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

Published in Member Communities on September 06, 2023

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

Read below for several billing & reimbursement-specific updates regarding audits, the competitive bidding program, using the ST modifier, Medicare Part C beneficiary complaints, and protecting your PTAN.  

Audits Amping Up!

As expected, the audits have increased since the end of the coronavirus PHE. Suppliers are seeing audits in many product categories, most recently the oxygen equipment. Remember the oxygen equipment had a new medical policy implemented in January 2023. Currently the oxygen audits are at a prepayment level (TPE), and I have only heard of CGS in jurisdictions B and C. I highly recommend suppliers review the policy again and attend any of my education sessions including a Live Chat on September 21 that will review the oxygen medical policy and audits. 

Oxygen equipment is not the only TPE audit in the respiratory area, CPAP devices and supplies are included. In addition to many other equipment and product categories such as wound care, commodes, wheelchairs, hospital beds, urological supplies, GW modifier related to hospice, and more!

I want to review the latest results of the GW modifier pre-payment audit. The error for this audit is 100%. The contractor reviewed the GW modifier being appended to claims with the patient lifts (E0630 and E1035). The two reasons for denials are invalid use of the GW modifier and the medical records lacked sufficient information about the beneficiary’s condition to determine if medical necessity coverage criteria were met.

As a reminder, 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 when 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. This means the conditions for hospice and for the DME benefit must be totally unrelated. It is not just a diagnosis! 

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."

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. As a reminder, before using the GW modifier, suppliers need to ask the hospice provider to send the Hospice Election Statement Addendum.

With audits back in full swing including the post payment contracts (RAC, UPIC, CERT) and many other payers outside of Medicare, it is in the best interest of your business to perform self-audits, whether this is done with internal staff or hired by a consulting group. It is essential to be prepared.

Where Are We With the Competitive Bidding Program?  

CMS released a notice with details regarding the competitive bidding program (CBP) and a temporary gap period. CMS did this same process in the past prior to this Round 2021.

The current round of the CBP includes certain OTS knee and back braces. The contracts began January 2021 and are set to expire on December 31, 2023. Beginning January 1, 2024, this market becomes any willing supplier as the contracts will have expired. Those suppliers that may want to accept referrals for those CB products need to remember the single payment amounts (SPA) remaining. The allowable is based on the patient’s permanent address on file with SSA.  

For example, on January 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.

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. 

When to Use the ST Modifier

The ST modifier was developed for use with specific HCPCS codes in the orthotic category that require a prior authorization (PA). If the PA requirement is being bypassed and the two-day day expeditated review would delay care and risk of health or life of the beneficiary, and there is an immediate need of the orthotic, the supplier would then use the ST modifier on the claim knowing the claim will go under a pre-payment review before being reimbursed.

The only HCPCS codes affected by the ST modifier are L0648, L0650, L1832, L1833, and L1851.

The medical record documentation by the treating practitioner must support the immediate need that would bypass the PA process completing and need to include the delay of care and risk of health in detail.

Where to Send Medicare Part C Beneficiary Complaints

Open enrollment for the switch to a Medicare part C plan (MAP) for beneficiaries is right around the corner! This becomes a challenging time for our industry as primary insurance coverage will change and the beneficiaries not fully understanding the effects of making the switch. 

My team and I are working on developing tools for you all to use to help educate beneficiaries on what these changes mean, and that does not include believing those commercials! I like the ole adage if it sounds too good to be true then it is.

Insurance verification is one area that must be confirmed with the beneficiary on a regular basis. Never assume the insurance is the same. Staff need to ask every time there is a conversation with the beneficiary, “I know we recently asked this; however, I need to ask again, what is your insurance? Can you verify the last four digits of your telephone number? And can you verify the home address?”  

By asking those few, simple questions frequently, it helps alleviate burden on the back end with billing. These few, simple questions only take a few seconds, literally. 

Beneficiaries can call 800-Medicare to issue complaints for the Medicare advantage plans. Our industry can submit complaints to this email on this website:

They need to hear when there are issues. Otherwise, the assumption is “no news is good news.” 

Below are a couple of resources that have some good information on Medicare Part C plans. 

Protect Your PTAN

Part of managing the DME company is maintaining the supplier number (PTAN) that maintains cash flow. I will continuously remind our members to monitor renewals for liability insurance, surety bonds, state license requirements, and basically any of the 30 supplier standards. To maintain the billing privileges, these supplier standards need to be met at all times. 

With changes to enrollment contractors now being two Jurisdictions, CMS has been enforcing the contractors, Palmetto GBA and Novitas Solutions, to follow the rules 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, making sure everything is up-to-date and the enrollment contractor has received the necessary information.

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


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