1. Bill Medicare Correctly the First Time to Prevent Unnecessary DenialsCB
1416_0213_bill_medicare_correctly_prevent_denials

2. Today’s Presenters
Charity Bright, Provider Outreach and Education Consultant
Tamara Hall, Provider Outreach and Education Consultant
Lisa Hare, Provider Outreach and Education Consultant CB

3. Webinar Access
All registrants received an from: Medicare Webinar by National Government Services
Click on the link within the to join the Web presentation
Using your telephone, dial into the conference call using the number and access code provided in the CB

4. Today’s PowerPoint Presentation
PowerPoint provided in an
PowerPoint available on events calendar
Go to the Web site
Select DME for the DME MAC Home Page
Click on the Training Events Calendar underneath Education and Training section
Select the Bill Medicare Correctly the First Time to Prevent Unnecessary Denials Webinar
Under attachments you will see the PowerPoint presentation link CB

5. Audio Once you are connected to the audio, the PIN displays
Input the PIN on your screen into your telephone
Dial in number and PIN are unique for each attendee CB

6. To Ask a Question Using the Question BoxCB

7. Disclaimer
National Government Services, Inc. has produced this material as an informational reference for suppliers furnishing services in our contract jurisdiction. National Government Services employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this material. Although every reasonable effort has been made to assure the accuracy of the information within these pages at the time of publication, the Medicare Program is constantly changing, and it is the responsibility of each supplier to remain abreast of the Medicare Program requirements. Any regulations, policies and/or guidelines cited in this publication are subject to change without further notice. Current Medicare regulations can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at CB

8. No Recording
Attendees/suppliers are never permitted to record (tape record or any other method) our educational events
This applies to our Webinars, teleconferences, live events, and any other type of National Government Services educational event CB

9. Acronyms ABN – Advance Beneficiary Notice of Noncoverage
ASCA – Administrative Simplification Compliance Act
ANSI – American National Standard Institute
BIB – Break in billing
BIN – Break in need
BIS – Break in service
CBT – Computer-based training
CEDI – Common Electronic Data Interchange
CMS – Centers for Medicare & Medicaid Services
CMN – Certificate of Medical Necessity
CPT – Current procedural terminology
DIF – DME Information Form CB

10. Acronyms DME – Durable medical equipment DMECS – DME coding system
DME MAC – Durable Medical Equipment Medicare Administrative Contractor
DMEPOS – Durable medical equipment, prosthetics, orthotics, and supplies
DNF – Do not forward
EDI – ELectronic data interchange
EFT – Electronic funds transfer
ERA – Electronic remittance advice
ESRD – End-stage renal disease
ET – Eastern time CB

11. Acronyms FAQ – Frequently asked questions
HCPCS – Healthcare Common Procedure Coding System
HICN – Health Insurance Claim Number
HIPAA – Health Insurance Portability and Accountability Act
ICD-9 – International Classification of Diseases, 9th Revision
IVR – Interactive voice response
LCD – Local coverage determination
MU – Medicare University
NTE – Note (segment)
PA – Policy article
PAP – Positive airway pressure (device)
PDAC – Pricing, Data Analysis, and Coding (Contractor) CB

12. Acronyms PEN – Parenteral/enteral nutrition
PHI – Protected health information
REM – Remark
SNF – Skilled nursing facility
SPR – Standard paper remittance
TENS – Transcutaneous electrical nerves stimulator CB

13. Objective
Provide education on appropriate coding and claim submission strategies so supplies can prevent unnecessary claim denials, avoid the appeals process, and increase the number of claims paid upon initial claim submission to Medicare. CB
Our goal today is to provide you with some important information about the IVR. We will familiarize you with the application so that you will be able to easily navigate the system and successfully obtain the information that your practice needs.
We also want to make certain that you are aware of all the features the IVR has to offer, in order to maximize the use of the Part B IVR system.

14. Agenda Front-end rejections vs. denials Modifiers Span date billing
NTE segment/Item 19
Interruptions in a period of continuous-use billing
Consolidated billing
CMN/DIF billing
Repair/replacement/beneficiary-owned equipment CB

15. Front-end Rejection Vs. Denials
CEDI Front-end Acknowledgement Report
National Government Services remittance
Electronic remittance advice (ERA)
Standard paper remittance (SPR) CB
I would like to clarify the difference between a Front-end rejection and a denial.
For suppliers who submit their claims electronically thru the Common Electronic Data Interchange, a report is received by the supplier. This report will identify claims received and claims that were rejected.
When claims are rejected on the front-end, suppliers are to resubmit the claims with the incorrect information corrected. For more information on front-end rejections, visit the CEDI Web site at
When a claim is processed by National Government Services, we will send a Paper Remittance Advice or the Electronic Remittance Advice.
If a claim denies, it does not automatically mean to resubmit the claim. It is possible that to correct the denial, the supplier would need to file an appeal. We will be discussing common denials that are received on the remittance advice, how to prevent them and how to correct them.

16. Modifiers Functions include pricing and informational
Modifier determination
DMEPOS payment category
LCDs and PAs
Liability issues
Repair or replacement
Competitive bidding TH
Let’s talk about the importance of modifiers. Modifiers provide pricing and additional information to the HCPCS code that is billed. Listed on this slide we have the avenues suppliers should refer to in order to determine what modifiers should be reported with each HCPCS code that is submitted to Medicare for reimbursement.

17. Payment Categories Most DMEPOS fall into the following categories:
Capped Rental
Frequent and Substantial Servicing DME
Inexpensive or Routinely Purchased DME
Oxygen and Oxygen Equipment
Prosthetics and Orthotics
Customized DMEPOS TH
The first thing suppliers should understand is the payment category the item they are billing for falls into. By having the understanding of the payment category, this will assist suppliers with determining the pricing modifiers that are required to be reported. Majority of all items billed to Medicare require a pricing modifier.
A couple of avenues suppliers may use to find out the payment category is using the DMECS Web site or the Fee Schedule published on our Web site. Let’s take a look at the Fee schedule first.

18. Determine the Payment Category
Alternative Text – Image of Fee Schedule which points out the payment category.
On our Web site located under Quick Links which is on the left side is the link for Fee Schedules. We have pulled an image of the PDF file however, this information also appears in the Excel files. Each HCPCS code is classified into a payment category. By searching for the HCPCS code that you will be billing, you will be able to identify the payment category the item falls into which will alert you to what pricing modifiers may or may not be required.
CR-primary and secondary pricing modifiers
FS – RR modifier always, no secondary
IN – primary only
OS – no pricing
OX – RR modifier always, no secondary
PE – primary and secondary for pump only
PO – no pricing
SD – no pricing
SU – no pricing
TENS – primary for unit
TS – no pricing
The other avenue that suppliers may use in order to determine the payment category is the DMECS Web site.

19. Pricing Modifiers for Payment Categories
CR – Capped Rental – primary and secondary pricing modifiers
FS – Frequently Serviced – RR modifier always, no secondary pricing modifier
IN – Inexpensive and Routinely Purchased – primary pricing modifier only
PE – Parenteral & Enteral – primary and secondary pricing modifiers for pump only
OX – Oxygen & Oxygen Equipment – RR modifier always, no secondary pricing modifier
PO – Prosthetics & Orthotics – no pricing modifiers
SD – Surgical Dressings – no pricing modifiers
OS – Ostomy, Tracheostomy & Urologicals – no pricing modifiers
SU – Supplies – no pricing modifiers
TS – Therapeutic Shoes – no pricing modifiers
TE – TENS – primary pricing modifier for unit

20. Medicare Pricing, Data Analysis and Coding ContractorTH
Alternative Tex: Image of Pridcing Data Analysis and coding contractor home page pointing out DME Coding system (DMECS)
On the PDAC Web site, suppliers are able to access the DME Coding System. As we show on this screen, on the home page, select DME Coding System Info

21. DME Coding System Home PageTH
Alternative Text: Image of the DME Coding System Home page with arrow pointing on where to search for Codes and Fees.
After selecting the DMECS info, select the Search DMECS for codes and fees as we are showing on this screen.

22. Search for Fee ScheduleTH
Alternative Text: Image of the Search for Fee Schedule page with K0001 and date of service 5/8/12 entered as search criteria for search for fee schedule.
As I mentioned, suppliers are able to use DMECS for several inquiries. We are wanting to search for the fee schedule so under the green fee schedule header, enter the HCPCS code and your date of service as we are showing here.
I do want to mention another search option on this page that we do not have listed. We refer suppliers to the DMECS web site to also search for product classifications. Suppliers are able to enter a HCPCS code, the product name, the product or model number or the manufacturer. By using the product classification search option, this allows suppliers to verify they are submitting the correct HCPCS code for the item they are billing.
Now, back to searching for the fee schedule….

23. Search for Fee ScheduleTH
Alternative Text: Image of the Search for Fee Schedule Results highlighting this item is a capped rental item.
On the results page, it does advise the payment category the HCPCS code falls into. This page will also show the listing of the fee schedule for all US states and territories.
Now let’s take our first question of today’s webinar. Please all participate in selecting the correct answer.

24. Question #1
To determine a payment category for a HCPCS code, suppliers should use the fee schedule or DMECS Web site.
True
False TH

25. Pricing Modifiers Primary pricing modifiers
NU, RR, UE
Competitive bidding pricing modifiers
KE, KG, KK, KU, KW, KY
Capped rental modifiers
Monthly rental modifiers
KH, KI, KJ
Additional capped rental modifiers
BP, BR, BU, MS TH
As I mentioned earlier, majority of all items billed to Medicare require a pricing modifier and we broke down the payment categories on slide 18. As you can tell on this slide, there is more than 1 pricing modifier. There are additional pricing modifiers which sometimes we refer to as secondary pricing modifiers.
The way we have the modifiers listed on this slide and the next is how the modifiers should be reported on the claim. The primary pricing modifier is first, then any secondary pricing modifiers that are applicable. If you are unsure what the modifiers mean, suppliers may refer to chapter 14 of our Supplier Manual or you can also use DMECS to search for the definition of the modifier.
With the breakdown on slide 18, I did mention how some items require a secondary pricing modifier such as capped rental, TENS, and PEN. The typical secondary pricing modifiers is the capped rental modifiers. Under the capped rental bullet, we have listed the additional capped rental modifiers. These are only applicable to some items such as PEN pumps and power mobility devices. The supplier must notify us that a decision was made with the initial claim. This is where the BP, BR, or BU modifiers comes into play. With the initial claim, the primary pricing modifier should be a RR, NU, or UE. Suppliers will also need to append the BP, BR, or BU modifier. Suppliers will also need to append the KH modifier on the initial claim. If the item is purchased, the first claim should be NUBPKH. If it is being rented it should be RRBRKH. Typically the BU modifier is no longer used.
For competitive bidding modifiers, suppliers should refer to the CBIC Web site in order to determine which competitive bidding modifier you should be using or if it a comp bid modifier is required.
Suppliers should refer to chapter 15 of our supplier manual for additional information when billing PEN pumps and power mobility devices.

26. Informational Modifiers
Documentation modifiers
KX, GA, GZ, GY, EY, KS, GW, KL
Location modifiers
RT, LT
Competitive bidding informational modifiers
KV, KT, J4
Policy-specific modifiers
Surgical dressings
Lower extremity prosthetics
Ostomy, tracheostomy, and urological supplies
Oxygen TH
After listing all applicable pricing modifiers, suppliers will need to report the informational modifiers. First is the documentation modifiers. Some of the modifiers for documentation refers to if the coverage criteria is met, if an ABN was properly executed, or if an order was received for the item.
Next is for items that can be placed on the left or right side of the body. These are location modifiers. Prosthetics, orthotics, therapeutic shoes, and some accessories for DME require a location modifier.
After all of those modifiers, suppliers should refer to the medical policy in order to determine if there are any additional modifiers required. For example, surgical dressings require an A!-A9 modifier to be appended with all other applicable modifiers.

27. Overflow Modifiers
99: Overflow modifier, more than four modifiers identified on claim line
KB: Beneficiary requested upgrade, ABN, more than four modifiers identified on claim line TH
Now with all those modifiers, several suppliers run into the issue of, not enough room to report all the applicable modifiers for the HCPCS code. Suppliers are able to utilize the overflow modifiers we have listed on this slide. There are big differences on when a supplier can utilize these modifiers and how they are reported. Let’s address the KB modifier. The KB modifier can only be used when the beneficiary has requested an upgrade, the supplier has properly executed an ABN, and there will be more than 4 modifiers reported on the claim. All other instances of when there are more than 4 modifiers reported on the claim must use the 99 modifier.
Now the reporting of the modifiers. For both overflow modifiers, suppliers should report all applicable pricing modifiers, then the documentation modifier of KX, GA, or GZ then report the overflow modifier in the 4th position.
For the 99 modifier, suppliers must report all modifiers in Item 19 or the NTE segment, excluding the 99 modifier.
For the KB modifier, suppliers must report the remaining modifiers in Item 19 or the NTE segment.
Let’s take a look at some examples:

28. 99 Modifier TH
Alternative Text: Image of bottom of CMS 1500 claim form
As you can see with this claim example for the 99 modifier, the applicable pricing modifiers were reported and the documentation modifier KX was reported with the 99 in the 4th position. If you look at Item 19, all applicable modifiers, excluding the 99 modifier are listed.

29. KB Modifier TH
Alternative Text: Image of bottom of CMS 1500 claim form with Item 19 highlighted
For the KB modifier, we have the pricing modifiers and the location modifier followed by the KB modifier in the 4th position. Looking at Item 19 we have the remaining location modifier of the RT and the documentation modifier of GA. As I mentioned you should report the documentation modifier on the claim line. It is not required, but it is a good practice.
As a reminder with the KB modifier, even though the definition advises ABN, it does not provide the liability that the GA modifier holds. So if you are reporting the KB modifier, you should also be reporting the GA modifier.
Now let’s take question 2 of this Webinar.

30. Question #2 All items billed to Medicare require a pricing modifier.
True
False TH
And now I will turn it over to Terri

31. ANSI 16
Received when the claim submitted contains missing, incomplete, or invalid information and cannot be processed as submitted.
Reference the REM field on the remittance advice to determine the reason for the denial
Must correct and resubmit as a new claim, cannot reopen or appeal CB

32. Glucose Monitor and Supplies
Requires pricing modifier
Monitor requires NU, UE, or RR
Test strips require NU
Lancets, control solutions, and spring-powered devices are considered supplies, require no pricing modifier
Common informational modifiers
KL: DMEPOS Item delivered via mail
KS: Glucose monitor and supplies for diabetic beneficiary not treated with insulin
KX: Glucose monitor and supplies for diabetic beneficiary treated with insulin
Check local coverage determination and policy article for any other applicable modifiers CB

33. Span Date Billing Items listed below require span date billing
Continuous passive motion devices
Diabetic testing supplies
A4253, A4259
Parenteral and enteral nutrition
Resource
Span Date Billing Guide
DME MAC Home page
Tools and Materials under Resources CB
CO-16, REM N64: If billing for items that require span date (from-to), then the from and to dates MUST be different. Items that do not require “span dates” may be billed with just a “from” date and no “to” date – or the from and to day may be the same. If billing electronically, you should follow the vendors, or software’s requirements regarding “From” & “To”.
Items that require billing of span dates are:
diabetic testing strips and lancets,
parenteral and enteral nutrition, and
continuous positive motion (CPM) devices.
PEN delivery and span dates is a big area of confusion. Are there any PEN suppliers in the audience? If so, let’s talk about PEN for a bit.
The supplier may deliver the enteral nutrition and supplies directly to the beneficiary, or the supplier may use a shipping service to ship the items. If the supplier delivers the items directly to the beneficiary, the “From” date of service on the claim will be the actual date the items were delivered. If the supplier ships the items to the beneficiary using a shipping service, the “From” date of service will be the date the items were shipped. To determine the “Thru” date of service, the supplier counts the number of days the nutrients are expected to last (ex: supplier ships a 28 day supply) and adds that number of days to the “From” date on the claim. Span dates on the claim will not usually match the dates of expected use of the nutrients.
 Suppliers use a separate claim line for each date that nutrients are shipped/delivered.

34. Common Reasons for ANSI 16 Denials on Glucose Claims
Span date is missing
“From” and “To” date must be different
KS or KX missing
KS, KX appended on the same claim line
NU missing from claim line for A4253 CB

35. PAP Devices and Supplies
Requires pricing modifier
PAP device - capped rental (E0601, E0470)
RR – rented item
KH – 1st month rental
KI – 2nd and 3rd month rental
KJ – 4th through 13th months rental
Accessories – inexpensive routinely purchased (i.e., mask, tubing, humidifier, etc.)
NU – new purchased item CB

36. KX Modifier Initial coverage (months 1–3)
KX modifier should be appended to equipment and accessory codes if coverage criteria is met
Continued coverage (months 4–13)
KX modifier should be appended to equipment and accessory codes if initial coverage criteria have been met
Reevaluation showing improvement (between 31st and 91st day)
Adherence
If continued coverage criteria cannot be verified in time for claim submission
Submit without KX modifier, or
Hold claim until coverage criteria is met CB
The KX modifier should be appended for claims meeting initial coverage criteria and the supporting documentation is available upon request for the first three months of pap therapy.
It is the suppliers responsibility to know whether this documentation exists leaving the decision up to the supplier on whether they will request the documentation up front or wait until an additional documentation request is received. 36 36

37. LCD and PA Coding SectionCB
Alternative text: Image of LCD section regarding GA and GZ modifiers

38. Billing for Accessories used with Patient-Owned Equipment
Beneficiary-owned equipment
NTE segment or Item 19
HCPCS code of base equipment
A notation that the equipment is beneficiary owned
Date the patient obtained the equipment
E0601 OWN111710 CB
Supplies and accessories used with beneficiary-owned equipment which was not paid for by traditional Medicare, i.e., equipment that was paid by other insurance or by the beneficiary, must contain the following information on the initial claim: 38 38

39. Common Reasons for ANSI 16 Denials on PAP Claims
Primary pricing modifier missing or invalid
RR, NU
KX, GA, GZ modifier missing
Narrative segment missing or incomplete
Supplies/accessories
Beneficiary owned equipment
LT, RT modifiers appended in error CB

40. Therapeutic Shoes for Persons with Diabetes
Pricing modifiers not required
Informational modifiers
KX, GY, EY
LT/RT required CB
Supplies and accessories used with beneficiary-owned equipment which was not paid for by traditional Medicare, i.e., equipment that was paid by other insurance or by the beneficiary, must contain the following information on the initial claim: 40 40

41. Correct Billing CB
Alternative text: Bottom of CMS 1500 claim form

42. Common Denial ANSI 4
Incorrect monthly rental modifier is appended, claim line denies unprocessable
Procedure code is inconsistent with the modifier used, or a required modifier is missing
Must correct and resubmit as a new claim, cannot reopen or appeal TH
Now let’s address a common denial that is issued by National Government Services. When suppliers bill for capped rental items, a capped rental modifier is required. If the incorrect modifier is appended the claim will deny with ANSI 4. As noted on this slide, this denial is not appealable. The claim must be correct and resubmitted.
Now let’s address some additional information for the ANSI denial.

43. Capped Rental Paid on rental basis only
RR: Rented item
Requires monthly rental modifier
KH: 1st month
KI: 2nd–3rd months
KJ: 4th–13th months TH
For capped rental items, the RR modifier is required along with the appropriate monthly rental modifier. When suppliers receive the ANSI denial of 4, this means per the rental modifier that was appended, Medicare already has a record of that payment. This means if you are billing with the KH modifier, Medicare has already paid for the HCPCS code you billed for the KH modifier. The biggest reason why suppliers receive this denial is due to the supplier attempting to start a rental period over. This could be due to an interruption in a period of continuous use or replacement equipment. We will get into billing for replacements a lil later but the key thing is that the RA modifier must be appended with all other applicable modifiers. The area I would like to address next is the interruptions in a period of continuous usage.

44. Interruptions in a Period of Continuous Use
Break in service/medical need
Change in medical condition to point that they no longer need original equipment
Greater than 60 days
Change in medical condition patient again meets medical necessity for same item as previously used
NTE segment or Item 19
Abbreviation BIS/BIN
Pick up date and delivery date
Previous ICD-9 and new ICD-9
Exp. BIN MMDDYY MMDDYY ICD-9 ICD-9
Let’s address the billing when there is a break in medical need, previously known as break in service. Under the first bullet we have the requirements listed. If the break does not meet these requirements, then it is not considered a break in medical need.
When reporting this information, it is imperative for suppliers to report the information just as we have it under the second bullet. If the information is not reported correctly, it is possible you will receive the denial of CO-4 since you are attempting to start a new rental period but the information in the NTE segment was not reported correctly.
I would also like to mention a common scenario we see with billing of break in medical need. There are situations where a beneficiary is renting equipment, then sometime down the road they call the supplier to pick up the equipment since they are no longer using it. A couple of months later, the beneficiary is calling the supplier back to redeliver the equipment. When this scenario happens, supplier have to be very careful in regards to billing a new rental period or resume billing where it left off. As it is noted on this slide, there must be a change in the medical condition that they don’t meet the medical necessity of the item. Just because a beneficiary says they don’t need it doesn’t mean that there was a change in their medical condition that they no longer meet the medical necessity. If Medicare determines that during the break that was reported in the NTE segment, the medical necessity was still present, a break in medical need will not be granted. It would be considered a break in billing. 44 44

45. Interruptions in a Period of Continuous Use
“Break in billing” is defined as any break in the supplier’s monthly billing that does not meet the definition of a “break in service.”
Inpatient stay
NTE segment or Item 19
BIB ADM TO SNF DISC TH
A break in billing is when there is a medical need for the item but the supplier is unable to bill. This is typically due to the beneficiary going inpatient or as I just mentioned with the scenario, the beneficiary didn’t want the equipment in their home for a period of time…basically against doctor’s orders they had it removed.
With break in billing, suppliers should report in the NTE segment BIB for break in billing, the reason why, the first day of admission/or removal from the home, and the date they were discharge/equipment delivered back to their home. 45 45

46. Reporting Noncompliance
Beneficiary noncompliant with continued coverage criteria
PAP, Oxygen
NTE segment or Item 19
Noncompliant TH
We have received several inquiries on how a supplier can report information when a beneficiary is noncompliant per the medical policy. Suppliers of PAP devices see this more often than others since there is a continuous coverage requirement in the policy. When a supplier is unable to bill Medicare since the beneficiary does not meet the continued coverage criteria and they have not been able to have the beneficiary sign an ABN, then later, the beneficiary does become compliant, the supplier may submit the month of service once the beneficiary becomes compliant and report the information we have listed on this slide. The supplier will report the word noncompliant along with two dates…the first is the first day the beneficiary become non-compliant and the second day is the day the beneficiary became compliant. This information should be reported on all claims submitted to Medicare once the compliance coverage has been met. This will allow us to extend out the dummy CMN so the supplier may receive all 13 rental payments.

47. Upgrades: Charging the Beneficiary
Properly executed ABN on file
Line 1 GA modifier – item that is provided
Line 2 GK modifier – item that is covered based on local coverage determination
All other applicable modifiers per local coverage determination, Medicare guidelines, and competitive bidding TH
Now let’s talk about upgrades. This is another area of concern since modifiers related to upgrade billing are being reported incorrectly. Suppliers must make a determination with upgrades if they will be charging the beneficiary, not charging the beneficiary or not charging the beneficiary or Medicare. On this slide we have the information when charging the beneficiary. Suppliers must have a properly executed ABN on file which means it must be completed, signed, and dated prior to the item being dispensed. Now for the claim lines as we have it noted. There has been questions surrounding what dollar amounts are reported. Suppliers should not adjust their billing when submitting claims for upgrades. Line 1 would be the dollar amount for that item. Line 2 would be the dollar amount for that item.
One last thing to point out before looking at the example, suppliers should not report the GA and the GK modifier on the same claim line.

48. Charging the Beneficiary
Alternative text: Bottom of CMS 1500 claim form
And here is a valid example of upgrade billing and charging the beneficiary. Line 1 would deny as patient responsibility. Line 2 we would process as normal.

49. Upgrades: Not Charging the Beneficiary
Properly executed ABN not on file
Line 1 GZ modifier – item that is provided
Line 2 GK modifier – item that is covered based on local coverage determination
All other applicable modifiers per local coverage determination, Medicare guidelines, and competitive bidding TH
When not charging the beneficiary, this is the same as billing the beneficiary for the upgrade as we mentioned on slide 46 however, instead of the GA modifier, you will report the GZ modifier.
Again, do not report the GZ and the GK modifier on the same claim line. Let’s take a look at a claim example

50. Not Charging the Beneficiary
Alternative text: Bottom of CMS 1500 claim form
With this example, line 1 would deny as supplier responsibility since an ABN was not properly executed and the GZ modifier was reported. Line 2 would be processed as normail.

51. Upgrades: Not Charging the Beneficiary or Medicare Program
ABN not required
Line 1 GL modifier – item that is covered based on local coverage determination
Item 19 or NTE segment
Specific make and model of the item actually furnished (the upgrade item) and the reason behind the upgrade
All other applicable modifiers per medical policy, Medicare guidelines, and competitive bidding TH
The final option for upgrade billing is not charging the beneficiary or Medicare. This is a common practice for suppliers who’s inventory are for the higher end items, for example total electric hospital beds. With this billing there is only 1 claim line that is billed, the HCPCS code for the item that the beneficiary meets Medicare coverage criteria for, all applicable modifiers, and the GL modifier. In the NTE segment, suppliers will need to report what item was actually furnished and why it was furnished. The dollar amount reported is for the item that meets Medicare’s coverage criteria. Let’s review an example

52. Not Charging the Beneficiary or Medicare Program
Alternative text: Bottom of CMS 1500 claim form
Here we have a beneficiary who meets coverage criteria for a semi-electric hospital bed but they received a total electric hospital bed since the semi-electric hospital bed was out of stock. The claim line is billed for the semi-electric with all applicable modifiers and the GL modifier. The NTE segment has the product information on the total electric hospital bed and the reason why it was dispensed instead of the semi-electric hospital bed.
Now let’s take question 3 of today’s webinar.

53. Question #3
When billing for an upgrade and not charging the beneficiary or Medicare, what modifier is required on the claim. GA GL KB EY TH

54. NTE Segment/Item 19 Narrative explanation required Resources
Information entered in Item 19 or NTE segment
Specific situations
Assists in proper claims processing
Limited to 80 characters
Spaces not required
Resources
Situations Requiring a Narrative Explanation in Item 19
Suggested Abbreviation List for Submitting Narrative Information
DME MAC Home page, Tools and Materials located under Resources TH
We have spoken about the NTE segment and Item 19 of the CMS-1500 claim form. On this slide we wanted to provide some additional information for our supplier community. Under the resources are 2 key articles that will assist suppliers when reporting information and why information must be reported in Item 19 or the NTE segment. As it is noted, these articles may be found under our Tools and Materials section of our Web site which is located under Resources which is on our top navigation menu.
I will now turn it over to Terri.

55. Certificates of Medical Necessity
CMS form
Required to help document medical necessity
Five medical policies require a CMN
Oxygen (CMS-484)
Pneumatic compression devices (CMS-846)
Osteogenesis stimulators (CMS-847)
TENS units (purchase only) (CMS-848)
Seat lift mechanisms (CMS-849)
Section B completed by physician, Section D signed by physician CB
A Certificate of Medical Necessity form is a CMS created form required by certain medical policies to help document the medical necessity and other coverage criteria.
A completed CMN must be submitted with the initial claim for certain items. Which include:
Oxygen
Pneumatic compression devices
Osteogenesis Stimulators
TENS units and
Seat Lift Mechanisms.

56. DME Information Forms DME Information Forms CMS form
Required to help document medical necessity
Three medical policies require a DIF
External infusion pumps
Parenteral nutrition
Enteral Nutrition
Completed and signed by the supplier CB
A DIF is a CMN created form required in three medical policies to help document medical necessity. The 3 policies that require a DIF are listed on this slide.

57. When are CMNs/DIFs Required?
Initial
Required for all new items
Revised
Required to be submitted when any changes are done
Recertification
Required at specific times per medical policy CB

58. ANSI 173 Service was not prescribed by a physician
Initial CMN/DIF is required and not on file CB
Initial CMN – An initial CMN is the first CMN filed for a particular beneficiary and item. An initial CMN is also required after an interruption in continuous use due to a break in medical need.

59. CB

60. ANSI 176 Prescription is not current
Recertification CMN is required and not on file
Group I oxygen – 12 months after initial certification
Group II oxygen – 3 months after initial certification CB

61. CB

62. Question #4
To correct a claim denial of CO-173, suppliers should do which of the following?
File a reopening
Resubmit the claim
Resubmit the claim with the CMN
Send a bill to the beneficiary CB

63. Determine Beneficiary Status
Does the beneficiary reside at home?
His or her own dwelling i.e., house, apartment, etc.
A relative’s home
Assisted living facility
Place of service 13
Is the beneficiary in the hospital?
Is the beneficiary in a skilled nursing facility/nursing facility?
Is Medicare covering the Part A stay? TH
Now a big area of concern for all suppliers. Prior to billing us for services, suppliers should determine the status of the beneficiary. By knowing where the beneficiary is residing will determine if a claim should be submitted to the DME MAC.
We have been questioned with facilities, how can a supplier determine how the facility is classified as. We do encourage suppliers to speak directly with the facility in order to determine if the facility is a skilled nursing facility, custodial care, assisted living, etc… Suppliers must report the correct POS code when submitting claims to the DME MAC. A complete listing of POS codes is available in chapter 12 of our supplier manual.
The other reason why suppliers need to know where the beneficiary is residing is to determine if services should be dispensed or not. When a beneficiary is in a facility that must bill Medicare Part A, the services may be part of the consolidated billing requirement. This requirement is when the hospital, SNF, or nursing home, bills Medicare for the entire package of care that residents receive during a covered Medicare Part A nursing home stay. The SNF also bills Medicare for physical, occupational, and speech therapy services received during a noncovered stay. 63 63

64. Determine Beneficiary Status
Is a home health agency providing care?
Is the beneficiary on hospice?
What is the primary diagnosis related to the hospice care?
Is the beneficiary an ESRD patient? TH
Listed on this slide are 3 other instances of where consolidated billing come into play. Again, it is imperative suppliers determine the status of their patients since it will determine if they will receive reimbursement or not. Now let’s take a deeper look into these situations. 64 64

65. Overlapping Hospital Stay
Part A has received a claim
ANSI 97
The benefit for this service is included in the payment/allowance for a service/procedure that has already been adjudicated
M2 remark code
Not separately payable when the patient is an inpatient TH
When a beneficiary is classified as inpatient in a hospital , the DME MAC will not make separate payment for DMEPOS items. If Medicare Part A has the claim on file, you will receive the denial of ANSI 97. This denial can be avoided by using the self service tools of the IVR or Connex to check inpatient status for the beneficiary.

66. Overlapping Hospital Stay
Part A has not received a claim
ANSI 109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor.
M2 remark code
Not separately payable when the patient is an inpatient TH
Now if Medicare Part A does not have a claim on file, the DME MAC will make payment for the services. The reason why we have the OA-109 listed is when Medicare Part A finally receives a claim, the claim we paid will be adjusted and on your remittance advice, the claim will be adjusted and denied as OA-109.

67. Overlapping Skilled Nursing Facility Stay
Part A benefits are not exhausted
ANSI 109
Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor
N538 remark code
A facility is responsible for payment to outside providers who furnish drugs to its patients/residents TH
Let’s talk about SNFs. Again, suppliers should verify with the facility if they are registered as a SNF or not. If Part A benefits have not been exhausted, all services billed to the DME MAC will be denied as OA-109. Beneficiaries have 100 benefit days for SNF stays. All services are reimbursed by Medicare Part A to the SNF via the consolidated billing requirement.

68. Overlapping Skilled Nursing Facility Stay
Part A benefits are exhausted
ANSI 96
Noncovered charges
MA18 remark code
Certain services may be approved for home use. Neither a hospital nor a SNF is considered to be a patient’s home.
DME is not payable
Diabetic testing supplies, PAP supplies, equipment
Prosthetics, orthotics, and supplies are separately payable
PEN, therapeutic shoes for persons with diabetes, etc. TH
If Medicare Part A has received a claim for a no-pay stay or exhausted benefits stay, the DME MAC may pay on some services. As listed on this slide, DME equipment, diabetic testing supplies, PAP supplies that are submitted to the , the supplier will receive a denial of PR-96. Remember, with PR-96 denials, an ABN is not required to hold the beneficiary liable for the charges since this is a non-covered denial.
Prosthetics, orthotics, and other supplies may be considered for payment from the DME MAC. Remember, these can only be reimbursed if Medicare Part A has received a no-pay stay or exhausted benefit stay.
Before moving on, I did want to mention the exception to the rule of services. For facilities, if a supplier is delivering due to anticipation of discharge, that is still acceptable. Suppliers just need to remember to bill with the date of discharge as the date of service.

69. Overlapping Home Health Episode
ANSI B15
This service/procedure requires that a qualifying/ service procedure be received and covered. The qualifying other service/procedure has not been received/adjudicated.
N70 remark code
Consolidated billing and payment applies
DME is separately payable
Supplies are not separately payable
Tracheostomy, urological, etc. TH
When a beneficiary is in a home health episode, DME is separately payable but all other services are not. Again, suppliers should check with their beneficiary prior to dispensing services.

70. Overlapping Hospice Care
ANSI B9
Patient is enrolled in hospice
DMEPOS items unrelated to terminal illness are separately payable by the DME MAC
GW modifier
Service not related to the hospice patient’s terminal condition TH
When a beneficiary is under Hospice care, hospice is responsible for all services related to the terminal illness. Other services may be reimbursed if not related to the hospice. Suppliers should append the GW modifier to the claim if the item they are furnishing is not related to the terminal illness. If a claim is received, regardless if the GW modifier is appended or not, if the diagnosis code is related to the diagnosis code on the hospice claim, the DME MAC claim will deny with B9 ANSI code.

71. Example of Correct BillingTH
Alternative Text: Bottom of CMS 1500 claim form
The claim should have been billed with the primary dx of tracheostomy. With the GW modifier indicating the suction pump is needed for a condition unrelated to the hospice dx.

72. Supplies Furnished to ESRD Patients, Not for ESRD Treatment
Item or service furnished to ESRD patient that is not for the treatment of ESRD
AY modifier required
AY modifier required even if using GA, GZ, GY, or EY modifiers
Item will be considered for separate payment by the DME MAC TH
For patients who are ESRD, some services may be furnished that are not part of the ESRD consolidated billing. For those services, supplier must append the AY modifier with all applicable modifiers.

73. Supplies Furnished to Non-ESRD Patients, Included in ESRD Consolidated Billing
DME ESRD supply HCPCS not payable to DME suppliers
GY modifier required
Item will be denied as statutorily noncovered
PR-96 TH
Supplies that are part of the consolidated billing are not separately reimbursable by the DME MAC. Suppliers may refer to the numerous articles we have posted to our News Article page for the listing of these codes. Suppliers may bill the DME MAC but these are noncovered services.
I will now turn the webinar back to Terri.

74. Repairs
Modifier RB
Used with all items that are furnished in conjunction with a repair for a beneficiary-owned base equipment
All other applicable modifiers per local coverage determination, Medicare guidelines, and competitive bidding
Repairs and labor are on same claim
K0739 Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
K0740 Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes CB

75. Replacements Modifier RA
Lost, stolen, irreparably damaged, or reasonable useful lifetime has been met
If item is a rental, only required on first month’s rental claim
All other applicable modifiers per local coverage determination, Medicare guidelines, and competitive bidding CB
National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC), would like to remind suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) to append modifier RA to only the first month’s rental claim following a replacement. Suppliers must not append modifier RA to claims for subsequent rental months following the replacement.
Also, please note that modifiers RA and RB, for repair and replacement of an item, are also available for use to indicate repair or replacement of prosthetic and orthotic items. The descriptors for RA and RB have been revised, effective April 1, 2010, to read as follows:
RA: Replacement of a DME, orthotic or prosthetic item RB: Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair
Replacement refers to the provision of an identical or nearly identical item. The RA modifier is used to denote instances where an item of durable medical equipment (DME), prosthetic, or orthotic is furnished as a replacement for the same or nearly identical item which has been lost, stolen, or irreparably damaged, prior to the equipments reasonable useful lifetime. Suppliers must also use the RA modifier for billing claims for replacement when the DMEPOS item has met the reasonable useful lifetime (RUL). The majority of DMEPOS items have an RUL of five years. However, there are some exceptions to the five-year RUL, which include but are not limited to:
Parenteral and enteral nutrition (PEN) pumps—RUL is eight years
Prefabricated knee orthoses L1810–L1832, L1836, L1843, L1845, L1847, and L1850—RUL varies from one to three years
Custom fabricated knee orthoses—RUL is three years
For DME items other than oxygen equipment, suppliers must use modifier RA when replacing the old base equipment with new base equipment within the same Healthcare Common Procedure Coding System (HCPCS) (e.g., replacing a K0001 wheelchair with a K0001 wheelchair or a K0004 wheelchair with a K0004 wheelchair). 
For oxygen equipment, modifier RA is used to denote oxygen equipment that is replaced with any new oxygen equipment (i.e., replacing an oxygen concentrator with stationary gaseous oxygen equipment) when the equipment is lost, stolen, irreparably damaged, or has met the reasonable useful lifetime (five years).

76. Replacements CB Image of an example for RUL claims
Suppliers must also include a narrative explanation to indicate the reason the item is being replaced. This information must be reported in Item 19 of the CMS-1500 paper claim form or the Note (NTE) segment of the electronic claim.
Below are suggested formats for the required narrative explanation:
Reasonable useful lifetime: RUL for reasonable useful lifetime and the date the original item was delivered (example: RUL )
Lost in a fire: Date of fire (example: FIRE050510)
Stolen: Date item was stolen (example: STOLEN050510)
Reason for irreparable damage: Date of incident (example: IRREPDAMAGED050510)
Suppliers are expected to have documentation to support reason for replacement. Depending upon reason for replacement, documentation may include a copy of the police report, fire report, etc.
Suppliers can expedite payment if the claim is submitted correctly the first time, as opposed to submitting incorrectly and then having to file a redetermination request.
Narrative abbreviation list/CBT

77. Question #5
If a supplier is providing a replacement item, the supplier must append which modifier? RB GL RA GW CB

78. Temporary Replacement for Patient-Owned Equipment
K temporary replacement for patient-owned equipment being repaired, any type
Submitted on the same claim as the claim for repairs (labor and parts)
Date of service should be the date the loaner equipment was delivered
NTE segment/Item19 should include:
Description of the item being repaired
Description of the loaner equipment
Detailed description of what was repaired
Brief explanation of why the repair took longer than one day CB

79. Resources Medicare University Jurisdiction B DME MAC Supplier Manual
CBTs on modifiers, CMN and DIF forms, span date billing, NTE segment, interruptions in a period of continuous use, and much more
Jurisdiction B DME MAC Supplier Manual
Jurisdiction B DME MAC ANSI Guide
Self-service tools
Connex, IVR CB

80. Total Electronic Environment InitiativeLH

81. Think Green and Go Paperless
Electronic claims
Electronic remittance advice
Electronic funds transfer LH

82. Electronic Claims ASCA Requirement Electronic claims Paper claims
14-day payment floor
Paper claims
29-day payment floor
Testimonials
Over 99% claims are electronic LH
The Administrative Simplification Compliance Act known as ASCA requires that all initial claims be submitted electronically, with limited exceptions.
Medicare is prohibited from paying claims submitted in a non-electronic manner unless the supplier has an ASCA waiver on file.
Certain suppliers can qualify for an ASCA waiver and continue to submit paper claims. An example of a supplier who qualifies for an ASCA waiver would be a small supplier. A small supplier is defined as one with less than 10 full-time equivalent employees.
ASCA information including the ASCA waiver form can be located on our Web site at under Claims tab select ASCA
Even if a supplier meets an ASCA exception and can bill on paper, National Government Services still STRONGLY Recommends that all suppliers bill electronically to save time and money.
We are now ready for our first polling question. Please take a moment to complete the question that appears on your screen. 82

83. How to Become An Electronic Submitter
Acquire Software
Obtain an electronic sender ID
Test with CEDI
Select Electronic Submission (EDI) under the Claims tab
Select EDI Products and Services
Then select Getting Started LH

84. Electronic Remittance Advice
Strongly encouraged
Many benefits
Faster account reconciliation
Paperwork reduction
Improved office productivity
Testimonials
Over 76% of remittances are electronic LH

85. How to Sign Up for ERA Obtain ERA software
Software vendor
MREP
Obtain a network service vendor
Enroll
Select CEDI Enrollment Forms
Complete the Submitter Action Request Form and Supplier Authorization Form (if applicable) LH

86. Electronic Funds Transfer
Required
How to sign up for EFT
Select Electronic Submissions (EDI) under the Claims tab
Select EDI Products and Services
Then select Electronic Funds Transfer
Lisa

87. Support Electronic Claims and ERAs EFTs CEDI Provider Contact Center
EFTs
Provider Contact Center
Lisa

88. Questions CB

89. How to Participate TodayCB

90. How to Participate Today
To Ask a Verbal Question: Raise your hand
The Green Arrow means your hand is not raised (Click to raise your hand)
The Red Arrow means your hand is raised (Click to lower your hand) CB

91. To Ask a Question By Raising Your HandCB

92. To Ask a Question Using the Question BoxCB

93. Closing Comments CB

94. Web Site Survey
This is your chance to have your voice heard—Say “yes” when you see this pop-up so National Government Services can make your job easier! CB

95. Medicare University http://www.MedicareUniversity.com
Interactive online system available 24/7
Educational opportunities available
Computer-based training courses
Teleconferences, Webinars, live seminars/face-to-face training
Self-report attendance CB
Note to User: Per revised Medicare University SOP (MAY 2011) – ensure that no event specific Event Number or Catalog Number is posted in any document posted on the NGS web site. The information can be in the PPT for the actual presentation and may be shared during the presentation. For webinars, the information will be sent in a follow-up to all registered participants.
On slide ??, we have the Medicare University training event number, catalog number, and topic. These pieces of information will help you locate and get credit for attending today’s session. 95 95
Date MU Slides Modified: 01/22/2010

96. Medicare University Self-Reporting Instructions
Log on to the National Government Services Medicare University site at
Topic = Bill Medicare Correctly the First Time to Prevent Unnecessary Denials
Medicare University Credits (MUCs) = 1
Catalog Number = AA-C-00995
Course Code = 13072WDCBH1
For step-by-step instructions on self-reporting please visit > Medicare University > Accessing the Self-Reporting Tool CB 96 96
Date MU Slides Modified: 01/22/2010

97. Thank You! CB