The Latest in Billing & Reimbursement from Ronda Buhrmester: May 2023

Published in Member Communities on May 05, 2023

By Ronda Buhrmester, Sr. Director of Payer Relations and Reimbursement, VGM & Associates

Read below for several billing & reimbursement-specific updates regarding the new ABN, oxygen policy, CGS DME MAC performing TPE audits on GW modifier related to hospice claims, CGM policy update, and F2F/WOPD required list and prior authorization required list. 

New ABN  

The ABN, form CMS-R-131, has been approved by the Office of Management and Budget (OMB) for renewal. The use of the renewed form with the expiration date of 01/31/2026 will be required to use on 6/30/23. There were no other changes made to the form. Suppliers may choose to use the existing ABN until June 29 or begin using the new ABN now.   

As a reminder, the ABN is used in advance of the delivery to inform beneficiaries in situations where Medicare payment is expected to deny the claim. The denial may be due to lack of medical necessity, same or similar equipment within the five-year reasonable useful lifetime, and over-utilization. The ABN needs to speak to the beneficiary so an informed decision can be made. Read the full instructions of the proper use of the ABN by clicking here. 

View the New ABN (English Version) View the New ABN (Spanish Version)

Oxygen Policy Updates and Information from Recent Webinar 

With the oxygen equipment medical policy (LCD/PA) continuously providing clarifications and updates, the information needs to be shared with suppliers. In my most recent webinar, there are a few discussions on being around the diagnosis of hypoxia. In the past, hypoxia (or hypoxemia) was acceptable if the underlying condition causing this symptom was noted. Now that oxygen equipment may be used for both short-term (or acute) and long-term (or chronic) conditions, hypoxia is acceptable to be treating with oxygen equipment. It’s vital to make sure this would be a short-term condition because it’s a symptom. To learn more, listen to the recording of the webinar. 

We also have a marketing and educational tool for referrals that prescribe oxygen equipment. The concept is for the physician, nurse practitioner, nurse, RT, or any clinician involved in referring patients for home oxygen to reference a quick guide with the new changes. The oxygen policy one-pager is available to be emailed or printed to share with the referrals. 

View the Webinar RecordingView the Webinar HandoutView the Oxygen Policy One Pager

Since the webinar, there is additional news to share with suppliers. On the current oxygen policy for initial claims, the treating practitioner must do the following: 

I have connected with the DME MACs’ medical directors, and the treating practitioner may co-sign the actual oxygen test results as proof they evaluated the qualifying testing for home oxygen. 

CGS DME MAC Performing TPE Audits on GW Modifier Related to Hospice Claims  

The Office of Inspector General (OIG) did a recent study that reported Medicare improperly paid suppliers an estimated $117 million over four years for DMEPOS provided to hospice beneficiaries. 

The GW modifier is used to indicate items/services that are not related to the hospice beneficiary's terminal illness or a related condition. The hospice benefit is under Medicare Part A and includes items and services provided to manage terminal illnesses and related conditions, including DMEPOS when part of treatment for condition/illness for hospice (bundled with per diem payment). Suppliers may bill DME MACs separately for an item or service that is not related to the hospice patient's terminal condition.  

As noted by the Centers for Medicare and Medicaid Services (CMS) and repeated in numerous CMS publications and regulations related to the hospice benefit, payment for items and services separate from the hospice per diem should be "exceptional and unusual" and that hospices are required to "provide virtually all the care that is needed by terminally ill patients." 

As a result of OIG study, CGS DME MAC contractor for Jurisdictions B and C are performing prepayment audits related to the use of the GW modifier. 

In addition to the standard documentation request that are part of the TPE audit, the letter will be requesting the Hospice Election Statement Addendum. This form is an educational document, and it promotes transparency for the hospice beneficiary, their families or caregivers, and any other stakeholders, such as DME suppliers and MAC contractors.   

Supporting claims under the DME benefit while the patient is in hospice care is challenging. Before using the GW modifier, suppliers need to ask the hospice provider to send the Hospice Election Statement Addendum.   

CGM Policy Update 

As the technology continues to advance with the continuous glucose monitors (CGM), the CGM medical policy has also been getting updates. New coverage criteria is effective for of service (DOS) on or after April 16, 2023.   

To be eligible for coverage of a CGM and related supplies, the beneficiary must meet ALL of the following initial coverage criteria (1-5): 

1. Beneficiary has diabetes mellitus (ICD-10 code list in the LCD-related Policy Article); and, 
2. Beneficiary’s treating practitioner has concluded that the beneficiary (or beneficiary’s caregiver) has sufficient training using the CGM prescribed as evidenced by providing a prescription; and, 
3. The CGM is prescribed in accordance with its FDA indications for use; and, 
4. Beneficiary for whom a CGM is being prescribed, to improve glycemic control, meets at least one of the criteria below: 
   1. The beneficiary is insulin-treated; or, 
   2. The beneficiary has a history of problematic hypoglycemia with documentation of at least one of the following (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section of the LCD-related Policy Article (A52464)): 
      1. Recurrent (more than one) level 2 hypoglycemic events (glucose <54mg/dL (3.0mmol/L)) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan; or, 
      2. A history of one level 3 hypoglycemic event (glucose <54mg/dL (3.0mmol/L)) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia 
5. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person or Medicare-approved telehealth visit with the beneficiary to evaluate their diabetes control and determined that criteria (1)-(4) above are met. 

F2F/WOPD Required List and Prior Authorization Required List 

As HCPCS codes are being moved from the master list to a required list, it can be challenging to keep track of the codes and the different lists. Some HCPCS codes are under the prior authorization list, other HCPCS codes are under the Face-to-Face/WOPD Required list, while codes are under both lists. Here is a chart to use as a quick reference if your company provides any of the following products. 

For any questions, please reach out to me, Ronda Buhrmester, via email at ronda.buhrmester@vgm.com or by calling 217-493-5440. 

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