REGION D DAC
MEETING with CIGNA Medicare
~
Tuesday, January 20, 2004
CIGNA Medicare Administration
2 Vantage Way ��Nashville, TN
1:00pm – 3:00 pm
MINUTES
DAC Representatives:
Troy Paz, Chair Deanne Birch Sandy Carden
Yvonne Cordoza Velma Goertzen Rick Graver
Mike Hayden Wade Hendrickson David Hosman
Connie Lind-Fraher Joe McKnight Gloria Peterson
Rich Pozesky Carlos Reyes Pat Spanel
Barb Stockert Mary Turner
CIGNA Representatives:
Robert Hoover, M.D., Medical Director
Kathy Brock Barbara Douglas Ellen Edenfield
Doug Frazier Scott Hudson John Kelly
Melissa Lamb Kim Largeant Trisha Luna
Mary Rheinecker
CMS Representatives (via teleconference):
Becky Chapman Lori O’Neil
I. GENERAL BUSINESS
The meeting was called to order at 1:00pm. After introductions, the minutes from the previous
meeting were approved as submitted.
The 2004 proposed calendar was also approved as submitted.
II. MEDICAL DIRECTOR UPDATE
Dr. Hoover reported on the following:
• Website Update - CIGNA added a section to its website containing educational
information to assist providers with medical review. CIGNA is in the process of
developing Net Courses to be added to the medical review section of the website,
including Progressive Corrective Action and Support Surfaces. Dr. Hoover requested the
DAC and that of State Associations to assist with informing providers about this new
tool.
• Claims Error Rate Testing (CERT) – The 2002 analysis results identified problem areas
with glucose monitors, Ostomy supplies, and nebulizer drugs. Wade asked what results
CIGNA has received from training providers in these three categories. Mary Rheinecker
indicated that many of the claims for items in these groups are billed by mail order
companies.
• Wheelchair LMRP – Clarified that the recent information released by the DMERCs was
not a new wheelchair LMRP, but rather guidance to providers outlining documentation
requirements. He reported that the Center for Medicare and Medicaid Services (CMS) is
working on a formal response to industry concerns.
Dr. Hoover indicated that he has always maintained a strict interpretation of national
policy that a beneficiary must be bed/chair confined. He informed the DAC that he had
appeared before a Congressional hearing on this issue and they concurred with his
interpretation. Region D has always allowed just a few steps for patient transfer.
However, two of the four regions did not maintain the same interpretation. Therefore, the
four DMERC medical directors needed to reach a consensus and clarify their
interpretation of policy to providers.
He also reported that CMS will be developing a physician/beneficiary educational
material on power wheelchairs, but he is not sure how that will be distributed.
• Physician Education Packet – CIGNA is in its final stages of developing a pocket size
tool for physicians on DMEPOS. Currently 7,000 packets will be printed and distributed
within the next few months. CIGNA plans to also make the packet available via its
website.
• BIPAA 2000 Requirements – CIGNA is in the process of converting policies to the Local
Coverage Determinations (LCDs) public information article format required by BIPAA.
The DMERCs have two years to convert current policy to this mandated format. Dr.
Hoover reported that some benefit information would not translate into the new format,
which will create the need for multiple documents. However, CIGNA’s website will
contain hyper links to the additional information.
The cervical traction policy will be the first reformatted to LCD.
Troy Paz asked for clarification on the Ostomy letters. Dr. Hoover responded that the letters have
been distributed quarterly to major providers. Any changes to the edit parameters will be posted
on the CIGNA website and possibly distributed through the list serve.
Dr. Hoover also indicated that power wheelchair frequently asked questions (FAQs) will be
included on the website under the medical review section.
Rick Graver asked Dr. Hoover to clarify functional ambulation. Dr. Hoover reported that patients
who can bear weight to transfer directly bed to chair would qualify. Not someone who parks their
wheelchair in the hallway and walks several steps to his or her bed/chair. Dr. Hoover was asked
how he would treat a beneficiary who can take four steps and then is going to fall down in terms
of ambulation; he stated that we should use an ABN in those circumstances.
In addition, Rick Graver asked about respiratory diagnosis being curtailed as an indicator for
power wheelchairs. Dr. Hoover indicated that the issue of respiratory diagnoses as an indicator is
tough and that they will need to find a way to deal with the issue.
Dr. Hoover also clarified that even though in some instances it may be medically indicated that a
patient have both a walker and a wheelchair, Medicare does not pay for both. Therefore, he would
recommend the provider obtain an ABN. He also informed the DAC that providers could request
that consideration be given to the wheelchair policy.
III. PET UPDATE
Kathy Brock provided the PET update. She reported that PET is approaching its 2 year
anniversary for Webinars. Net courses are in the final stages of development. She invited the
DAC to participate and present at CIGNA’s Spring Seminars.
Ms. Brock provided a copy of the CIGNA Medicare Fax Back Survey and asked for provider’s
participation on the survey. She indicated that this is available on the CIGNA website.
IV. A-TEAM LEADERS Q&A REVIEW
ORTHOTICS AND PROSTHETICS A-TEAM
Phil Danz, O&P A-Team Chair prepared a statement that was read by Wade Hendrickson on each
of the following questions:
Question #1 –Stance Control Knee Orthotic HCPCS Coding
Thank you for your input to this very important question. The O/P A-Team has already made
contact with AOPA and various manufactures groups and will work with them to help provide
further information to the SADMERC and the DMERC'S.
Dr. Hoover indicated that CIGNA is happy to hear we were continuing to move forward on this
and will assist where when possible.
Question #2 – LMRP for Lower Extremity Prostheses
What is the process by which DMEPOS products other than specific manual wheelchairs and
power wheel chairs can be added to the Advance Determination of Medical Coverage (ADMC)
process?
Dr. Hoover indicated that CIGNA is looking into to the possibility and are working on it to see if
the ADMC can be expanded to include Lower Extremity Prosthesis within the scope of current
regulations. CIGNA will get back to the DAC or help think of another avenue.
#3 – Prefabricated Appliances Coding
The O&P A-Team would like to confirm that the CMS/SADMERC update stating that the article
titled "Orthoses – Coding Clarification" that was published in the Winter DMERC Dialogue
(January 2004) relating to "Addition" codes used in conjunction with some prefabricated orthosis
base codes has been rescinded.
The O&P A-Team would request that CIGNA’s response to question #3 be changed to reflect that
the "addition to" policy has been rescinded.
Dr. Hoover indicated that the DAC’s observation is correct.
#4 – Therapeutic Shoes Fee Schedule
The O&P A-Team thanked CIGNA for its clarification relating to Therapeutic Shoes, and has no
follow up questions at this time.
Previously Submitted Question
Does CIGNA have any idea when guidelines for the implementation of Inherent Reasonableness
will be provided by CMS to the DMERCS?
Dr. Hoover indicated that it is not known at this time, but will let us know as soon as they do.
EDI / EMC A-TEAM
Sandy Carden asked for clarification to the following responses received from CIGNA:
#6 – Electronic Claims Forwarding to Other Carriers
Would Region D require electronic claims testing if a provider has already been tested by 1 to 2
of the other DMERCs?
Scott Hudson indicated that CIGNA believes that it would require testing; however, they will
need to research the issue and get back to the DAC.
Post Meeting Follow-up – Provided by Doug Frazier: If CIGNA has no record of testing then yes,
they will be required to test. But, there is no reason to have separate submitter numbers for each
region when one submitter can be used for all regions.
EDUCATION / COMMUNICATION
Question # 8 – Capped Rental / SNF
Connie Lind-Fraher thanked CIGNA for the answers provided to our question. She asked if it
would be possible to include this question and answer in the FAQs area of the CIGNA website
since the answer is different from the answer given at the "Dining with Medicare" fall seminar
program.
Doug Frazier responded that it would not be possible to put in on the FAQs since those are
generated from supplier questions submitted via the website. He will look into other options that
may be available to distribute the information. He will notify DAC Central of the result.
Post Meeting Follow-up provided by Doug Frazier: The clarification will be added to the
combined list of FAQs under capped rental and CMNs.
Question # 9 – Website as Official Provider Notification
Connie read back CIGNA’s answer "…web site serves as the supplier’s "official notice
date"…and DMERC Dialogues and the DMERC Region D supplier manual and updates
distributed via CD-Rom or hardcopy are considered the "official records." She asked if this
wasn’t a step back from what we had been told previously, that the web site was the "official
record"?
Doug Frazier said research was done and CMS has only stated that the website was for official
notification. Barbara Douglas pointed out a mistake that occurred on the CD-roms that were sent
out and the corrections were put on the website (the CD-roms were not corrected and re-sent) thus
making the website the corrected official record. CIGNA will do further research on this and
contact DAC Central with final clarifications.
RESPIRATORY A-TEAM
Question #10 – Oxygen CMN Re-certification
Joe McKnight asked for further clarification to Question # 10 regarding the re-certification of an
oxygen patient inherited from another provider. He specifically asked which method the carrier
would prefer providers use, a re-certification from the date that the provider began servicing the
patient or a new initial CMN.
CIGNA responded that providers should use a re-certification from the date that we start service
for that patient, even if that is in month 15 following the need for the recert.
Question #12 – Oxygen LMRP Re: Sleep Oximetry Studies
Joe McKnight asked that CIGNA further clarify whether a homecare company can own an sealed
tamper proof oximeter used to assess a patients O2 saturation levels if the results are downloaded
by an independent diagnostic testing facility (IDTF).
Dr. Hoover indicated that he felt that since the test was a result of the oximeter, if the oximeter
was owned by the HME company, the test could not be used for qualification regardless of who
downloaded the results. However, Dr. Hoover and Mary Rheinecker both noted that new
information was forthcoming from CMS on this issue; therefore, CIGNA could provide more
clarity on the issue at a later date.
INFUSION THERAPY
Deanne Birch thanked CIGNA for its response to their questions. She also asked whether the
physician education packet her referred to earlier would include in formation on PEN. Dr.
Hoover responded that it would include PEN information.
REHAB
Question #14 – Wheelchair CMN Transmittal
Rick Graver asked whether there is a technical way for providers to transmit CMN information
with the claim when a CMN is not necessarily required in order to qualify the patient for the
equipment. CIGNA said that there is no way to transmit a CMN as we would with a claim that
requires it. They suggested providers indicate in the HAO record that we have a CMN on file to
qualify the patient and include the necessary information in a narrative format. CIGNA can create
a "dummy" CMN for the patient in their common working file.
Rick Graver indicated that the DAC would track a claim using this method and communicate the
results to CIGNA.
Question #15 – Replacement Tire / Tubes Coding
Rick Graver noted that providers have received feedback from the SADMERCs on the proper
coding for replacement tires and tubes. He asked if CIGNA could clarify the description for
K0090 and K0091. Dr. Hoover indicated that clarification is provided in policy.
Question #16 – Coverage of Replacement Tires
Rick Graver sought further clarification on the frequency of tire replacements covered by
Medicare. Mary Rheinecker reported that she is not aware of any policy indicating how
frequently tires can/should be replaced.
Question #17 – ADMC Documentation
Rick Graver thanked CIGNA for is feedback to providers concerns that faxed documentation to
support ADMC is being lost. However, the Rehab A-Team has reported that 30% of its faxed
documentation is not accounted for. He requested that providers be able to call and verify receipt
of faxed information.
Mary Rhienecker indicated that she would check with the supervisor of the ADMC Department
and provide the DAC with a name and phone number.
Post Meeting Follow-up provided by Doug Frazier: Suppliers who wish to confirm receipt of
faxed ADMC requests should, no sooner than one week after transmitting the request, contact a
DMERC customer service representative (CSR) in the usual manner. Additional contact
information was provided to the Rehab A-Team for instances when a CSR is unable to confirm
receipt.
Question #20 – Re: CMN Timeliness for ADMCs
Rick Graver asked whether the CMN timeliness change has been proposed to the other DMERCs.
Dr. Hoover indicated that it has not been communicated and that it will be when other more
urgent matters have been addressed.
HOME MEDICAL EQUIPMENT (HME)
Barb Stockert thanked CIGNA for its answers and indicated that her team has no additional
comments or questions at this time. In closing she indicated that the HME A-Team would like
the opportunity to revisit the issues brought forth in question #18 regarding patients with capped
rental in a SNF. CIGNA indicated that this would not be a problem.
MEDICAL SUPPLIES
Pat Spanel thanked CIGNA for its response to its questions and indicated that they do not have
any further questions at this time.
IV. NEW BUSINESS
CIGNA provided information on where providers can write to report potential fraud and abuse.
The following address was provided for contacting the Benefits Integrity Unit:
CIGNA Healthcare Medicare Administration
B.I.U.
P.O. Box 950
Nashville, TN 37202
Wade Hendrickson asked whether providers would receive a response on their submissions. Doug
Frazier indicated that providers would not receive a response, as it is a privacy matter.
Troy Paz indicated that the DAC would compile the results from the Vendor Fair surveys and
share them with CIGNA. Doug Frazier indicated that those results should be sent to his attention.
With no further new business, the meeting adjourned.
Region D DMERC Advisory Committee
CIGNA Meeting
June 28, 2004
Via Conference Call
CIGNA Staff:
Boise: Kathy Brock Doug Frazier David Smith
Miranda Kiles
Nashville: Dr. Robert Hoover Ryan Burkholder Nancy Orman
Mary Rheinecker
DAC: Troy Paz, Chair Violeta Arnobit Deanne Birch
Yvonne Cordoza Phillip Danz Sha Eppley
Ed Erickson Rick Graver Mike Hayden
Wade Hendrickson David Hosman Mary Jackson
Janna Jurovich John Kenney Connie Lind-Fraher
Joe McKnight Gemma Perry English Gloria Peterson
Rich Pozesky Carlos Reyes Kimberly Rogers-Bowers
Pat Spanel Barb Stockert Val Taylor
Judy Thompson Mary Turner
I. GENERAL BUSINESS
At 12:31 Troy Paz called the meeting to order. Roll call and introductions were conducted and Troy Paz reviewed the meeting protocol.
II. MEDICAL DIRECTOR UPDATE
CIGNA Medical Director Dr. Hoover provided an update on the following:
· Wheelchairs – Medical Directors continue to work with CMS on wheelchair coding. A CMS open door forum in early September is the anticipate time for a coding proposal to be presented for comment. He will try to get feedback from the Rehab A-Team prior to September.
· The medical directors have been looking at the definition of bed or chair confined. However the definition is primarily being addressed at the CMS level.
· A Knee Orthosis policy is currently in development and will likely be available for public comment in the next month. Dr. Hoover requested feedback from the DAC.
a. Medicare Beneficiary Information Provider Access
Troy Paz reviewed guidance by CMS that the DAC prioritize issues relating to provider access to Medicare beneficiary information. John Kenney then summarized the background and a detailed outline of providers access needs included with the meeting agenda. He then requested feedback on how to proceed.