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

Published in Member Communities on July 05, 2023

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

Read below for several billing & reimbursement-specific updates regarding the PTAN, the KX modifier and dates of service, reminder of the new ABN form, oxygen equipment modifiers and news with the policy, TPE audits, and TPE audits on GW modifier related to hospice claims.  

Does Your Business Have a PTAN? Keep reading if the answer is yes. 

As you are aware, the enrollment contractor that governs the PTAN for billing privileges was transitioned into two contractors in November 2022. The PTAN enrollment contract for the DMEPOS industry is now separated into two jurisdictions with the Mississippi River as the dividing line. See the chart below for the details. 

Revalidations are happening. Please make sure your staff knows to be on the lookout for this notice in the mail. Suppliers can only respond to a revalidation when the notice has been issued. Suppliers cannot be proactive by sending the revalidation early without having received the notice from the National Provider Enrollment (NPE) contractor. They will send back the revalidation packet if you try to be proactive! Wait for the notice to arrive in the mail. 

Anytime there is a change to the enrollment information related to the company’s PTAN profile, there is a 30-day window. Suppliers have 30 days pre or post change to notify the NPE contractor. This includes changes to the surety bond certificate, products/services offered, states your business is servicing, hours of business, etc.   


NPE West Palmetto GBA 

NPE East Novitas Solutions

July 2, 2023, and the KX Modifier 

The product categories listed below require the KX modifier for dates of service (DOS) on or after July 2, 2023. This is being implemented because of the elimination of the CMS CMN and DIF forms. If the KX is not appended beginning with DOS 07/02/2023 and beyond, the claim will be rejected. In addition to updating staff and billing software, it would be wise to review the respective medical policy (LCD) and related policy article. 

  • Enteral Nutrition 
  • Parenteral Nutrition 
  • Seat Lift Mechanisms 
  • Osteogenesis Stimulators 

Reminder of the New ABN Form 

The ABN, form CMS-R-131, has been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 01/31/2026 will be required to use on 06/30/23. There were no other changes made to the form.  

As a reminder, the ABN is used in advance of the delivery to inform beneficiaries in situations where Medicare payment is expected to deny the claim. The denial may be due to lack of medical necessity, same or similar equipment within the five-year reasonable useful lifetime, and over-utilization. The ABN needs to speak to the beneficiary so an informed decision can be made. Read the full instructions of the proper use of the ABN by clicking here.

View the New ABN (English Version) View the New ABN (Spanish Version)

Oxygen Equipment Modifiers 

The oxygen medical policy (LCD) that was implemented January 1, 2023, has provided welcomed changes but also provided some confusion. The oxygen modifiers are a good area to start with some head scratching moments. Why? There was this “thing” called the pandemic public health emergency (PHE) in in addition to new modifiers effective April 1, 2023. To determine the correct modifiers to append, we need look at the date of service (DOS) and determine if a PHE waiver/flexibility was used or if the LCD coverage met. Oh wait, then we have to look at DOS between January 1 and March 31, 2023, because those DOS require the KX modifier. Are you scratching your head yet? Take a look at this helpful resource to determine the correct modifiers

Here are a few reminders with the oxygen policy:   

  • Within the current oxygen policy, one of the requirements for coverage is:  
    • The treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need; and, 
      • Evidence of qualifying test results at the time of need; and, 
      • Evidence of an evaluation of the qualifying test results by a treating practitioner 
        Solution: The treating practitioner may co-sign the actual oxygen test results as proof they evaluated the qualifying test for home oxygen. If they do not co-sign the oxygen test results, then they must mention this information within the patient notes. This does not mean a new office visit is required. 
  • Acute or short-term conditions are acceptable; however, the following should be considered: 
    • When the condition is a short-term or acute condition such as pneumonia or hypoxia (not all inclusive), suppliers need to monitor the oxygen coverage and usage. If the treating practitioner does not indicate a length of need, suppliers should inquire for more details with the referral or set a company policy. 
      Solution: Consider setting a company policy where acute/short-term conditions require a “touch” at three months. From what I am hearing, the industry seems to be setting a standard for following up with these patients at three months to gather additional documentation for ongoing medical need or possibly picking up the equipment due to no longer medically necessary (condition resolved). 
  • Proving ongoing medical need is a must with any DME equipment. With oxygen equipment, the requirement of continued medical need can be done with a valid standard written order (SWO). 
    • Continued medical need is an area that suppliers are not always mindful of because the focus tends to be at initial setup. Proving ongoing (continued) medical need is an area that we as suppliers can control with the correct parameters and education in place. 
      Any of the following may serve justifying continued medical need for oxygen therapy: 
      • A recent order/prescription by the treating practitioner for refills of supplies; 
      • 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. 
    • Most states require an annual order for oxygen therapy. 
      Solution: Suppliers can complete all the elements of a SWO for oxygen except for the treating practitioner’s signature. Suppliers need to set placeholders within the billing software as a reminder to complete the SWO then send to the treating practitioner for a signature. The parameter within the billing software should be 30-45 days in advance of the current SWO expiring. By setting a good parameter and following through with the referral, this will help with meeting the ongoing medical need and to avoid cash flow being interrupted. The continued medical need requirement must be performed annually to remain compliant with the standards. In addition, education with staff, patients, and referrals are important to maintain smooth communication and insurance requirements. 

TPE Audits Back in Full Swing 

The local DME MAC contractors are back in full swing for TPE audits since the expiration of the PHE on May 11, 2023. Suppliers have reported that TPE notices have been received for CPAP supplies. Surgical dressing is always a top category for audits, and be prepared for the oxygen equipment to be forth coming.   

What can you do in preparation for the TPE? Review medical policies (LCD) regularly with staff. More importantly, perform self-audits which are important for staff education, training, and remaining compliant. This will also help to ease through a TPE audit. 

Reminder: TPE Audits on GW Modifier Related to Hospice Claims

The reason for submitting a claim under the DME benefit while the patient is on hospice care must be totally unrelated to the hospice condition, not just the diagnosis. 

The GW modifier is used to indicate items/services that are not related to the hospice beneficiary's terminal illness or a related condition. The hospice benefit is under Medicare Part A and includes items and services provided to manage terminal illnesses and related conditions, including DMEPOS as part of treatment for condition/illness for hospice (bundled with per diem payment). Suppliers may bill DME MACs separately for an item or service that is not related to the hospice patient's terminal condition.  

As noted by the Centers for Medicare and Medicaid Services (CMS) and repeated in numerous CMS publications and regulations related to the hospice benefit, payment for items and services separate from the hospice per diem should be "exceptional and unusual" and that hospices are required to "provide virtually all the care that is needed by terminally ill patients." 

Currently, CGS DME MAC contractor for Jurisdictions B and C are performing prepayment audits related to the use of the GW modifier. 

In addition to the standard documentation request that are part of the TPE audit, the letter will be requesting the Hospice Election Statement Addendum. This form is an educational document, and it promotes transparency for the hospice beneficiary, their families or caregivers, and any other stakeholders, such as DME suppliers and MAC contractors.   

Supporting claims under the DME benefit while the patient is in hospice care is challenging. Before using the GW modifier, suppliers need to ask the hospice provider to send the Hospice Election Statement Addendum. 

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


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