DMERC MEDICARE ADVISORY

Transcription

1 Palmetto Government Benefits Administrators, LLC DMERC MEDICARE ADVISORY Durable Medical Equipment Regional Carrier PO Box Columbia SC Summer 1999 Issue 29 Page Accessories used with CPAP devices AFO/KAFO/Ankle Positioning Splint Claim filing reminder CMN Completion Cover letters External Infusion Pump Fee Changes Fee Update...53 Get Hooked on the Web...45 HCPCS Helpline HCPCS code J7506 fee clarification Heated Humidifier Hospital Beds Physician information sheet NEW MEDICAL POLICY RESPIRATORY ASSIST DEVICES A new Respiratory Assist Devices (RAD) DMERC Regional Medical Review Policy (RMRP) is published with the manual revisions accompanying this Advisory. Its effective date of implementation is for dates of service on or after October 1, The Health Care Financing Administration (HCFA) proposed that the policy on Respiratory Assist Devices be effective October 1, Before implementing this policy, however, there will be an IN THIS ISSUE Immunosuppressive drugs New HCPCS code K New Product Classification...56 NSC Change of Address OIG Special Fraud Alerts...46 Ombudsmen New Ombudsmen Addresses/territories Oral Anti-cancer drug correction...54 Oral Anti-emetic drugs PACES software/y2k Compliant Portable Oxygen...38 Prompt Payment Interest rate correction Region C Directory Respiratory Assist Devices New Medical policy...33 Supplier Reinstatement Actions...62 Supplier Sanctions...60 Voluntary Refunds...50 Overpayment Refund form...51 Web site overview...70 Workshop Wizard Team Tips Y2K Toll-free help line Year 2000 and Your PC...48 Web site Survey on back cover! open meeting in the near future at HCFA in Baltimore to discuss the appropriate DME payment category for respiratory assist devices with bi-level pressure capability and with the backup rate feature. Please watch for the Federal Register notice of the meeting. HCFA hopes that all interested parties including the physician community, the supplier community and beneficiaries will be in attendance and that there will be a full discussion of the assignment of these devices into the capped rental payment category. It is HCFA's view that these devices are excluded from the class of items requiring frequent and substantial servicing in MEDICARE Palmetto Government Benefits Administrators, LLC Alabama Arkansas Colorado Florida Georgia Kentucky Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee Texas Virgin Islands Comments and suggestions are welcome. Please direct them to Communications Specialists in the Professional Relations department at the address listed above or

2 Page 34 Summer 1999 DMERC Medicare Advisory NEW MEDICAL POLICY Respiratory Assist Devices (continued) accordance with Section 1834(a)(3) of the Social Security Act. HCFA will be accepting written comments on the appropriateness of the DME payment category for respiratory assist devices with bi-level pressure capability and with the backup rate feature. Additional information on providing comments has been published in the Federal Register. Comments should be mailed to the following address: Health Care Financing Administration Division of Community Post-Acute Care Attn: Joel Kaiser C Security Boulevard Baltimore, MD Comments may also be submitted electronically to the following address: comments must include the full name, address, and affiliation (if applicable) of the sender, and must be submitted to the referenced address in order to be considered. All comments must be incorporated in the message because we may not be able to access attachments. A special DMERC bulletin will be issued some time after the public meeting and prior to October 1, 1999, and will contain the determination of the payment category for each code and all applicable billing instructions. NEW HCPCS CODE RAD: K0534 For dates of service on or after October 1, 1999, another HCPCS code has been established: K0534: Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) K0534 describes a bi-level pressure device used with an invasive interface. For dates of service on or after October 1, 1999, E0453 used with an invasive interface should be billed to the DMERC using HCPCS code K0534. Accessories used with the K0534 will have the same utilization parameters as are described in the RAD RMRP for accessory HCPCS codes K K0189.

3 Summer 1999 DMERC Medicare Advisory Page 35 HEATED HUMIDIFIER New HCPCS Code A new HCPCS code has been established for a heated humidifier that is used with a CPAP device (HCPCS code E0601) or a respiratory assist device (HCPCS code K0532, K0533, or K0534): K Humidifier, heated, used with positive airway pressure device This HCPCS code is effective for dates of service on or after October 1, HCPCS code K0531 is in the Inexpensive or Routinely Purchased (IRP) DME payment category. Published clinical evidence has not demonstrated that a heated humidifier provides a significant benefit compared to a nonheated humidifier. Therefore, if a K0531 humidifier is provided for use with a covered CPAP device or a covered respiratory assist device, payment will be based on the allowance for the least costly medically appropriate alternative, HCPCS code K0268 (nonheated humidifier). This is a continuation of current DMERC policy. ACCESSORIES USED WITH CPAP DEVICES The Respiratory Assist Devices Regional Medical Review Policy describes usual maximal amounts of accessories (HCPCS codes K0183-K0189) used with respiratory assist devices HCPCS codes K0532 and K0533 which are expected to be medically necessary within a period of time. Since these are the same accessories used with CPAP devices (HCPCS code E0601), for dates of service on or after October 1,1999, the published amounts for these accessories will apply to their use with CPAP devices as well. COVER LETTERS Suppliers should remind physicians of their responsibility to properly and conscientiously complete Certificates of Medical Necessity. It is the physician's responsibility to determine both the medical necessity and utilization of all health care services, including DME, prostheses, orthoses and supplies used in the home setting. The physician should ensure that the information relating to the beneficiary's condition is correct. Suppliers may use cover letters to remind the physician of these responsibilities - to review the answers to Section B of the CMN for accuracy, and also to assure that adequate notes are entered into the patient's chart to corroborate answers supplied on the CMN. Future DMERC audits may require copies of relevant portions of the patient's chart to ultimately establish the existence of medical necessity, as represented on CMNs submitted with claims.

4 Page 36 POLICY REVISION AFO/KAFO/Ankle Positioning Splint Summer 1999 DMERC Medicare Advisory A revision of the Ankle-Foot and Knee-Ankle-Foot Orthoses policy is included in the accompanying Supplier Manual update. This revised policy will become effective for dates of service on or after October 1, The basic elements of the AFO/KAFO policy have not changed. Some of the minor changes include: Adding HCPCS codes for all additions to AFOs to the HCPCS section for completeness, Adding definitions for prefabricated and custom fabricated orthoses, Adding definitions and coding guidelines distinguishing AFOs from foot orthoses, Distinguishing AFOs used in ambulatory patients from those used in nonambulatory patients for coding and coverage purposes, Placing Coverage and Payment information from the current AFO/KAFO policy in a subsection titled "AFOs and KAFOs used in ambulatory patients," Adding a statement that socks used in conjunction with orthoses are noncovered (effective for dates of service on or after October 1, 1999), Specifying codes for custom fabricated orthoses in the Coding Guidelines section, Incorporating information that had been previously published about HCPCS code L2860 into the Coding Guidelines section, Adding statements to the Documentation section about using the ZY modifier when billing for noncovered uses of AFOs (effective for dates of service on or after October 1, 1999). The revised policy also incorporates and updates all the information from the current policy on Recumbent Ankle Positioning Splints. Therefore the Recumbent Ankle Positioning Splint policy as a separate policy will be deleted when the revised AFO/KAFO policy becomes effective (i.e., dates of service on or after 10/1/99). Some of the changes relating to recumbent ankle positioning splints include: Updating the HCPCS codes because all of the codes in the current Recumbent Ankle Positioning Splint policy have either been previously converted to L codes or eliminated, Clarifying definitions and coverage statements relating to ankle positioning splints, Placing Coverage and Payment information from the Recumbent Ankle Positioning Splint policy in a subsection titled "AFOs used in nonambulatory patients," Adding statements to the Documentation section about use of the ZY modifier when billing for noncovered uses of AFOs (effective for dates of service on or after October 1, 1999).

5 Summer 1999 DMERC Medicare Advisory Page 37 POLICY UPDATED External Infusion Pump The Regional Medical Review Policy on External Infusion Pumps has been included in the accompanying manual revisions. The following changes were made: Coverage and Payment Rules have been reformatted to improve clarity Liposomal amphotericin B (HCPCS code J0286) is now covered for patients who have had significant toxicity to standard amphotericin and are unable to complete that course of therapy or for those patients who have significantly impaired hepatic function. Flolan (epoprostenol, HCPCS code J1325) will additionally be covered for those patients with pulmonary hypertension secondary to a connective tissue disease. IMMUNOSUPPRESSIVE DRUGS Pancreas Transplant As the result of a revision to the Medicare Coverage Issues Manual, Section 35-82, coverage of immunosuppressive drugs is being extended to include patients who meet all of the following criteria: The patient receives a Medicare-covered whole organ pancreas transplant on or after July 1, 1999, and The patient has had a prior Medicare-covered kidney transplant because of diabetic nephropathy, and The patient was enrolled in Medicare Part A at the time of both transplants and is enrolled in Medicare Part B at the time that the drugs are dispensed, and The drugs are medically necessary to prevent or treat rejection of the organ transplants in the particular patient, and The drugs are furnished within 36 months after discharge from the hospital following the pancreas transplant. Immunosuppressive drugs will be denied as noncovered if they are used following a whole organ pancreas transplant that was not simultaneous with or preceded by a kidney transplant for diabetic nephropathy. Coverage of immunosuppressive drugs already exists and will continue for patients who have had a pancreas transplant simultaneous with a Medicare-covered kidney transplant because in these situations coverage is based on the kidney transplant. Because Medicare does not cover transplantation of partial pancreatic tissue or islet cells, if these tissues are transplanted subsequent to a Medicare-covered kidney transplant, coverage of immunosuppressive drugs will be limited to those furnished within 36 months after hospital discharge following the kidney transplant. Refer to the Immunosuppressive Drugs policy in the Region C DMERC DMEPOS Supplier Manual for more information on Coverage and Payment Rules, Coding Guidelines, and Documentation requirements. On the DMERC Information Form (DIF), in question #5, which asks for the organ that has been transplanted most recently, enter the statement "whole organ pancreas transplant subsequent to Medicare-covered kidney transplant" if this

6 Page 38 IMMUNOSUPPRESSIVE DRUGS Pancreas Transplant (continued) Summer 1999 DMERC Medicare Advisory correctly describes the patient's situation. Initial claims for immunosuppressive drugs related to a pancreas transplant subsequent to a kidney transplant must be filed hard copy. Subsequent claims in these situations may be filed electronically. PORTABLE OXYGEN For beneficiaries with initial dates of service on or after October 1, 1999, Medicare will cover only a stationary oxygen system if the oxygen test was conducted during sleep and all coverage criteria are met. Portable oxygen systems for beneficiaries tested during sleep will be denied as not medically necessary. ORAL ANTI-EMETIC DRUGS Effective for dates of service on or after January 1, 1999, the DMERCs will begin processing claims for oral anti-emetic drugs dispensed by a pharmacy when they are used in conjunction with intravenous cancer chemotherapeutic regimens. (If these drugs are dispensed by the ordering physician, they are billed to the local carrier. If they are dispensed in an outpatient hospital facility, they are billed to the local intermediary.) Special Q HCPCS codes (Q0163-Q0181) have been established to bill for these drugs in this situation. The HCPCS codes are: Q0163 Q0164 Q0165 Q0166 Q0167 Diphenhydramine hydrochloride 50mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen Prochlorperazine maleate 5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Prochlorperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Granisetron hydrochloride 1mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen Dronabinol 2.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute

7 Summer 1999 DMERC Medicare Advisory Page 39 ORAL ANTI-EMETIC DRUGS (continued) Q0168 Q0169 Q0170 Q0171 Q0172 Q0173 Q0174 Q0175 for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Dronabinol 5mg, oral, FDA approved prescription antiemetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Promethazine hydrochloride 12.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Promethazine hydrochloride 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Chlorpromazine hydrochloride 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Chlorpromazine hydrochloride 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Trimethobenzamide hydrochloride 250mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Thiethylperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Perphenazine 4mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Q0176 Q0177 Perphenazine 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treat ment, not to exceed a 48 hours dosage regimen Hydroxyzine pamoate 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time

8 Page 40 Summer 1999 DMERC Medicare Advisory ORAL ANTI-EMETIC DRUGS (continued) Q0178 Q0179 Q0180 Q0181 of chemotherapy treatment, not to exceed a 48 hour dosage regimen Hydroxyzine pamoate 50mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Ondansetron hydrochloride 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Dolasetron mesylate 100mg, oral, FDA approved pre scription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen Oral anti-emetic drugs billed with HCPCS codes Q0163-Q0181 are covered only if all of the following criteria are met: 1) The drug has been approved by the Food and Drug Administration (FDA) for use as an anti-emetic, and 2) The drug has been ordered by the treating physician as part of a cancer chemotherapy regimen, and 3) The drug is used as a full therapeutic replacement for an intravenous anti-emetic drug that would otherwise have been administered at the time of the chemotherapy treatment, and 4) The initial dose of the oral anti-emetic drug is administered within 2 hours of the administration of the chemotherapy drug. If all of the above criteria are met, the quantity of oral anti-emetic drugs covered for each episode of chemotherapy cannot exceed the initial loading dose plus 48 hours of therapy. However, for the drugs granisetron (Q0166) and dolasetron (Q0180), the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy. Criterion 3 is not met when the chemotherapy drug is an oral drug or when the chemotherapy drug is administered intravenously in the home setting because the type and dosage of chemotherapy drugs administered in these situations do not require intravenous anti-emetic drugs. Oral anti-emetic drugs which do not meet all of the criteria described above are noncovered under Section 1861(s)(2)(T) of the Social Security Act.

9 Summer 1999 DMERC Medicare Advisory Page 41 ORAL ANTI-EMETIC DRUGS (continued) The supplier may bill for only a single course of oral anti-emetic drugs at a time and the quantity of drugs billed using HCPCS codes Q0163-Q0181 must not exceed the 24 or 48 hours of therapy specified above. Documentation: Order: The supplier must have a detailed written order for the drug which has been signed and dated by the treating physician. There must be a statement on the order which indicates that the oral anti-emetic drug is a full therapeutic replacement for an intravenous anti-emetic drug as part of a cancer chemotherapy regimen. The patient's cancer diagnosis must be entered on the order by the physician. This order must be available to the DMERC on request. The supplier may bill using HCPCS code Q0163-Q0181 only if they have a written order with the specified attestation. HCFA-1500 (12/90) claim form: The supplier must enter an ICD-9 diagnosis code corresponding to the patient's cancer diagnosis on each claim. HCPCS code Q0181 is a miscellaneous code which may be used only when all the requirements of the policy are met, but the drug administered does not have a specific HCPCS code (Q0163-Q0180). Claims for HCPCS code Q0181 must be accompanied by the name of the drug, the dosage strength dispensed, the number of tablets and frequency of administration during the covered time period (24-48 hours) as specified on the order. This information should be entered in the HAØ record of an electronic claim or attached to a hard copy claim. Two Separate Oral Anti-Emetic Benefits: The coverage of oral anti-emetic drugs described above (i.e., as a full therapeutic substitute for an intravenous anti-emetic at the time of chemotherapy treatment) and billed using HCPCS codes Q0163- Q0181 is distinct from coverage of oral anti-emetic drugs (billed using HCPCS code K0415) which are related to the administration of oral anti-cancer drugs.

10 Page 42 Summer 1999 DMERC Medicare Advisory Dear Physician: The following is a summary of the Durable Medical Equipment Regional Carrier's (DMERC's) Regional Medical Review Policy (RMRP) upon which Medicare bases reimbursement decisions for some of the equipment physicians might order for patients. It describes the equipment, its usual clinical indications, Medicare's coverage criteria for reimbursement, and the adjudication criteria for claims. The DMERC strongly believes that the physician is still the "Captain of the Ship." Palmetto Government Benefits Administrators (Palmetto GBA) requires a physician's order before reimbursing any item. Sometimes Palmetto GBA requires a Certificate of Medical Necessity (CMN) and extra documentation. While this may inconvenience physicians with additional paperwork, it is only through physician cooperation that Medicare can provide beneficiaries with the appropriate equipment and supplies they need. Physicians are also helping to protect the Medicare Trust Fund from abusive and fraudulent claims for items that are not medically necessary or physician-ordered. Funds lost to unnecessary utilization of and fraudulent claims for DME come from the same Part B Medicare Fund from which physicians are reimbursed for their own services. The following Physician Information Sheet (PHYIS) is only a summary of the RMRP published in the DMERC Region C DMEPOS Supplier Manual. The definitive and binding coverage policy will always be the RMRP itself, which reflects national Medicare policy, and upon which actual claims adjudication is based. The Physician Information Sheet is intended only as an effort to educate the physician community on conditions of coverage for items of durable medical equipment, prostheses, orthoses, and supplies when ordered for the care of Medicare beneficiaries. If more detailed information is desired, the physician is encouraged to obtain a copy of the RMRP from the supplier servicing your patient, or directly from the Region C DMERC office of Professional Relations at (803) , ext or Paul D. Metzger, M.D. Medical Director Region C DMERC Palmetto Government Benefits Administrators, LLC Columbia, SC

11 Summer 1999 DMERC Medicare Advisory Page 43 HOSPITAL BEDS PHYSICIAN INFORMATION SHEET Description of Equipment: An ordinary bed (not a hospital bed) is one which is typically sold as furniture. It consists of a frame, box spring and mattress. The frame is a fixed height from the floor and has no head or leg elevation adjustments. An ordinary bed will accommodate most transfers to a chair, wheelchair or standing position. If needed, it can almost always be adjusted to accommodate these transfers. The need for a particular height from the floor would rarely by itself justify the need for a hospital bed. Hospital beds allow the patient's position to be changed at the head and foot of the bed, as well as the distance of the bed frame from the floor. Hospital beds may be: Totally Manual and of Fixed Height, having manual (a cranking mechanism) head and leg elevation adjustments, but no height adjustment; Totally Manual and with Variable Height, having additionally, manual height adjustment; Semi-Electric, having electric head and leg adjustment, but still manual height adjustment; Total Electric, having electric head and leg adjustment, plus electric height adjustment. Indications for Hospital Beds: Fixed Height (One or more of the following): A patient who requires positioning of the body in ways not feasible with an ordinary bed, for the alleviation of pain. A patient who requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges should first have been considered. A patient who requires traction equipment which can only be attached to a hospital bed. Variable Height (In addition to one of the above): The patient requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position. Semi-Electric: In addition to the above indications, the patient requires frequent or immediate changes in body position. Total Electric: (Not covered by Medicare): The additional feature allowing for motorized adjustment of the height of the bed frame from the floor is strictly for the convenience of the caregiver. While the caregiver may have true limitations in his/her ability to minister to the patient, the laws upon which Medicare national payment policy is based do not allow for consideration to be extended to the patient's caregiver. Therefore, this added feature is not covered. However, this does not mean that the more basic (semi-electric) feature of the bed will be denied. If the indications for a semi-electric bed are met, then payment will be made by Medicare at the level of a semi-electric bed.

12 Page 44 Summer 1999 DMERC Medicare Advisory Comment: It is rarely necessary for a patient to require changes from one type of hospital bed to another (e.g., variable height to semi-electric) once, in the judgment of the physician, a particular level of bed has been ordered. It is inconceivable that a patient should "progress" from a higher to a lower level bed (e.g., semi-electric to a variable height). Medicare should not pay for two beds, when the needs of the patient could have been anticipated based on the clinical condition originally judged to require a hospital bed. DOCUMENTATION: The supplier of your patient's equipment must submit a Certificate of Medical Necessity (CMN) with the claim in order to obtain Medicare reimbursement. Section B of the CMN contains questions pertaining to the medical necessity of the equipment which may not be completed by the supplier. The physician or another health care clinician involved in the care of the patient may complete Section B, BUT ONLY THE PATIENT'S PHYSICIAN MAY SIGN THE CMN, INDICATING THAT HE/SHE HAS REVIEWED SECTION B OF THE CMN FOR ACCURACY AND COMPLETENESS. In addition, the physician should review Section A to affirm that this is the appropriate patient, and Section C to ascertain that this is the equipment that has been ordered, and that the supplier's charges and expected Medicare reimbursement have been entered onto the form for the physician's review. The physician's medical record of the patient must contain documentation substantiating that the patient's condition meets the above coverage criteria and the answers given in Section B of the CMN. These records may be requested by the DMERC to confirm concurrence between the medical record and the information submitted to the DMERC. Paul D. Metzger, M.D. Medical Director Region C DMERC Palmetto Government Benefits Administrators, LLC Columbia, SC

13 Summer 1999 DMERC Medicare Advisory Page 45 HCPCS HELPLINE SADMERC Effective May 1, 1999, the HCPCS Helpline Representatives at the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) will be available to answer your coding questions from 9:00 am - 4:00 pm EST Monday through Friday with extended hours on Wednesday. Our Helpline will remain open until 6:00 pm EST on Wednesday. Please also note that our Helpline remains open throughout the lunch hours. We received your comments on our customer survey regarding the desire for extended hours to accommodate our West Coast customers. The SADMERC is always looking for ways to improve service to our customers. If you have suggestions, please feel free to contact us through our web site address, Helpline or in writing. In addition to assisting with proper HCPCS code recommendations, the representatives are able to address your fee schedule requests. Please note we are not able to assist customers with allowables for items not on a fee schedule (e.g. reasonable charge, individually considered). Questions and inquiries regarding HCPCS code usage and fee schedule allowances should be directed to: or HCPCS Helpline (803) or SADMERC/HCPCS Unit P.O. Box Columbia, South Carolina GET HOOKED ON THE WEB The SADMERC strives to the stay on the cutting edge of technology. Our latest effort to better serve our customers is our web site. If you're connected, it's easy to access up to date SADMERC information. Located on our site are all HCPCS advisory articles that are available through the DMERC Advisories and speciality publications such as the Required Documentation List for Coding Verification reviews. Also located on our web site is a copy of all product classification lists, frequently asked questions and any pertinent related links such as the HCFA fee schedule for HCPCS codes. The site also permits you to give us feedback. We want to know what you think of our site and any additional information you would like to see. To give us feedback, just click on the feedback button located on all screens. Please remember that the SADMERC cannot address coverage or any claims information. These are questions to direct to your DMERC. The web site strives to better serve our customers by giving them 24-hour access to HCPCS information. Our address on the internet is:

14 Page 46 Summer 1999 DMERC Medicare Advisory OIG SPECIAL FRAUD ALERTS In January of this year, the Office of Inspector General (OIG) issued a Special Fraud Alert in an effort to promote voluntary compliance in the health care industry and assist providers in their compliance efforts. The Alert addressed potential problem areas with regard to physician certification in the provision of medical equipment and supplies and home health services. Among other things, this newly issued Special Fraud Alert addressed: (1) the importance of physician certification for Medicare; (2) how improper physician certifications foster fraud; and (3) potential consequences for knowingly signing a false or misleading certification, or signing with reckless disregard for the truth. Special Fraud Alerts are intended for widespread dissemination to the health care provider community, as well as those charged with administering the Medicare and Medicaid programs. It is the OIG's intention to publish future Special Fraud Alerts in this same manner as a regular part of their dissemination of such information. Medicare recognizes the physician as the key figure in determining appropriate utilization of all medical services. Payment for certain non-physician services, such as medical equipment and supplies, are conditional on the existence of a physician's order or certificate of medical necessity which must be kept on file by the supplier. The Office of Evaluation and Inspections has undertaken a series of studies to look at the role of the physician in certifying these nonphysician services. The first report is about physicians' perceptions of the certification process for durable medical equipment, prosthetics, orthotics and supplies. The second report looks at the relationship between the physician and the patient and its effect on the certification of medical equipment and supplies. These reports can be accessed at: PROMPT PAYMENT Interest rate correction The prompt interest rate published in the Spring 1999 DMERC Medicare Advisory (page 18) was incorrect. The prompt interest rate is 5.00 percent. The rate applies to clean paper and electronic claims that have not paid by the 30th day after having been received by Palmetto Government Benefits Administrators. This rate was effective January 1, 1999, and ends June 30, 1999.

15 Summer 1999 DMERC Medicare Advisory Page 47 CLAIM FILING REMINDER Please remember that cyclophosphamide and methotrexate are covered under two separate Medicare medical policies, the Oral Anti- Cancer policy and Immunosuppressive Drug policy. When billing as oral anti-cancer drugs, NDC numbers and an order are required. When billing as immunosuppressive drugs, HCPCS codes and the DMERC Information Form (DIF) are required. Y2K TOLL-FREE HELP LINE As part of its continuing efforts to help healthcare plans and providers prepare their computer systems for the Year 2000, the Health Care Financing Administration has launched a new toll-free telephone line, HCFA ( ). "We are doing what we can to help the people and institutions that deliver healthcare services get ready for the Year 2000," HCFA Administrator Nancy-Ann DeParle said. "While HCFA is responsible for the financing of health care for our beneficiaries, continuity of care depends on far more than our own Medicare payment systems. It depends on doctors, hospitals, plans and other service providers making sure that their equipment will work, so that they can be paid and medical records will be properly handled. "While most providers are aware of the challenge, there are still many who have to take action to prepare their computer systems for the Year 2000," DeParle said. "That is why we are taking our role seriously to help them prepare for the millennium." The toll-free telephone line, along with upcoming managed care conferences, are part of the agency's ongoing efforts to provide information on the Y2K computer date change to all healthcare providers. HCFA has also posted materials about Y2K readiness, including a provider checklist, on the agency's web site: Callers to HCFA ( ) will be able to get answers to Y2K questions that relate to medical supplies, their facilities and business operations as well as referrals for more specific billing information. The toll-free line will also update callers on HCFA's Y2K policies and provide general assistance to help callers prepare their own computer systems for the millennium. "HCFA's foremost concern has been, and continues to be, assuring that our more than 70 million Medicare and Medicaid beneficiaries continue to receive the health care services they need," DeParle said. "That is why we are addressing the Year 2000 issues in our systems while engaging in an unprecedented effort to raise awareness and provide information to states and private sector individuals and organizations that serve them."

16 Page 48 PACES SOFTWARE Y2K Compliant Summer 1999 DMERC Medicare Advisory Over the past several years, Palmetto GBA has distributed several commercial software products to support the needs of our DMERC electronic submitters. The low-cost claims data entry product distributed and supported by Palmetto GBA is called "PACES." This product is Year 2000 ready. In addition to "PACES," Palmetto GBA has distributed several commercial communications packages for the convenience of our customers. These packages include: Advantis Passport for DOS, Version 1, Release 2.2-H (CSI access) Advantis Passport for Windows 3.x Version 1, Release 3.1 (CSI access) Advantis Passport for Windows 95/NT, Version 1, Release 3.2, Level A (CSI access) ProComm communications software, Version (DOS) It is likely that these products will continue to function smoothly subsequent to the millennium. However, to confirm the Year 2000 viability of these products, or to upgrade to the version suggested by the vendors who supply these products, please consult the web sites listed below. The Year 2000 ready versions of ProComm are 4.6 and 4.7. For upgrade information about ProComm products, visit: There is no Year 2000 ready DOS version of Advantis. The Year 2000 ready version of Advantis Passport for Windows 3.x and Advantis Passport for Windows 95/NT is Version 2, Release 1.LC. To confirm the Year 2000 viability of IBM (Advantis Passport) products, or to upgrade to the version suggested by the vendor who supplies these products, please consult IBM. Information is available from their website at: PALMETTO GOVERNMENT BENEFITS ADMINISTRATORS, LLC, HAS NOT VERIFIED THE CONTENTS, NOR IS IT THE SOURCE, OF THE YEAR 2000 STATEMENTS REGARDING IBM OR PRO- COMM PRODUCTS MENTIONED IN THIS ARTICLE. YEAR 2000 AND YOUR PC As mentioned in the previous article, PACES, Palmetto GBA s lowcost data entry software, is Year 2000 ready. Although PACES will run on non-compliant hardware, it is imperative that all users take the responsibility to ensure that their hardware is Y2K compliant. There are several ways to determine if your personal computer is Y2K compliant. To test your PC yourself, follow these steps: 1. Set the date on your PC to December 31, 1999 and the time to 23:59 p.m.

17 Summer 1999 DMERC Medicare Advisory Page 49 YEAR 2000 AND YOUR PC (continued) 2. Turn off your PC. 3. Reboot your PC after a five-minute wait. 4. When your machine boots up, the date and time should read January 1, 2000, at (approximately) 12:04 a.m. 5. If the date and time on your PC does not read January 1, 2000, at (approximately) 12:04 a.m., your software may not function on and after this date. 6. Check with your hardware vendor, whether or not your PC passes this simple test, to verify the Y2K validity of your hardware. To review lists of PCs that are considered Y2K compliant, you may wish to consult the Web site at which provides lists of Y2K compliant personal computers and Y2K compliance testing software. Finally, perhaps the most important precaution to ensure Y2K compliant hardware is to contact your hardware vendor or personal computer manufacturer. These entities can verify the compliance of your personal computer and peripheral hardware components. CMN COMPLETION PHYSICIAN OBLIGATION When a physician bills for his/her services, including examination, diagnosis and treatment, any cost associated with paperwork is considered part of the charges made for his/her professional services. If a patient needs an item of durable medical equipment orthotics, prosthetics and supplies (DMEPOS), the completion of an order or Certificate of Medical Necessity is a service to the patient rather than the supplier. This view is shared by the Health Care Financing Administration and the American Medical Association. Section 4152 of the Omnibus Reconciliation Act of 1990 requires a physician to complete a CMN or an order for DMEPOS items prescribed. The language in the statute does not authorize physicians to separately charge the patient or supplier for completing the certificates. Allegations of physicians charging suppliers for completing CMNs will be investigated under one or more of the following principles: As potential kickback situations under Section 1128B (b) of the Social Security Act; and/or As false representation with respect to the physician's actual charge for professional services furnished on or near the date of his/her DMEPOS order for the beneficiary; and/or As a potential assignment violation on assigned claims for professional services on or near the date he/she orders DMEPOS for the beneficiary; or As a potential charge limit violation on unassigned claims for professional services on or near the date he/she ordered DMEPOS for the beneficiary. Send information regarding improper payments issued to the physician to the Anti-Fraud Unit (address on page 76). Include all pertinent information in the referral, such as physician name, beneficiary name, health insurance claim number and proof of payment made.

18 Page 50 Summer 1999 DMERC Medicare Advisory VOLUNTARY REFUNDS The Office of the Inspector General (OIG), working with the Department of Justice and the Health Care Financing Administration, has developed two initiatives to help combat fraud and abuse and to encourage providers and suppliers to comply with rules and regulations of Federal health care programs. Both initiatives are designed to ensure that providers and suppliers refund inappropriately received Medicare monies. These two initiatives are Compliance Program Guidances and Corporate Integrity Agreements. Compliance Program Guidances provide guidance and recommendations to providers/suppliers in developing effective internal controls to meet program requirements of Federal, State, and private health programs. These Guidances describe the fundamental elements of a compliance program. Currently, Compliance Program Guidances have been published for hospitals, home health agencies, clinical laboratories and thirdparty medial billing companies. OIG will issue compliance program guidance for additional entities in the future. Corporate Integrity Agreements (CIAs) are entered into between a health care provider/supplier and OIG as part of a global settlement of a fraud investigation. Under the CIA, which can be for a period ranging from three to five years, the provider/supplier is required to undertake specific compliance obligations, such as designating a compliance officer, undergoing training, and auditing. The provider/supplier must report compliance activities on an annual basis to OIG, which is responsible for monitoring the agreements. When returning voluntary refund checks, suppliers can ensure that the monies will be credited timely and accurately by correct completion of the attached Overpayment Refund Form. If a supplier has a CIA, he/she should indicate that fact in the space provided for OIG reporting requirements on the Overpayment Refund Form.

19 Summer 1999 DMERC Medicare Advisory Page 51

20 Page 52 Summer 1999 DMERC Medicare Advisory FEE CHANGES Effective for claims processed on or after July 1, 1999, for dates of service on or after January 1, 1999, HCPCS code E0457 (Chest shell (Cuirass)) will be processed as a inexpensive routinely purchased item. The fee schedule allowances for HCPCS code E0457 are listed below. Since E0457 (Chest shell (Cuirass)) is used as a supply with HCPCS code E0460 (Negative pressure ventilator; portable or stationary), the Health Care Financing Administration (HCFA) has changed the payment category from frequently serviced to inexpensive and routinely purchased. The payment category published in the 1999 Region C DMEPOS Fee Schedule Catalog for HCPCS code E Form fitting conductive garment for delivery of TENS or NMES form, post mastectomy has changed from supply to inexpensive and routinely purchased Fee Schedule Changes E Change in Payment Category L8015 PAYMENT REVISION The fees published in the 1999 Fee Schedule Catalog for HCPCS code L External breast prosthetics garment, with mastectomy form, post mastectomy have been revised. These fees are effective immediately for dates of service on or after January 1, L Payment Revision

21 Summer 1999 DMERC Medicare Advisory Page 53 FEE UPDATE The following DMEPOS Drug fees were effective for claims processed on or after April 1, 1999, with dates of service on or after January 1, Fee changes are shaded. In addition, fees for Oral Anti- Emetic Drugs, HCPCS codes Q Q0180 are provided. NOTE: The Region C Drug Fee Schedule is updated quarterly. The unit of measure for the fee amounts noted corresponds to the unit of measure noted in the code descriptions published in the 1999 HCPCS coding manual. Please be sure to report the same unit of measure in the Days/Unit field (Item 24g) of the HCFA-1500 (12-90) claim form as is listed in your HCPCS manual. For example, if the HCPCS manual lists one unit as 50 mg, be sure to report 50 mg as one unit on the claim form. If you administered 100 mg, you would list two units on the claim form. The Region C Drug Fee Schedule is based on the lesser of the median average wholesale price (AWP) of the generic forms or the lowest brand name product AWP.

22 Page 54 FEE UPDATE (continued) Summer 1999 DMERC Medicare Advisory Oral Anti-Cancer Drug Fees The following Oral Anti-Cancer Drug fees were effective for claims processed on or after April 1, 1999, with dates of service on or after January 1, Fee changes are shaded. Currently the following Oral Anti-Cancer drugs meet the requirements for coverage under OBRA '93. Unlike other drugs billable to the DMERC, these oral anti-cancer drugs are not submitted with HCPCS codes. Oral anti-cancer drugs are billed using the National Drug Code (NDC) number. Note: The listing of a HCPCS drug code along with its allowable does not constitute coverage. ORAL ANTI-CANCER DRUG CORRECTION The NDC numbers for the 5-FU prodrug, Capecitabine, trade name: Xeloda, manufactured by Roche and published in the Spring 1999 DMERC Medicare Advisory (page 13), are incorrect. The correct NDC numbers are as follows: Capecitabine, 150 mg, oral, 1 tab per unit Capecitabine, 150 mg, oral, 1 tab per unit Capecitabine, 150 mg, oral, 1 tab per unit Capecitabine, 500 mg, oral, 1 tab per unit Capecitabine, 500 mg, oral, 1 tab per unit Capecitabine, 500 mg, oral, 1 tab per unit HCPCS CODE J7506 FEE CLARIFICATION The 1999 Region C DMEPOS Fee Schedule Catalog listed the fee for HCPCS code J7506 as $3.03. This amount was incorrect. Due to the change in nomenclature for this code, the correct fee is $0.02. The verbiage for HCPCS J7506 previously read "Prednisone, any dosage, 100 tablets (various)". It currently reads "Prednisone, oral, per 5 mg." Please ensure your days/units are billed correctly. That is, if you provide mg tablets, your days/units should reflect 100.

23 Summer 1999 DMERC Medicare Advisory Page 55 NSC CHANGE OF ADDRESS NOTIFICATION Any changes to the information provided on the HCFA form 855S (1/98), including change of address and telephone number, should be reported to the NSC within 35 days of the occurrence of such changes. You may contact the NSC at: National Supplier Clearinghouse P.O. Box Columbia, SC (803) NEW OMBUDSMEN As part of our continuing efforts to meet educational needs, Palmetto Government Benefits Administrators, LLC is pleased to announce two new members of its Professional Relations department: Ronja Fayne and Eric Kast. They are profiled below. A complete directory of Palmetto GBA ombudsmen and their territories can be found on page 68 of this Advisory. Tennessee A graduate of Tennessee State University, Ronja earned a Bachelor of Science degree in speech communication and theatre, as well as a Master of Arts degree in interpersonal/health communication from the University of Kentucky. Before joining Palmetto GBA, Ronja worked as an instructor of public speaking, sociology, and computer courses. Her communication and education experience will serve her well in assisting Tennessee suppliers with billing and policy issues. A native of Tennessee, Ronja is pleased to be working in Nashville. Having presented Medicare information at several conferences, Ronja is looking forward to conducting future Palmetto GBA workshops as well as educational onsite visits with her Tennessee suppliers. Oklahoma/Arkansas Eric Kast is the new ombudsman for Oklahoma and Arkansas. He comes to the DMERC with four years experience in the durable medical equipment (DME) industry. Eric s professional experience includes Medicare reimbursement for infusion and DME services. Eric earned his Bachelor of Arts and Master of Arts degrees in journalism/public relations from the University of Oklahoma. After several months of intensive training, Eric has returned to Norman, Oklahoma, where his office is located. He looks forward to serving Arkansas and Oklahoma suppliers.

24 Page 56 Summer 1999 DMERC Medicare Advisory New Product Classification The following are product classification additions for 1999: Product Name Manufacturer HCPCS Code Effective Date Enteral Nutrients: Ensure HN (Category I) Ross Labs B4150 9/9/96 Jevity RTH (Category I) Ross Labs B4150 2/2/99 Nebulizers: Pulmo Aide Compressor De Vilbiss E0570 3/24/99 Pulmo Aide LT Compressor De Vilbiss E0570 3/11/99 Pulmo Mate Compressor De Vilbiss E0570 3/11/99 PulmoSonic Ultrasonic Nebulizer De Vilbiss K0270 2/16/99 Ultra-Neb Ultrasonic Nebulizer De Vilbiss E0575 3/11/99 Power Operated Vehicles: 5000 Series Transport Tuffcare E1031 4/12/99 Activa POV Hoveround E1230 3/5/99 Cabbie Companion Lumex E1031 3/5/99 Chauffeur Models 250, 255, 270, 275 Electric Mobility E1230 3/5/99 Escort II 3000 Tuffcare E /10/96 Excel Passenger Transport Medline E1031 3/19/99 EZ Fold 400 McBon E1031 8/5/98 Limo III 3500 and 4000 Tuffcare E /10/96 Maple Leaf MLT 700B Tilt Chair Maple Leaf Wheelchairs E /18/98 Maple Leaf MLT 500 T/R Chair Maple Leaf Wheelchairs E /18/98 Optiway 2001 LXS3 Optiway Technology E /17/98 Optiway 2001 LXS4 Optiway Technology E /17/98 Panda Pediatric Positioning System Otto Bock Rehab E1031 3/19/99 P2 Companion Wheelchair Everest & Jennings E1031 4/12/99 PM 100 McBon E1031 8/5/98 Ralley Scooter Pride Healthcare E1230 9/22/98 Rascal Models 250, 255, 270, 275 Electric Mobility E1230 3/5/99 RC 200 McBon E1031 8/5/98 Shuttle Pride Pride Healthcare E1230 9/22/98 Tracer Transport Invacare E1031 3/19/99 Transporter Tuffcare E1031 3/5/99 Trekker C Lumex E1031 3/5/99 Ultra Lightweight Transporter Tuffcare E1031 3/5/99 Pressure Reducing Support Surfaces, Group I: AccuMax Mattress BG Industries E /08/98 AccuMax PC Mattress BG Industries E /08/98 AccuMax Residential Mattress BG Industries E /08/98 Air-O-Pad (AOP1) WITH PUMP Huntleigh Healthcare E /16/99 Bubble Pad (OPB2, OPB2FF) WITH PUMP Huntleigh Healthcare E /16/99 CareGuard APP Invacare E /16/99