(Medicare Claims Processing Manual)

AB-01-61  A. Method Selection and Form CMS -382  For services furnished prior to January 1, 2011, the beneficiary was required to complete Form CMS -382 to choose either Method I or Method II dialysis.  Method I dialysis patients receive their home dialysis equipment and supplies from a dialysis facility.   Method II patients chose to deal with a home dialysis supplier that is not a dialysis facility.  Once a beneficiary made a method selection choice, the beneficiary or dialysis facility submitted the Form CMS -382 to the appropriate A/B MAC (A).  The A/B M AC (A) then processed information from the form to CWF.  Chapter 8 provided the instructions for completing the form.   For dates of service prior to January 1, 2011, the  DME MACs deny Method II claims where there is no method selection or the method selection has a value of '1' on file at CWF.   For dates of service on and after January 1, 2011, please refer to Section 30.8.3 for information on the elimination of Method II home dialysis.   B. Changes in Method Selection   Prior to the implementation of the ESRD PPS, for dates of service prior to January 1, 2011, if a beneficiary decided to change his or her choice of method selection, he or she filled out a new Form CMS -382 to indicate the change.  The beneficiary could have filled out a new method selection form at any time, but in most circumstances, the change did not take effect until January 1 of the following calendar year.  If a beneficiary requested an exception to the January 1 implementation date in writing from the A/B MAC  (A), the A/B MAC (A) could have chosen to grant his or her request.  See Chapter 8 for related requirements.   The DME MAC systems must be able to interpret the CWF trailer record that contains the method effective date.   For dates of service on and after January 1, 2011, please refer to Section 30.8.3 for information on the elimination of Method II home dialysis.  30.8.2 - Installation and Delivery Charges for ESRD Equipment  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  3-5105.1  ESRD facilities are responsible for all reasonable and necessary expenses incurred in the initial installation of home dialysis equipment, but not those expenses attributable to items that are basically for the purpose of improving the patient's home, e.g., plumbing or electrical work beyond that necessary to tie in with existing power or water lines.  The delivery and installation of renal dialysis equipment, unlike that involved when a hospital bed is delivered and set up, requires testing and assurance of equipment performance. Therefore, if the supplier of home dialysis equipment customarily charges for delivery and service, and this is a common practice among other suppliers as well, this is payable.  30.8.3 - Elimination of Method II Home Dialysis  (Rev. 2487, Issued: 06- 08-12, Effective: 01 -01-11, Implementation: 06- 19-12)  Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims.  Specifically, Method II home dialysis is no longer recognized as a beneficiary option for dates of services beginning January 1, 2011, therefore, all ESRD patients that previously selected Method II are covered under Method I.  All home dialysis claims must be billed by an ESRD facility and paid under the ESRD PPS.  As a result, the submission of the CMS -382 form to the A/B MACs (A) or DME MACs  is no longer required for home dialysis patients on or after January 1, 2011.   Method II claims will not be accepted for dates of service on or after January 1, 2011.  Method II claims for dates of service prior to January 1, 2011 will continue to be processed within normal timely filing limitations.  For more information on timely f iling, see Pub. 100- 04, Chapter 1, Sections 70 through 70.8.6.  For dates of service on or after January 1, 2011, MACs shall continue to allow separate billing for certain ESRD supply HCPCS codes subject to the ESRD PPS consolidated billing requirements when submitted by suppliers for services not related to the benefi ciarys ESRD dialysis treatment and billed with the modifier AY.  MACs shall pay for ESRD supplies subject to ESRD CB when billed on a CMS -1500 or electronic equivalent if the ESRD supply claims contain modifier AY.  A list of equipment and supplies eligib le for separate payment when billed with modifier AY can be found in the first table (DME ESRD Supply HCPCS for ESRD PPS Consolidated Billing Edits) of the document titled Items and Services Subject to Consolidated Billing for the ESRD PPS located at the ESRD Payment website: http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage .  Some equipment and supplies are ESRD -related but are not used in other provider settings and will, therefore, never be used for reasons other than for the treatment of ESRD.  These equipment and supplies can be found listed in the second table (DME ESRD Su pply HCPCS Not Payable to DME Suppliers) of the document titled Items and Services Subject to Consolidated Billing for the ESRD PPS located at the ESRD Payment website:  http://www.cms.gov/ESRDPayment/50_Consolidated_Billing.asp#TopOfPage . DME suppliers will not be capable of billing and being paid for any of the supplies on this list using the AY modifier.   30.9  Payment of DMEPOS Items Based on Modifiers  (Rev. 3824, Issued: 08- 02-17; Effective: 07 -01-17, Implementation: 07- 03-17)  The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:    AU  Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;   AV  Item furnished in conjunction with a prosthetic device, prosthetic or orthotic;  and  AW  Item furnished in conjunction with a surgical  dressing.  Codes A4450 and A4452 are the only codes that have been identified at this time that would require use of all three of the above listed modifiers.  Providers must report these modifiers on claims for items identified by codes A4450 and A4452 that are furni shed on or after January 1, 2005. Modifier AU may also be applicable to code A4217. Providers must report modifier AU on claims for items identified by code A4217 that are furnished in conjunction with a urological, ostomy, or tracheostomy supply on or after January 1, 2005. Items identified by code A4217 that are furnished in conjunction with durable medical equipment are reported without a modifier.  In the future, other codes may be identified as codes that must be submitted with these modifiers. Medicar e contractors base payment for the codes A4217, A4450, and A4452 on the presence or absence of these modifiers.  Codes L8040 thru L8047 describe facial prostheses. Providers must report the following modifiers on claims for replacement of these items:   KM  Replacement of facial prosthesis  including  g new impression/moulage;  and  KN  Replacement  of facial prosthesis using previous master  model.   Providers must report these modifiers on claims for replacement of items identified by codes L8040 thru L8047 that are furnished on or after January 1, 2005. Medicare contractors base payment for the codes L8040 thru L8047 on the presence of these modifier s. These modifiers are only used when the prostheses is being replaced.  In accordance with section 302(c) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the fee schedule update factors for 2004 thru 2008 for durable medical equipment (DME), other than items designated as class III devices by the Food and Drug Administration (FDA), are equal to 0 percent. The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule available on the above mentioned web site by presence of the KF modifier.  Elevating/stair climbing power wheelchairs are class III devices. Suppliers billing the DMERCs must submit claims for the base power wheelchair portion of this device using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims s ubmitted on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing featur e for this device should be billed using HCPCS code A9270. Regional home health intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair cl imbing wheelchairs with HCPCS code E1399. For claims with dates of service on or after January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code K0011 with modifier KF.  The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme . For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair  bases should be paid using the fee schedule amounts for K0011 without the KF modifier. Effective for claims with dates of service on or after January 1, 2005, HHAs must submit modifier KF along with the applicable HCPCS code for all DME items classified by the FDA as class III devices.  The following modifier was added to the HCPCS in 2007 as a placeholder modifier:    KU DMEPOS Item Subject to DMEPOS Competitive Bidding Program Number  3