DMERC Dialogue Durable Medical Equipment Regional Carrier (DMERC) Region D July 2004 (Summer) General Release 04-3 A Medicare Newsletter for Region D DMEPOS Suppliers - A service of CIGNA HealthCare Medicare Administration Subscribe to the CIGNA Medicare Electronic Mailing List From the Medical Director… To receive automatic notification Robert Hoover, Jr., MD, MPH via e-mail of the posting of LMRPs, publications and other important BAM!!! Let’s Take It Up A Notch Medicare announcements, subscribe to the CIGNA Medicare electronic mailing list at www.cignamedicare.com/mailer/subscribe.asp. By now most of you are familiar with the Comprehen- sive Error Rate Testing (CERT) program from previous articles in the DMERC Dialogue. CERT is the Centers In This Issue for Medicare & Medicaid Services (CMS) initiative that measures claim payment errors in the Medicare pro- FROM THE MEDICAL DIRECTOR gram. BAM!!! Let’s Take It Up A Notch ........................................... 1 MEDICAL POLICY Through oversight audits by the CERT contractor, Durable Medical Equipment: AdvanceMed, contractors like CIGNA Medicare receive Wheelchair Options/Accessories And Wheelchair data on various types of claim errors and use this data Seating - Policy Revisions ............................................ 3 to develop strategies to reduce errors in the Medicare General: program. LMRP Conversion To LCD And Policy Articles .................. 3 Orthotics: Clarification - Coding Of Night Splints For Plantar One of the major types of error is lack of documenta- Fasciitis ........................................................................ 3 tion. Although suppliers who have claims chosen for Pharmacy: CERT review are informed in their notification letter of External Infusion Pumps - Coverage For Gallium the importance of submitting documentation to Nitrate Added ................................................................ 4 AdvanceMed, there is still an unacceptably high non- New Immunosuppressive Drug .......................................... 4 response rate. This is occurring even after several fol- COVERAGE AND BILLING low-up letters are sent. Consequently, CMS has asked Durable Medical Equipment: contractors to make phone contact with suppliers who Billing Reminder - Elevating Leg Rests ............................... 4 have not responded after 30 days. Correct Coding Of Flutter® And Acapella™ Devices ........... 4 Humidifiers – HCPCS Codes E0550, E0555, E0560, Why is CMS so interested in a response? E0561, And E0562 ........................................................ 4 Rules For Maintenance And Servicing Claims .................. 5 Written Order Prior To Delivery - HCPCS Codes Added ... 5 The Medicare error rate has greater validity when there Wheelchair Cushion Codes And Definitions ..................... 6 is complete documentation for a claim. Without a re- General: sponse from suppliers, by default, the claim must be CERT Revisited ................................................................... 6 denied because the contractor is unable to determine if Completion Of Section B Of The Certificate Of Medical Necessity Form................................................ 7 the item or service was truly medically necessary. Elimination Of The 90-Day Grace Period For Billing Discontinued ICD-9-CM Codes ...................................... 7 Why should suppliers care? Manualization Of POS Code Set Program Memorandum; Revision To Group Home Code Description ....................... 8 A couple of reasons. First, you are helping to accu- Reminder To Stop Duplicate Billings ...................................... 9 rately determine the magnitude of claim errors in the Pharmacy: Correction “Epoetin And Darbepoetin - New Codes” ......... 9 Medicare program. Contractors, like CIGNA Medicare, Prosthetics:RETIREDuse CERT data to develop educational programs that TPN Lessons Learned ....................................................... 9 assist suppliers in the correct submission of claims. Cont’d on page 2 Fewer claim errors means lower denial rates which saves Page 2 DMERC Dialogue July 2004 (Summer) In This Issue (Cont’d) MISCELLANEOUS (cont’d) Frequency Limitations For Darbepoetin Alfa (Trade Name Aranesp) For Treatment Of Anemia In End FEE SCHEDULE Stage Renal Disease (ESRD) Patients On Dialysis ...... 30 New Payment Allowance Percentages For DMERC Guidelines For Filing Paper Claims ................................. 31 Drugs .......................................................................... 10 New Medicare-Approved Drug Discount Cards And July Quarterly Update For 2004 Durable Medical Transitional Assistance Program: A Summary For Equipment, Prosthetics, Orthotics, And Supplies Physicians And Other Health Care Professionals ....... 32 Fee Schedule .............................................................. 10 New Part B Annual Deductible ....................................... 33 July Quarterly Update DMEPOS Fee Schedule (Fees) ..... 12 Offset Option Available On The DMERC Supplier IVR.... 34 Order Influenza Vaccine Now ....................................... 34 HCPCS UPDATES Quarterly Provider Update ............................................. 34 2004 Jurisdiction List ....................................................... 14 Region D Publications Distribution Options ..................... 35 Elimination Of The 90-Day Grace Period For HCPCS Reporting Address And Other Changes To The National Codes .......................................................................... 14 Supplier Clearinghouse (NSC) .................................... 35 HCPCS Code L0474 ......................................................... 16 Revised Proof Of Delivery Requirements ...................... 36 The DMERC Advisory Committee (DAC) ......................... 37 ELECTRONIC DATA INTERCHANGE (EDI) The Provider Communications Advisory Group Beneficiary Eligibility Options ........................................... 16 (PCOM-AG) ................................................................. 38 New Requirements For Q4054 And Q4055 On Update To The American National Standard Institute Electronic Claims ......................................................... 16 (ANSI) Codes .............................................................. 39 Revised American National Standards Institute Remittance Advice Remark Code And Claim Adjustment X12N 837 Professional Health Care Claim Reason Code Update .................................................. 40 Companion Document ................................................. 16 FREQUENTLY ASKED QUESTIONS .................................. 43 HIPAA Additional Guidelines For Implementing The National APPENDIX Council For Prescription Drug Program (NCPDP) Standards Under HIPAA .............................................. 17 Financial Statement of Debtor - Form CMS-379 Gap Filling For X12N 837 COB (Coordination Of (01/83) ...................................................................... A-1 Benefits) Claims .......................................................... 18 Supplier Interactive Voice Response (IVR) System Health Insurance Portability And Accountability Act Script ......................................................................... A-2 (HIPAA) X12N 837 Professional Health Care DMERC Region D Publications Designation Form ......... A-3 Claim Implementation Guide (IG) Editing ....................... 18 Medicare Review Request Form.................................. A-4 Medicare Providers: Their Vendors, Clearinghouses, Medicare Hearing Request Form.................................. A-5 Or Other Third-Party Billers And The HIPAA/ Medicare Administrative Law Judge Request Medicare Contingency Plan ......................................... 19 Form.......................................................................... A-6 Modification Of CMS’ Medicare Contingency Plan For DMERC Region D Publication Order Form..................... A-7 HIPAA Implementation .................................................. 20 Suggested Intake Form ................................................ A-8 Update To The Healthcare Provider Taxonomy Codes Authorization Agreement For Electronic Funds (HPTCs) Version 4.0 ................................................... 21 Transfer (EFT) Form ................................................. A-9 Customer Service Available ....................................... A-10 MEDICARE SECONDARY PAYER Medicare As The Secondary Payer ................................. 22 Medicare Secondary Payer Fact Sheets ......................... 22 APPEALS BAM!!! Let’s Take It Up A Notch Appealing Medicare Overpayments ................................. 22 Changes In The Appeals Process .................................... 23 (cont’d) Submitting Additional Documentation With The Review Request ......................................................... 23 money and resources for both the contractor and the supplier. MISCELLANEOUS Are Your Claims Being Rejected? .................................... 24 CMS Creates Additional Supplier-Specific Web Pages .... 25 Second, if documentation is not submitted to Consolidation Of The Claims Crossover Process: AdvanceMed, the claim is denied and an overpayment Additional Common Working File (CWF) assessed. Functionality ................................................................ 26 The Consolidation Of The Claims Crossover Process: Smaller-Scale Initial Implementation ............................. 27 So don’t be surprised if someone from CIGNA Medicare