(Medicare Claims Processing Manual)

The information shown on the certification must support the need for PEN supplies as billed.  A diagnosis must show a functional impairment that precludes the enteral patient from swallowing and the parenteral patient from absorbing nutrients.  Initial assigned claims with the following conditions are denied without development:    Inappropriate or missing diagnosis or functional impairment;   Estimated duration of therapy is less than 90 consecutive days;   Duration of therapy is not listed;   Supplies have not been provided;   Supplies were provided prior to onset date of therapy; and  Stamped physician's signature.   Unassigned claims are developed for missing or incomplete information.   A. Revised Certifications/Change in Prescription   A revised certification is required when:    There is a change in the attending physician's orders in the category of nutrients and/or calories prescribed;    There is a change by more than one liter in the daily volume of parenteral solutions;    There is a change from home- mix to pre -mix or pre -mix to home -mix parenteral solutions;    There is a change from enteral to parenteral or parenteral to enteral therapy; or    There is a change in the method of infusion (e.g., from gravity- fed to pump- fed).  The PEN payments are not adjusted unless a revised or renewed certification documents the necessity for the change.  Payment levels for the most current certification or recertification may not be changed unless a prescription change is documented by a new recertification.   The DME MAC may adjust the recertification schedule as needed.    100.2.3.1 - Scheduling and Documenting Recertifications of Medical Necessity for Oxygen  (Rev. 1, 10- 01-03)  Recertification scheduling and documentation requirements depend on the date when home oxygen therapy began.  DME MACs request the following information on all recertifications:   Date and results of the most recent arterial blood gas or oximetry tests prior to the recertification date;    Name of the provider conducting the most recent arterial blood gas or oximetry tests performed prior to the recertification date and the conditions under which this test were conducted; and    Estimated length of need for oxygen (Section B on the Form CMS -484).   DME MAC establish the schedule for recertifying the need for oxygen for patients beginning home oxygen therapy in accordance with the requirements below:   1. Recertifications   Group I:  Recertification requirements are to be determined by the DME MAC.  Group II:  If oxygen test results on the initial certification were in Group II, according to 1834(a)(5) of the Act, recertification of all oxygen patients must be performed within 90 days after initial certification for all patients who begin coverage after January 1, 1991, with an arterial blood gas r esult at or above a partial pressure of 55 mm Hg or an arterial oxygen saturation percentage at or above 89.  Repeat blood gas study must be performed between the 61st - 90th day of home oxygen therapy.  Retesting is required only if a claim for oxygen the rapy will be filed for the fourth or later months.  If recertification is due, DME MACs do not pay the next month's claim if the test was not performed during the required time frame.  If a qualifying test is not obtained between the 61st and 90th day of home oxygen therapy, but the patient continues to use  oxygen and a test is obtained at a later date, DME MAC instruct suppliers to use the date of the repeat test as the date of service on a subsequent claim, and if that test meets Group II criteria, they resume payments from that point of time.   2. New Orders - In the following situations, a new order must be obtained and kept on file by the supplier, but neither a new CMN nor a repeat blood gas study are required:    If the prescribed maximum flow rate changes but remains within one of the following categories: (a) less than 1 LPM, (b) 1- 4 LPM, (c) greater than 4 LPM    If the physician has initially specified a delivery system, and a change is made from one type of stationary system to another (i.e., concentrator, liquid, gaseous).   100.2.3.2 - HHA Recertification for Home Oxygen Therapy  (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  Section 1834(a)(5)  of the Act requires patients who receive home oxygen therapy and who at the time such services are initiated have an initial arterial blood gas value of 56 or higher or an initial oxygen saturation at or above 89 percent to be retested between 60 and 90 days after the start of oxygen therapy in order to continue to receive payment.  HHAs must initiate the request for the retesting as promptly as possible because the recertification at three months must reflect the results of an arterial blood gas or oxygen saturation test conducted between the 61st and 90th day of home oxygen therapy.  Payment for the fourth month of home oxygen therapy is possible only if the patient's attending physician certifies that retesting results establish the continuing medical necessity for the services.  The physician must certify based on the test of the patient's arterial blood gas value or oxygen saturation that there is a medical need for the patient to continue to receive oxygen therapy.   Value codes have been assigned for HHA reporting of the arterial blood gas and oxygen saturation.  HHAs report value code 58 or 59 on every initial bill for home oxygen therapy and on the fourth month's bill.  Information regarding the form locator numbers  that correspond to value codes is found in Chapter 25.  For patients receiving oxygen therapy, who are not under a plan of care (bill type 34X), HHAs obtain a physicians recertification of the retesting and maintain a copy in their files for verification.   For patients receiving oxygen therapy, who are under a plan of care (bill types 32X and 33X), HHAs obtain a physician's recertification of the retesting and reflect this on Form CMS -485 or CMS -486 for verification.  A/B MACs (HHH) do not continue to make payment where the HHA fails to have the patient retested to determine continuing need of oxygen therapy within the specified time frames.   100.2.3.3 - A/B MAC (HHH) or DME MAC  Review of Oxygen Certifications  (Rev. 1, 10- 01-03)  All claims with initial certifications calling for oxygen flow rates of more than 4 liters per minute must be reviewed before payment is authorized.   Items Requiring Special Attention    a. Oxygen Delivery or Supply Prescribed -  If the treating physician has specified the oxygen equipment to be supplied, A/B MACs (A) and (HHH) and DME MACs ensure that the equipment furnished is consistent with that prescribed.   b. Treating Physician Identification -  A/B MACs (A) and (HHH) and DME MACs must ensure that the CMN or Form CMS -484 has been signed by the treating physician.  A stamped signature is unacceptable.  The physician's identification number must be the Unique Phys ician Identification Number (UPIN).   100.3 - Limitations on DME MAC  Collection of Information  (Rev. 1, 10- 01-03) B-02-031  The Paperwork Reduction Act (PRA) of 1995 44 USC 3500, et seq. requires that the Director of the Office of Management and Budget approve any collections of information performed by or for the Federal Government unless the collection fits within exceptions  for audits and investigations.  Absent such approval, the collection violates the PRA and agencies may not hold the public to the requirement.  Therefore, DME MACs must adhere to the following:   1. Power operated vehicles additional documentation requirements   A Certificate of Medical Necessity (CMN) must accompany initial claims for power operated vehicles (POV).  Except during the course of audits and investigations, DME MACs must not require that additional documentation accompany all POV claims.  DME MACs ma y continue requesting information during the course of audits and investigations and when developing individual claims on either a pre - or a post -payment basis.  If DME MACs choose to conduct such investigations, they must follow the guidelines in the Program Integrity Manual, Chapter 3.  2. Power wheelchair additional documentation requirements re: make and model name/number   There must be no requirement that all claims for power wheelchairs include the make and model name/number of the wheelchair separate from the claim or the CMN.   The CMN, an OMB approved information collection form, can be used to collect this information.  Specifically, DME MACs can require that the make and model name/ number of the power wheelchair be included in Section C of the CMN.  Section C requires the supplier to include a narrative description of the items, options and accessories ordered.   3. Power wheelchair additional documentation requirements re: functional abilities   There must be no requirement for suppliers to submit additional documentation to describe a beneficiary's medical condition and functional abilities when the supplier bills for a higher level of equipment than previously supplied.  While it is appropriate to avoid paying for duplicate equipment, it is inappropriate to require this documentation for all claims for "higher level equipment."  DME MACs may choose to perform pre - or post - payment probe samples to review these types of cla ims individually in order to determine medical necessity.  If DME MACs choose to conduct such investigations, they must follow the guidelines in the Program Integrity Manual, Chapter 3.   100.4 - Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physicians Order  (Rev. 1368:  Issued:  11- 02-07; Effective:  05 -23-08; Implementation:  04 -07-08)  Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription f rom the   For Coordination of Benefit purposes, DMEPOS suppliers shall use the modifier EY (no physician or other licensed health care provider order for this item or service) and report their own name and National Provider Identifier (NPI) in the Ordering/Referring Provider Name fields on claims submitted on or after May 23, 2008 to secure a Medicare denial.   If the supplier has obtained a physician order for some, but not all, of the items provided to a particular beneficiary, the supplier must submit a separate claim for the items with no physician order.   110 - General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies  (Rev. 330, Issued: 10- 22-04, Effective: 01 -01-05, Implementation: 04- 04-05)  Part B suppliers and providers other than Home Health Agencies (HHAs) must bill DMEPOS to the DME MAC, except claims for implanted DME.  Implanted DME and supplies for the implanted equipment are billed to the A/B MAC (B).   Suppliers and providers must have a supplier billing number issued by the National Supplier Clearinghouse (NSC) prior to billing the DME MAC.  Institutional providers bill their A/B MAC (A) for prosthetics and orthotics devices and supplies.  Generally, Medicare does not pay for DME in a facility.  For hospital outpatient DME, bills go to the appropriate DME MAC.  DMEPOS provided under a home health plan of care may be billed either by the HHA or by the supplier (including the HHA with a supplier number if the HHA prefers to bill that way) to the DME MAC.  If the HHA chooses to bill to the A/B MAC (HHH), the HHA includes the DME on the PPS claim (32x or 33x).  If the beneficiary is not under a plan of care and receives DMEPOS from a HHA, the agency uses bill type 34x.  Beneficiary Submitted Claims must contain an enrolled Medicare Supplier Number.   110.1 - Billing/Claim Formats (Rev. 2993, Effective: ASC X12 -  01-01-12, ICD -10 - Upon Implementation of ICD -10; Implementation: ASC X12 -  08-25-14, ICD -10 - Upon Implementation of ICD -10)  The DME MAC and the A/B MAC (B) are billed on the ASC X12 837 professional claim format or if permissible Form CMS -1500.  The A/B MAC (A) (including the A/B MAC (HHH)) is billed on the ASC X12 837 institutional claim format or if permissible Form CMS -1450.   Note that the ASC X12 formats support reporting of the CMNs in the FRM segment   The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and related coordination of benefits (COB).