMEPOS fee schedule file: 

  • A4238 - Supply allowance for adjunctive, non-implanted continuous glucose monitor (CGM), includes all supplies and accessories, one month supply = one unit of service 
  • E2102 - Adjunctive, non-implanted continuous glucose monitor or receiver 

Also, effective January 1, 2023, suppliers may submit claims for HCPCS codes A9276, A9277, and A9278 codes to get a Medicare denial for the claim. 

If you have questions, please contact Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement. 


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