Questions to Noridian/CEDI/RAC
Fall, 2010
CEDI
Leader: Edwin Wahjosoedibjo
Assistant: Duane Ridenour
EC Liaison: Gemma English
97. PECOS file contains special characters that are not X12 compliant. As a result, when we submit claims using names based on PECOS file, our claims are rejected. In fact, CEDI rejects the entire file of claims.
a. When will the PECOS file be fixed?
b. Why is PECOS file containing bad data that leads to claims being rejected?
CEDI & CMS Response: CMS has made this fix.
98. (http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp
The PECOS Website paragraph 3, item (3) states: “(3) there are no “duplicates” in the file. Many physicians or non-physician practitioners share the same first and last name; their corresponding NPI’s are the assurance of uniqueness.” However, we did find duplicate records whereby a single NPI has many combinations of first and last names.
a. Which name do we use to match with in this situation?
b. When will the PECOS file be fixed?
c. Why are duplicate records not removed as stated on the PECOS website?
d. What controls are in place to guarantee that this would not happen again (assuming this shouldn’t happen again)?
CEDI & CMS Response: CMS has made this fix.
99. For a given NPI in NPPES file (available from CMS’s Data Dissemination website: http://nppes.viva-it.com/NPI_Files.html),
a. Will the first and last name be different compared to PECOS record?
CMS Response: The first and last name should be the same. However, a name can change. Depending on the date when the record was created or updated, a name could be different.
b. Aside the obvious different systems, why are the records allowed to be different?
CMS Response: Is there an example?
The first and last name should be the same. However, a name can change. Depending on the date when the record was created or updated, a name could be different.
c. Which one of the 2 is the true CMS source of information in case there are differences?
CMS Response: See response to 99.a above.
The Medicare enrollment record is the source for enrollment data. The NPPES record is the source for NPI data. Both systems are maintained by CMS.
100. Recently we were mandated to discontinue transacting Medicare files (Claims and ERA’s) using CEDI’s dialup connection effective 6/1/2011. Furthermore, we were mandated to pay a fourth party to transact Medicare files. Questions pertaining to this are as follows:
a. Can CEDI elaborate on the file transaction process between the provider, NSV, CEDI, and DME MAC’s?
i. Aside from the obvious of going through a fourth party, what does the file transaction flow look like and what turnaround times should we look for?
CEDI Response: There will be no change to the “turnaround” time. The Network Service Vendor is a communications method. They do not handle, process or store transactions. They are not a clearinghouse or billing service.
ii. Are the reports (997, TA1, TRN, GENRPT, and RPT) and X12 (e.g., 837, 835) going to be in the same format without any changes whatsoever?
CEDI Response: There will be no change the transaction or report formats. The Network Service Vendor is a communications method only and not a transaction type.
iii. Do we need to redo our EDI Enrollments?
CEDI Response: No. The EDI Enrollment Form and CEDI agreements are between the supplier and/or Trading Partner and CEDI. How you connect to CEDI is an agreement between the Trading Partner and the Network Service Vendor.
b. How are exceptions handled? For example:
i. Does CEDI or Medicare mandate that each NSV handle exceptions in the same manner?
CEDI Response: Please define “exceptions”.
ii. How can we decisively determine whether the issue is with NSV or CEDI, or DME MAC?
CEDI Response: The Trading Partner will connect to the NSV and then be routed over
the NSVs connection to CEDI. If you cannot connect to the NSV, you will contact the NSV. If you are unable to login to CEDI, you will contact CEDI.
iii. What happens when the NSV “accidentally” resends our claim – not at our instruction?
CEDI Response: An NSV is only a communications method. They do not handle, process or store transactions. They are not a clearinghouse or billing service and they cannot resend a file for a Trading Partner.
iv. If there is a “crossing” of our files with another provider, what happens next?
c. Can CEDI elaborate on the process for testing file transactions with CEDI through the NSV? Or, is this different for each NSV?
CEDI Response: NSVs test with NGS/CEDI in order to become an approved NSV. Customers using an NSV approved by NGS do not need to test their connectivity.
NSVs are only a method of communication and do not handle, process or store transactions. There is no change to the data that passes from the Trading Partner through the NSV to CEDI and from CEDI through the NSV to the Trading Partner. Because of this there is nothing to test.
i. Should we use our test submitter ID’s?
ii. Do we need a new submitter ID when going live?
CEDI Response: No. See responses above.
d. Are the NSV’s ready for the 5010 transition? What kind of guarantee or certification should we look for?
CEDI Response: NSVs are only a method of communication and do not handle, process or store transactions. 5010/D.0 are transactions and not communication methods so the two are unrelated.
EDUCATION
Leader: Connie Lind-Fraher
Assistant: Cindy Coy
EC Liaison: Leslie Rigg
No Questions Submitted
HME
Leader: Lelia Wilkerson
Assistant: Sha Eppley
EC Liaison: Teri Jamison
No Questions Submitted
IV PEN
Leader: Deanne Birch
Assistant: Rosalie Weber
EC Liaison: Sheila Roberson
101. In the situation of multiple IV therapy administered, wherein both are meeting coverage
requirements under the EIP benefit (external infusion pump Part B DMEMAC), Can the supplier bill for 1- A4221/week for each therapy being administered? Below I will list several examples that require multiple supplies/flush solutions, and/or dressings that make it very cost prohibitive with reimbursement of only #1 A4221.
a. Patient receiving both chemotherapy, and sub q pain management via an external Infusionpump. We have to provide supplies for both sites, and they do require sterile dressing to both sites.
b. Patient has a double lumen to receive both therapies IV, which results in flushing supplies for both drugs, both lumens.
c. Patient received both drugs via one lumen, therefore still requires multiple flush supplies after each drug administration.
2nd Scenario is when patient has two lumens, one therapy is covered under the EIP benefit however, the other therapy is statutorily non-covered. Can we provide the voluntary ABN, and bill for denial withA4221 for the non covered therapy? Example would be receiving Chemotherapy or Pain management (covered) and IV anti-infective (non-covered). Both of these therapies should be billed with the codes that pertain to the supplies required for that individual therapy.
Coverage for A4221 is predicated on the pump, not the medication(s) administered. Only 1 UOS for A4221 is allowed per week, per medically necessary pump and is considered to be “all-inclusive”, regardless of the number of medications being administered.
102. New Question regarding qualifying documentation: Based on the answer noted below from one of the Ask the Contractor sessions, we would like to know if the following situation would meet the documentation requirements: Note: we would expect to receive a written signed order from the physician for the increase in calorie requirements & to support a revised DIF:
A typical situation is that a DMEPOS provider-employed RD observes during a home visit/assessment that the patient’s caloric needs are not being met. The RD discusses the patient’s condition with the physician, who agrees that a >2,000 calorie plan is necessary. Though the RD documents this, the physician does not seem to do so independently, nor is there necessarily another visit to the physician’s office to confirm this caloric increase via the physician’s own updated assessment. Is this scenario valid as per the Q&A to Enteral question #3 (hosted on the Enteral Nutrition Questions and Answers part of the NAS website)?
Can a dietician do the evaluation to determine the patient needs and requirements, i.e., calories required and specialty formula?
A registered dietician can evaluate a patient to determine what type of nutrition is required to maintain weight and strength commensurate with the patient's overall health status. The dietician would then contact the physician to share this information and make a recommendation to the physician and the physician would then evaluate, write the order, and document the medical necessity in the patient's chart.
If the only documentation to support the additional caloric need is provided by the DMEPOS provider-employed RD, that documentation cannot be considered by itself. That is supplemental documentation, which must be supported in the beneficiary’s medical record. NAS recommends the DMEPOS provider-employed RD communicates to the physician the need to document the need for the increased calories in order for Medicare to allow payment for his patient.
103. With regards to the September 9th publication titled Request for Refill-Documentation (attached ) , please clarify the following:
Part one written document For items that are delivered to the beneficiary's home, would the delivery ticket suffice as to the written document provided the delivery ticket included the following?
· Beneficiary's name
· A description of each item or of each type of item that is being requested (e.g., diabetic testing supplies, inhalation drugs, nebulizer accessories, etc.); a list of each separate item is not required
· A statement that the beneficiary is requesting a refill of the items
· Beneficiary signature (If signed by a caregiver, indicate relationship to beneficiary)
· Date of signature
Most of the items are already on the delivery ticket as required by the proof of delivery instructions in the manual.
A signed delivery slip is not a substitute for a beneficiary’s request for refills, except when purchased at a retail store.
Part two-phone conversation Most providers databases have a note section where this type of communication can be documented. Would the beneficiary's name have to be in the actual note, or would it suffice to be in the notes section of that specific patient, provided all the other elements required were in the note.
Inclusion in the notes section is acceptable as long as that field properly identifies the patient and can be provided in the event of an audit.
Part three-unable to get a hold of patient: The supplier has made several attempts to get a hold of the patient regarding their next delivery and has not been successful. For therapies that would put the patient at grave medical risk by missing a dose, for example inotropic therapy or pain management, what advice do you have for providers? Suppliers must ship according to the physician orders/prescriptions they have on file nor would a supplier put the patient in peril. Under these circumstances, the pharmacy may well decide to ship the next dose to ensure continuity of care, and would get the signed DT for POD.There needs to be an assurance that suppliers are not at risk during an audit in these scenarios.
Suppliers should provide products according to the physician’s order; however, for Medicare reimbursements purposes, the requirements related to refills are a CMS manual instruction and no exceptions are allowed.
MED SUPPLIES
Leader: Teresa Brammer
Assistant: Robert Clock
EC Liaison: Sharon Nichelson
No Questions Submitted
O & P
Leader: JR Brant
Assistant: Janet Malinowski
EC Liaison: Sharon Nichelson
104. The Region D DAC committee for Prosthetics and Orthotics is inquiring as to if the recently published Jurisdiction C revision of Lower Limb Prostheses dated 4-01-10 by CIGNA Government Services will be adopted by Jurisdiction D and Noridian Administrative Services Policy on Lower Limb Prostheses? Specifically we are interested in knowing if the section on Ultra-light materials will be adopted as written.
Jurisdiction C CIGNA Government Services Article for Lower Limb Prostheses - Policy Article - Effective April 2010 (A25528) and L5940-L5960 Ultra-light materials changes
A copy of the policy mentioned is attached for your reference.
“Codes L5940-L5960 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar®, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeleton prosthesis. They are not used for ultra light materials used in other components of a prosthesis –e.g., knee/shin system, pylon, ankle, foot, etc. For codes L5940-L5960, the unit of service is per limb.”
Yes. CMS requires all four jurisdictions LCDs and Policy Articles to be the same. NAS Policy Article was updated effective April 2010.
REHAB
Leader: Rick Graver
Assistant: Mike Osborn
EC Liaison: Leslie Rigg
105. In regards to coverage guidelines for K0005, will individual consideration include activities that the beneficiary may perform outside the home, and or past experience using same or similar equipment?
“Outside the home” usage cannot be considered to qualify a beneficiary for any wheelchair. Outside the home usage does not meet the definition of the DME benefit category. All other individual consideration reviews must be well documented in the medical record giving specific reasons why the K0005 is required for the beneficiary.
106. Has Medicare established a quantitative number that relates to the qualification for a k0005? On one of the Medicare “webinars” it was stated that one of the factors for qualifying for a K0005 was upper extremities strength cannot be stronger than -3 / 5.
There is no specific quantitative number. Specific reasons for a K0005 must be well documented and available upon request.
107. If a power center mount footrest is billed and coded as K0108, can the billed code be changed by NAS to E1010 during processing? If so, what is the rationale behind changing the code through claims processing?
Power center mount footrests should be coded as a K0108 and should not be changed during processing. K0108 = Wheelchair component or accessory, not otherwise specified. This code is applied to many different things and does not and should not have a set price. A thorough description of the item billed with K0108 is required in the narrative section of your claim. Center mount power ELRs are articulating mounts with a single actuator. The issue is whether the additional actuator for the Sunrise system ELRs is medically necessary (it has two). A decision was made that there is no evidence for medical necessity of the dual actuator mount. Therefore, since no medical necessity, we do not feel it is necessary to have a separate code for the dual actuator system. However a new code for the ELR center mount system is being discussed/pursued. NAS is allowing the center mount power ELR equal to code E1010.