DME MAC Jurisdiction B Insider

53 Pages·2017·1.02 MB·English

EDITION 3 ∙ WINTER 2017
This newsletter should be shared with all health care practitioners
and managerial members of the provider/supplier staff. Newsletters
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© 2017 Copyright, CGS Administrators, LLC.
Table of Contents
From the Medical Director Medical Policy
From the Medical Director, Stacey V. Brennan, MD ................4 LCD and Policy Article Revisions Summary for
October 6, 2016 .....................................................................25
myCGS
LCD and Policy Article Revisions Summary for
Correction to Information in the Implementation and November 10, 2016 ................................................................27
Cutover Special Edition Insider - CGS Publication ..................6
2017 HCPCS Code Annual Update - Correct Coding -
How to Check Same or Similar Equipment in myCGS Correction - DME MAC Joint Publication ..............................29
- CGS Publication ....................................................................6
Appeals
News from the Inside
Notification of the 2017 Amounts in Controversy Required
Using The Correct Lockbox For Refunds to Sustain Appeal Rights for an Administrative Law Judge
- CGS Publication ....................................................................8 (ALJ) Hearing or Federal District Court Review ....................34
CGS Connect™: Working Together To Eliminate Did CGS Get My Faxed Redetermination Request? .............34
Denials - CGS Publication .......................................................8
Miscellaneous
Introducing MR WIZARD – a powerful new online
tool for CGS Jurisdiction B DME MAC suppliers! Voluntary Refunds - Calendar Year 2016 - CGS
- CGS Publication ....................................................................9 Publication .............................................................................35
Healthcare Provider Taxonomy Codes October 2016 Code
Coverage & Billing
Set Update (MM9659) ...........................................................36
Argus® II Retinal Prosthesis System - Correct Coding
Claim Status Category and Claim Status Codes
- DME MAC Joint Publication ..................................................9
Update (MM9680) ..................................................................37
Pneumatic Compression Devices and Related
New Physician Specialty Code for Hospitalist (MM9716) ......38
Appliances – Correct Coding - Revised
- DME MAC Joint Publication ................................................10 Implement Operating Rules - Phase III Electronic
Remittance Advice (ERA) Electronic Funds Transfer (EFT):
Otto Bock C-Leg Coding - Correct Coding - Revised
CORE 360 Uniform Use of Claim Adjustment Reason Codes
- DME MAC Joint Publication ................................................13
(CARC), Remittance Advice Remark Codes (RARC) and
Eclipse™ Vaginal Insert system (Pelvalon, Inc) - Claim Adjustment Group Code (CAGC) Rule - Update from
Correct Coding - REVISED - DME MAC Joint Council for Affordable Quality Healthcare (CAQH)
Publication .............................................................................13 Committee on Operating Rules for Information Exchange
(CORE) (MM9766) .................................................................39
CUVITRU™ - Correct Coding - DME MAC Joint
Publication .............................................................................14 Issuing Compliance Letters to Specific Providers and
Suppliers Regarding Inappropriate Billing of Qualified
Not Otherwise Classified (NOC) HCPCS Codes Used for
Medicare Beneficiaries (QMBs) for Medicare
Drugs - Correct Coding - DME MAC Joint Publication ..........15
Cost-Sharing (MM9817) ........................................................41
Immunosuppressive Drugs – Billing Errors
Fingerprint-based Background Check Begins
- CGS Publication ..................................................................18
August 6, 2014 (SE1427 Revised) .........................................44
Immunosuppressive Drugs – Units of Service (UOS)
- CGS Publication ..................................................................18 Fees & Pricing
Documentation for Durable Medical Equipment October Quarterly Update for 2016 Durable Medical
Prosthetics, Orthotics, and Supplies (DMEPOS) Claims Equipment, Prosthetics, Orthotics, and Supplies
for Replacement of Essential Accessories for (DMEPOS) Fee Schedule (MM9756).....................................44
Beneficiary-Owned Continuous Positive Airway
January 2017 Quarterly Average Sales Price (ASP)
Pressure (CPAP) Devices and Respiratory Assist
Medicare Part B Drug Pricing Files and Revisions to
Devices (RADs) (MM9741) ....................................................20
Prior Quarterly Pricing Files (MM9843) .................................45
IVIG Demonstration: Payment Update for 2017 (MM9746) ...21
HCPCS UPDATES
Guidance to Physician/Practitioner and Supplier Billing
Offices that Submit Hard Copy Claims to Medicare to 2017 Annual Update of Healthcare Common Procedure
Help Reduce Incidence of Claims Not Crossing Over Due Coding System (HCPCS) Codes for Skilled Nursing Facility
to Duplicate Diagnosis Codes and Diagnosis Code (SNF) Consolidated Billing (CB) Update (MM9735) ..............46
Pointers (SE1629) ..................................................................22
The CMS articles in this edition of the Insider are current as of November 14, 2016.
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Table of Contents continued...
The 2017 HCPCS Updates – New, Revised, and
Discontinued HCPCS Codes .................................................48
Competitive Bidding
Quarterly Update for the Durable Medical Equipment,
Prosthetics, Orthotics and Supplies (DMEPOS) Competitive
Bidding Program (CBP) - January 2017 (MM9792) ...............50
eNews ................................................................................52
DME MAC Jurisdiction B
Contact Information ...................................................53

http://go.cms.gov/MLNGenInfo
The CMS articles in this edition of the Insider are current as of November 14, 2016.
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© 2017 Copyright, CGS Administrators, LLC. EDITION 3 ∙ WINTER 2017
FROM THE MEDICAL DIRECTOR
From the Medical Director, Stacey V. Brennan, MD
In this, my first “From the Medical Director” article, I would like to let you know that I am
delighted to be again associated with the Jurisdiction B states as the medical director for
DMEPOS here at CGS. Many of you have met me already, but for those who have not, I am
a Family Physician, with over 20 years of direct patient care and 18 years of administrative/
insurance industry experience. My work in the area of DMEPOS started off within a commercial
product line, and now for over 8 years I have been a DME MAC Medical Director (DMD).
While my primary responsibility is the oversight of the Local Coverage Determinations (LCDs)
or policies, the Policy Articles and Reconsideration Requests, I also work closely with our
leadership in Medical Review, Provider Outreach and Education, Appeals and Quality, to
name only a few. It is important to me that as a supplier, you are able to better work with your
physician providers, which in turn will afford greater satisfaction to the beneficiaries in our seven
states.
There are a few new and exciting opportunities for you to better serve your clients. First, since
early October last year, letters have been sent to suppliers of oxygen and diabetic supplies who
have experienced denials from prepay medical reviews. These contain detailed information
about the denial reasons, precluding the need to call our customer service department.
Next, the Jurisdiction B CGS Connect™ Program was recently implemented and is an exciting
opportunity for personalized education for you. Under this program, if you submit a CGS
Connect™ review request, our professional medical review staff will review the documentation
and provide detailed feedback on any documentation issues that would lead to a future claim
denial. This program is strictly voluntary, and does not guarantee payment or release from
potential audit. Our program is modelled after the same one offered in Jurisdiction C, and I
expect it to be enthusiastically embraced as it has been there. More details are provided in the
accompanying article in this edition of the Insider.
Now let me tell you about AESOP – an acronym (clever, don’t you agree?) for “Analyze and
Educate Suppliers on Policies” – which accomplishes just that. Really, this is not a fable! (I could
not resist). AESOP is a collaborative program between Medical Review and Provider Outreach
and Education (POE) that provides one-on-one education to suppliers. Suppliers are selected
by CGS to participate in the program based on their Medical Review denial rates. The program
provides quarterly education to participating suppliers with the goal of reducing their denial rate
and possibly being excluded from future Medical Review audits.
Also, in November, CGS launched our new MR WIZARD self-service tool for Jurisdiction
B suppliers. MR WIZARD is a full-service, self-service tool that instantly gives you specific
reasons for medical review denial(s) and links to important education and resource materials
designed specifically for your particular denial. No other online tool provides this level of detail
without requiring access to a secure portal! Plus, MR WIZARD also provides very detailed
information on the status of your additional documentation request.
MR WIZARD results are so detailed that it completely eliminates your need to call customer
service because you can view exactly the same information available to customer service
advocates! And, our denial information is consistent across all CGS tools including myCGS!
There is additional information on MR WIZARD available in this edition of the Insider. I
encourage you to see how much information is available to you from this online self-service tool.
Before I close, I wanted to announce that I’m going to be a television star! That’s right! This
year, I will be hosting a series of new Medicare Minute programs created just for Jurisdiction
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B suppliers. My video education will focus on policy-specific topics, policy interpretation and
important information you need to bill the Medicare program correctly. The videos will be
featured on the Jurisdiction B website and on YouTube. Hey! If you’re on YouTube…you’re a star,
right? Be watching our listserv and social media channels for details on my television debut.
Lastly, as the DMD for Jurisdiction B, I look forward to getting to know you and serving any
needs related to medical policies you may have. It is easy to contact me – see my email
address below - and I am hopeful that you will also participate in our webinars and other on-line
educational offerings. For 2017, I will work to be present at as many of our in-person seminars
in Jurisdiction B as possible. Please do not hesitate to let our dedicated POE staff know of
suggestions you may have for innovative educational programs, including those that reach out
directly to physicians.
So as 2017 begins, I look forward to accomplishing much in our Jurisdiction B states – so that
we can prove that our beneficiaries are the best served in the country!
Wishing you a healthy and prosperous New Year,
Stacey V. Brennan, MD
[email protected]
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© 2017 Copyright, CGS Administrators, LLC. EDITION 3 ∙ WINTER 2017
myCGS
Correction to Information in the Implementation
and Cutover Special Edition Insider
- CGS Publication
In the Implementation and Cutover Special Edition Insider (http://www.cgsmedicare.com/
jb/imp_pubs/insider/2016_insider_se.pdf), published on June 1, 2016, we incorrectly stated
that Additional Documentation Request (ADR) Letters can be submitted via the myCGS Web
Portal (http://www.cgsmedicare.com/jb/mycgs/index.html). Although we are working to add this
functionality to myCGS, ADR submission is currently unavailable through the web portal. Stay
tuned to our website (http://www.cgsmedicare.com/jb/index.html) and ListServ (http://www.
cgsmedicare.com/medicare_dynamic/ls/001.asp) for updates and announcements regarding
future enhancements to myCGS.
How to Check Same or Similar Equipment in
myCGS
- CGS Publication
In myCGS (http://www.cgsmedicare.com/jb/mycgs/index.html) there are several avenues for
checking same or similar equipment. For capped rental items, the CMN Status option looks for
CMNs on file—both real and dummy—for the HCPCS code entered or similar equipment and
provides detailed information about the CMN. There is also a wild card feature that allows you to
enter the first letter of the HCPCS code followed by an asterisk (i.e., E*) to retrieve all CMNs on
file for the HICN entered that begin with the designated letter.
For those items that are not capped rental, the Claim History option is available. This option
provides claim detail information for the HCPCS code entered within the dates of service you
designate. You may enter the first letter of the HCPCS (i.e., L) to return all items beginning with
that letter for the designated dates of service.
Additionally, the Diabetic Supplies and Shoes option is also available. For test strips and
lancets, myCGS will search 90 days before and after the date of service specified and return
claim information for the HICN entered. For other diabetic supplies, it will search six months
before and after the date of service specified and return claim information for the HICN
entered. For diabetic shoes and inserts, myCGS will search the year specified and return claim
information for the HICN entered.
CMN Status option returns the following information:
y Submitted HCPCS
y Approved HCPCS
y Type (initial, revised, or recertification)
y Length
y Initial date
y Revised/Recert date, if applicable
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y Supplier Name
y Supplier Phone Number
y CMN status
y Rental months paid
y Last rental date
Claim History option returns the following information:
y From date
y To date
y HCPCS (with modifiers)
y Units
y Provider Name
y Provider Phone Number
y Status (Allowed or Denied)
Diabetic Supplies and Shoes option returns the following information:
y From date
y To date
y HCPCS (with modifiers)
y Units
y Provider Name
y Provider Phone Number
y Status (Allowed or Denied)
Same or similar information is just one of many benefits to using myCGS. Learn more by visiting
our myCGS page at http://www.cgsmedicare.com/jb/mycgs/index.html.
Try myCGS Today!
Not a myCGS user? Why not give it a try? We think that you will find myCGS to be a fast and
user-friendly application that will help you save time and money.
Visit our myCGS page at http://www.cgsmedicare.com/jb/mycgs/index.html to get started today!
http://www.cgsmedicare.com/jb/mr/cgsconnect.html
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NEWS FROM THE INSIDE
Using The Correct Lockbox For Refunds
- CGS Publication
Each CGS DME MAC Jurisdiction has a separate lockbox that refund checks should be sent to.
Sending your refund to the incorrect lockbox or combining refunds for separate jurisdictions into
one check could cause a delay in the processing of your check. Thank you for your cooperation
that helps us process your refund checks more timely and efficiently by using the correct
lockbox for the contract that is being refunded.
DME JB CGS Administrators, LLC
PO Box 953479
St. Louis, MO 63195
DME JC CGS Administrators, LLC
PO Box 955152
St. Louis, MO 63195
If you need additional information on refund checks please see the CGS Website at http://www.
cgsmedicare.com/.
CGS Connect™: Working Together To Eliminate
Denials
- CGS Publication
CGS Connect™ is a concierge level service that provides Jurisdiction B suppliers with clinical
and non-clinical review of documentation prior to submitting a claim. CGS Connect™ is a
voluntary program that provides you with a higher level of assurance that your supporting
documentation meets the necessary requirements to process your claim for payment
consideration.
When you use CGS Connect™, we combine our professional review with education and
resources so you get customized service to help you avoid future documentation-related errors.
Connect now, connect often and let’s work together to eliminate your denials! Start using CGS
Connect™ today!
CGS Connect™ is not a prior approval or authorization program. Participation in
CGS Connect™ does not exempt suppliers from the audit process. Our review and
recommendations under the CGS Connect™ program are for educational purposes only and
do not guarantee payment for services billed. CGS Connect™ does offer you professional
evaluation of your pre-claim documentation and it provides you with individualized education
to prevent future documentation-related errors.
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Introducing MR WIZARD – a powerful new online
tool for CGS Jurisdiction B DME MAC suppliers!
- CGS Publication
MR WIZARD Tool is a full service, self-service tool that eliminates your need to call customer
service for an explanation of an MR denial. The information we provide online is exactly the
same information available from our customer service advocates.
MR WIZARD provides details on:
y The type of denial received
y A detailed denial explanation
y The Provider NPI
y Date-of-Service
y HCPCS code billed
y Links to education and resources designed specifically for your particular denial
When you use MR WIZARD, you can choose to view individual claim information or, you can
use our export feature to view multiple CCNs by date range and NPI.
The MR WIZARD is always available to provide you with everything you need to understand why
the denial occurred and what you need to do next.
COVERAGE & BILLING
Argus® II Retinal Prosthesis System - Correct
Coding
- DME MAC Joint Publication
Link to current version on the CGS website: http://www.cgsmedicare.com/jb/pubs/news/2016/09/cope551.html
The Argus® II Retinal Prosthesis System (Second Sight Medical Products, Inc.) is an implanted
retinal prosthesis. FDA approval for marketing under this indication was granted on February 13,
2013. According to the manufacturer, the Argus® II Retinal Prosthesis System consists of the
implanted system, head mounted telemetry and video data collection system, video processing
unit, video processing rechargeable batteries, and battery charger.
The device is surgically implanted. This procedure is billed using a CPT code. The implanted
device is billed using HCPCS Level II code C1841 (RETINAL PROSTHESIS, INCLUDES ALL
INTERNAL AND EXTERNAL COMPONENTS). Services billed with a CPT code are not billable
to the DME MACs as CPT codes are not within DME MAC jurisdiction. Items provided as part
of the service by the CPT code are considered incident to that service and are not separately
billable to the DME MACs.
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The Argus® II Retinal Prosthesis System does have external replacement parts such as
batteries and the head mounted device. These external replacement parts are not billable to the
DME MAC even if the device is being used in the home. The replacement parts must be billed
to the A/B MAC. Medicare’s Benefit Policy Manual (Internet Only Publication 100-2) Chapter 20
Section 10 states, in relevant part:
[I]mplanted prosthetic devices, replacement parts, accessories and supplies for the implanted
DME must be billed to the A/B MACs … and not the DME MAC.
Questions concerning HCPCS code classifications should be directed to the Pricing, Data
Analysis and Coding (PDAC) contractor - Contact Center at [phone] during the hours of
8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME
PDAC Contact Form located on the PDAC website www.dmepdac.com/dmecs.
Pneumatic Compression Devices and Related
Appliances – Correct Coding - Revised
- DME MAC Joint Publication
Link to current version on the CGS website: http://www.cgsmedicare.com/jb/pubs/news/2016/09/cope553.html
Revised: September 22, 2016
Original Published: August 2010 under “Correct Coding for Pneumatic Compression Devices”
This revision provides additional information regarding the HCPCS coding requirements for
these items.
Pneumatic compression devices (PCD) consist of an electrical pneumatic pump and an
inflatable appliance that encloses the applicable body part. The pump fills the appliance with
compressed air to predetermined pressures and intermittently alternates inflation and deflation
to preset cycle times. The pressure and cycles vary between devices and, in some devices, are
user-adjustable. Several types of PCDs exist. It is important to use the correct HCPCS codes for
the PCD and related appliance.
The only products that may be billed to the DME MACs using codes E0650, E0651, E0652,
and E0675 are those for which the Pricing, Data Analysis, and Coding (PDAC) contractor has
completed a Coding Verification Review. The coding determination subsequently is published
on the appropriate Product Classification List. Information concerning the documentation
necessary to request a Coding Verification Review can be found on the PDAC web site or by
contacting the PDAC.
PCDs for the Treatment of Lymphedema or Chronic Venous
Insufficiency (CVI) With Ulcers
PCDs used for the treatment of lymphedema or CVI with ulcers are coded based upon the
characteristics of the compression pump. The only HCPCS codes for PCDs used to treat
lymphedema or CVI with ulcers are:
E0650 - PNEUMATIC COMPRESSOR, NON-SEGMENTAL HOME MODEL
E0651 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITHOUT
CALIBRATED GRADIENT PRESSURE
E0652 - PNEUMATIC COMPRESSOR, SEGMENTAL HOME MODEL WITH CALIBRATED
GRADIENT PRESSURE
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© 2017 Copyright, CGS Administrators, LLC. EDITION 3 ∙ WINTER 2017