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

Published in Member Communities on November 01, 2023

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

Read below for several billing & reimbursement-specific updates regarding expiring competitive bid contracts, PTAN, open enrollment, audits, CGM supplies, the CPAP prohibition rule, nebulizer policy, telehealth, and key changes to the oxygen policy.

Current Contracts in Competitive Bid Set to Expire on Dec. 31, 2023 

CMS released a notice with details regarding the competitive bidding program (CBP) and a temporary gap period. The current round of the CBP includes certain OTS knee and back braces. The contracts began Jan. 2021 and are set to expire on Dec. 31, 2023.   

Beginning Jan. 1, 2024, this market becomes any willing supplier as the contracts have expired. Those suppliers that may want to accept referrals for those CB products need to remember the single payment amounts (SPA) known as the allowable remain the same. The allowable is based on the patient’s permanent address on file with SSA.   

For example, on Jan. 2, 2024, open to any willing supplier, if a supplier dispenses and bills for an L0650 for a patient that lives in the Minneapolis/St. Paul, MN competitive bidding area, the supplier will be reimbursed at that SPA for that CBA. 

If you are adding these products to the services your company will be offering in 2024, be sure to update your PECOS/855s to reflect these services in addition notifying accreditation. If the enrollment contractor is not updated, when a claim is submitted it will be denied. 

As the notice reads, there will be a formal public notice and comment rulemaking process prior to the instructions for opening the next round of CB. We will share information as we learn more details. 

Protect Your PTAN - Surety Bonds Should Not Expire 

The number one issue enrollment contractors encounter is expired surety bonds. Suppliers can easily avoid the errors by making sure there is a reminder set to renew the bond (calendar, spreadsheet, etc.), in addition to making sure the surety bond company has the correct correspondence and contact information (pay attention to mail and emails). Part of managing the DME company is maintaining the supplier number (PTAN) that maintains cash flow.  

With changes to enrollment contractors now being two Jurisdictions, CMS has been enforcing the contractors, Palmetto GBA and Novitas Solutions, to follow the rules by making sure every “I” is dotted, and every “T” is crossed.   

If there is an error that causes a revocation of the PTAN, to correct and reinstate the number could take at least 60 days. Let’s not go down that path and instead review the supplier standards by making sure everything is up-to-date and the enrollment contractor has received the necessary information. 

Open Enrollment - Remain Participating or Change to Non-Participating 

Open enrollment only occurs once a year between Nov.15 and Dec. 31. This is the time for suppliers to consider their enrollment status that would take effect Jan. 1, 2024. Changing your status to non-participating allows options at any time during the year. This means that a claim can be submitted non-assigned, especially for those items that are costing more than the allowable. We have seen more and more suppliers ask questions and gather information to move to non-assigned claims, especially with purchase items like walkers, CPAP masks, and some wound care.  

There are options to show CMS the current allowables are not sustainable with cost of goods and overhead expenses such as salaries at record highs. To protect the financial health of your business, this does mean passing on the costs to the patient. Ultimately, this is the patient’s choice.  

The good news is Dan Fedor with U.S. Rehab and I are hosting a two-part webinar series in November on the rules and regulations with enrollment status, followed up with the second webinar presenting detailed examples of non-assigned claims and a Q&A session. 

Register for the webinars on Nov. 9 and Nov. 30

Post-Payment Audit on L0631 Spinal Orthoses 

The supplement medical review contractor (SMRC) announced at the beginning of October audits will begin for the L0631 back brace. The audit has stemmed from a fraud scheme targeting Medicare beneficiaries to get a free or at-no-cost brace, as well as the Federal Trade Commission (FTC) issuing a consumer alert on scammers. There was an article and video published by CNBC, “Inside the minds of criminals: How to brazenly steal $100 billion from Medicare and Medicaid.” Unfortunately, a few bad apples spoil the batch for the rest of the industry. 

The dates of services (DOS) being reviewed in this post-payment audit are Jan. 1, 2021-Dec. 31, 2022. Do these dates ring any bells? 

These are DOS during the coronavirus pandemic PHE. If you receive an audit from the SMRC contractor, it will more than likely include several claims for this code (not just one). If there was as CR appended on the claim along with the claim narrative of COVID-19, possibly due to a waiver being used such as the COVID-19 for the signature on the proof of delivery, I would highly recommend including the waiver with the audit.   

The contractor is required to abide by the waivers and flexibilities that were in place; however, we know contractors tend to forget or are not aware. If your company receives the audit request, the goal is to move through the audit/review smoothly.  

CGM Supplies Billable with 90-Day Supply! 

CMS announced recently that effective for dates of service on Jan. 1, 2024, CGM supplies such as the A4239 will be billable and payable as a 90-day supply. Currently, suppliers can dispense a 90-day supply; however, the billing can only occur monthly (every 30 days). Effective Jan. 2024, this will change to allow billing for the 90-day supply that was delivered to the patient for the next 90 days. There will be more to come from the DME MACs as they will need to update the glucose monitor policy article. Once the MLM article is released with further instructions, I will be sharing this with our members! In the meantime, check out this VBLOG that has additional tips for CGM coverage criteria. 

Have You Heard of the CPAP Prohibition Rule? 

The Medicare CPAP payment prohibition under 42 CFR 424.57 states as follows: No Medicare payment will be made to the supplier of a CPAP device if that supplier or its affiliate is, directly or indirectly, the provider of the sleep test used to diagnose the beneficiary with obstructive sleep apnea. This prohibition does not apply if the sleep test is an attended facility-based polysomnogram

It is important to understand how Medicare defines an “affiliate.” An “Affiliate,” for purposes of the prohibition, is “a person or organization that is related to another person or organization through a compensation arrangement or ownership.” The term “compensation arrangement” is not defined in the section of the CMS regulations that the prohibition appears, but the same term is used in and defined by the Stark statute as “any arrangement involving any remuneration ….” (i.e., health systems or clinics/labs with affiliates) 

Basically, what this means is that Medicare will not pay XYZ supplier for the CPAP if XYZ is the “provider of the HST sleep test.” That term is defined as “the individual or entity that directly or indirectly administers and/or interprets the HST sleep test and/or furnishes the sleep test device used to administer the sleep test.” 

The payment prohibition is applicable to Medicare FFS beneficiaries. As to whether or not there is a similar prohibition with commercial insurances including Medicare Advantage Plans, the supplier will need to examine the insurance contracts and insurance company’s payment and coverage guidelines.  

If a supplier determines that they have violated the payment prohibition, the supplier needs to refund the money it was reimbursed for the CPAP devices and supplies. 

Good News for Suppliers Providing Nebulizer Machines 

There was a request for additional ICD-10 codes to be added to the nebulizer policy, and the request was granted. The request was a result of our quarterly council meetings with the DME MACs (CGS and Noridian). With the uptick in coronavirus cases, suppliers have been getting referrals for patients needing a nebulizer machine with the coronavirus diagnosis. Prior to Oct. 1, 2023, this was not allowed; however, effective for dates of service Oct. 1, 2023 and beyond, the COVID-19 diagnosis is acceptable. In addition, there are more codes added to the policy. See the update below: 

Policy Update

Policy Update

Telehealth Update! 

Our industry has been under the impression that for telehealth visits, the encounter must be both audio and video. We learned during a recent council meeting with the DME MACs that CMS posted a list of approved telehealth CPT codes, and the list includes several codes identified as audio only. Evaluations conducted using CMS-approved methods of telehealth are acceptable for supporting that an item of DMEPOS is reasonable and necessary, as long as all of the coverage criteria are met and sufficiently documented via an audio-only encounter.   

Remember, there are certain policies that will still require both audio and video for telehealth due to the statute, such as power mobility devices.  

For example, a patient is at home with the coronavirus and needs a nebulizer for U07.1 ICD-10 diagnosis. They can have an approved telehealth audio evaluation with their treating practitioner to determine the medical need for the nebulizer machine and medications, making sure the coverage criteria is documented. 

Quick Glance at Key Changes to the Oxygen Policy 

Removed: 

  • Removal of the CMS CMN-484 for oxygen for initial, recerts, and revisions 
  • Removal of language alternative treatment language 
  • Removed of chronic stable state for outpatient 
  • Removed testing done within 30 days  
  • Removal of “total 5 minutes of 88% or below” for testing done during sleep 
  • Removed in-person visit within 30 days of initial date of certification 

Added/Changed 

  • Evidence of qualifying testing done during “time of need”  
  • Evidence that treating practitioner evaluated qualifying testing      
  • Visit can be in person or approved telehealth 
  • Allowing for both acute and chronic conditions 
  • Cluster headaches are in Group 3 coverage 
  • Use of “N” modifiers instead of KX (DOS 4/1/2023) 
  • Continued need proven with a valid SWO 
  • Test results accepted when entering Medicare FFS from any insurance plan (must meet current LCD)

Be sure to register for our webinar in December that is AARC approved for 1 contact hour with me!  

Lessons Learned with the Oxygen Equipment Medical Policy 

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


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