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

Published in Member Communities on October 05, 2022

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

“Do I need to have an RT on staff?” 

Many DME companies that service respiratory equipment often ask this question. 

Just like any state license requirements for a business, each state governs the requirement for the scope of practice for RTs in the home. Many suppliers are aware there is a licensure directory housed on the NSC (Palmetto GBA) website. While this is a great starting point to reference, it should not be the final answer. On a quarterly basis, the NSC reaches out to each state to seek any updates related to licensure and state requirements. It is up to the governing board for that state to respond to the NSC’s request in addition to providing the correct and updated information.   

From the response requesting updates (if any) is the information the NSC uses to update the licensure directory. Hence, the reason not to rely on the licensure directory as the final resource for your business.   

What can be done is to contact the governing board for that license. Using the RT license requirement for each state, a supplier can contact the governing board for the RTs. The other option is to explore the scope of practice for the RT in the state. I reference the scope of practice for an RT for the state in question and use the control/find keys to locate key words RT requirements in the home.   

Referencing the scope of practice is your best bet for confirming the RT requirement(s) that ensures your business is meeting the important supplier standards, and it also serves to protect your billing number. 

We have been seeing more HST studies scored using the REI method. Is this an acceptable scoring method to use for sleep studies?

We have always been told to follow the PAP policy using the AHI or RDI for scoring a sleep study. We have seen more and more sleep studies using the REI scoring method. After some back and forth with the DME MACs, we finally got a response on whether or not REIs are accepted. The answer is that both DME MACs (CGS and Noridian) have stated they will accept REIs for scoring in a sleep study, making sure the RERAs are not included in the result. 

The PAP policy will not be updated with this language. However, I do have resources for suppliers from both CGS and Noridian with this language accepting the REI scoring method. We know this is an area they will review during an audit, which means you need to make sure the sleep study is not scored with the RERAs. Make sure your RTs review the sleep study. 

Are you reviewing and updating the products/services offered section within PECOS (855S)? 

Each supplier is responsible for making sure the products and services being offered are updated within PECOS (855S). Many suppliers tend to rely on the accreditation company to update the NSC with this information.   

The supplier standards state that each DMEPOS supplier is responsible for providing any updates to the NSC. The supplier has 30 days to provide changes and updates. The notification can be submitted 30 days prior to the change or 30 days after the change. Either way, it’s the supplier’s responsibility to provide the updates, including removing or adding products and services being offered.   

The DME MACs are becoming more stringent on this requirement by providing informational edits on the remittance summary to the supplier that could essentially result in denial. Please review the information to ensure it’s up to date to avoid claim issues. 

Who is the contractor for the National Supplier Clearinghouse (NSC)?

Those that have been in the industry for some time now are familiar with Palmetto GBA. Palmetto has been the contractor for the NSC contract for several years.   

As with any CMS contract, bidding occurs for these contracts when terms are expiring. In late October 2022, there will now be two contractors for the NSC contract. The Mississippi River divides which states the contractors are accountable for within their jurisdictions. Palmetto GBA, who is the current contractor for the entire country, will now be the contractor for the west. Novitas has been awarded the contract east of the Mississippi River. As with any new contractor, we will expect a learning curve with NPE East contractor, Novitas.   

With the changes of having two jurisdictions, there is a name change from National Supplier Clearinghouse (NSC) to National Provider Enrollment (NPE). We have a new acronym to learn for our vocabulary, which is NPE.   

NPE East is Novitas and NPE West is Palmetto GBA. 

We have not seen an official announcement released by CMS yet, but we will pass along any updates and information to our members. 

When are the CMS CMNs and DIFs being eliminated? 

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, the DIFs for enteral, parental, and external infusion pumps are also being eliminated.   

The coverage criteria outlined within the medical policy (LCDs) are still required. Obtaining medical records from the referring practitioner is 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 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.   

When is the new oxygen equipment medical policy (LCD) being released? 

Suppliers providing home oxygen services are aware that a new oxygen medical policy will be implemented soon. Since September 2021, there has been an array of articles released regarding the new policy. The National Coverage Determination has been posted and is viewable to the public. However, the local coverage determination is currently being updated. The DME MACs have indicated that the LCD will be released at a minimum of 45 days prior to implementation in January 2023. This means we should see the policy in mid-November at the latest.  

Once we know the details of the LCD, I will be hosting several webinars for our VGM members. Stay tuned! 

When does the prior authorization go into effect nationally for the five orthotic HCPCS codes? 

The five orthotic codes that are under the required prior authorization list will be effective nationally October 10, 2022. The PA process for these codes has been following the phase-in approached. Phase 1 started in April with one state in each jurisdiction. In July, Phase 2 included a few more states within each of the four jurisdictions. October 10 is Phase 3 and the final phase where it’s required in all states, nationally. For traditional Medicare FFS, a PA is required prior to delivery for L0648, L0650, L1832. L1833, L1851. The PA is required when the product is being submitted for payment under the DME benefit to the DME MAC contractor. A CMS prior authorization is not accepted post-delivery.   

There was a webinar presented by me in August. Click here for the recording. 


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