May 1, 2009, Home Health & Hospice Medicare A Newsline - CGS

Medicare Payment Policy Publications—Available in Print FormatThe following Medicare payment policy publications are now available in print format from the Centers forMedicare & Medicaid Services (CMS) Medicare Learning Network. To place your order, visithttp://www.cms.hhs.gov/MLNGenInfo/, scroll down to “Related Links Inside CMS” and select “MLNProduct Ordering Page.”• Hospice Payment System Fact Sheet (revised January 2009), which provides general informationabout the Medicare hospice benefit including coverage of hospice services, certification requirements,election periods, and how payment rates are set.• Home Health Prospective Payment System Fact Sheet (revised December 2008), which providesinformation about coverage of home health services and elements of the Home Health ProspectivePayment System.• Medicare Physician Fee Schedule Fact Sheet (revised January 2009), which provides generalinformation about the Medicare Physician Fee Schedule.• Hospital Outpatient Prospective Payment System Fact Sheet (revised January 2009), whichprovides general information about the Hospital Outpatient Prospective Payment System, ambulatorypayment classifications, and how payment rates are set.ICD-10-CM/PCS Medicare Learning Network Publication and FAQs Now AvailableThe “General Equivalence Mappings - ICD-9-CM To and From ICD-10-CM and ICD-10-PCS" Fact Sheet(March 2009), which provides information and resources regarding the General Equivalence Mappings thatwere developed as a tool to assist with the conversion of International Classification of Diseases, 9thEdition, Clinical Modification (ICD-9-CM) codes to International Classification of Diseases, 10th Edition(ICD-10) and the conversion of ICD-10 codes back to ICD-9-CM, is now available in downloadable formatat http://www.cms.hhs.gov/MLNProducts/downloads/ICD-10_GEM_factsheet.pdf on the Centers forMedicare & Medicaid Services (CMS) Medicare Learning Network. The General Equivalence Mappingsinformation discussed in this fact sheet has also been posted in the CMS Frequently Asked Questionsdatabase at: https://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?p_sid=l2s5ZoujHome Health & Hospice May 1, 2009 2Medicare A Newsline Vol. 16, No. 8

National Provider Conference Call—ICD-10-CM/PCS Implementation and GeneralEquivalence Mappings (Crosswalks)Providers may now register for the Centers for Medicare & Medicaid Services' ICD-10-CM/PCSImplementation and General Equivalence Mappings (Crosswalks) National Provider Conference Call thatwill be conducted on May 19, 2009, from 1:00 p.m. - 2:30 p.m. Eastern Daylight Time.This conference call will include a discussion of the following topics:• An overview of the ICD-10 final rule, which requires the implementation of ICD-10-CM/PCS onOctober 1, 2013;• The differences between ICD-9-CM and ICD-10-CM/PCS codes;• The use of the General Equivalence Mappings that have been created to assist in converting policies,edits, and trend data from ICD-9-CM to ICD-10-CM/PCS; and• The resources that are available to assist in planning for the transition from ICD-9-CM to ICD-10-CM/PCS.Conference call discussion materials and registration information can be accessed at:http://www.cms.hhs.gov/ICD10/07a_2009_CMS_Sponsored_Calls.aspResponse to Public Comments on the Revised OASIS-CAs a result of the latest public comment period regarding Outcome and Assessment Information Set(OASIS-C), the Centers for Medicare & Medicaid Services (CMS) is providing the Agency's responses topublic comments and concerns for industry's reference.These responses can be found at http://www.cms.hhs.gov/HomeHealthQualityInits/06_OASISC.asp underthe “Downloads” section on the CMS Web site.REMINDER: Durable Medical Equipment, Prosthetics, Orthotics and Supplies(DMEPOS) Supplier AccreditationTime is Running Out - Deadline is September 30, 2009Time is running out for suppliers of durable medical equipment, prosthetics, orthotics and supplies(DMEPOS) who bill Medicare under Part B to obtain accreditation by the September 30, 2009, deadline orrisk having their Medicare Part B billing privileges revoked on October 1, 2009. While the accreditationHome Health & Hospice May 1, 2009 3Medicare A Newsline Vol. 16, No. 8

Provider Action NeededAll Medicare physicians, providers, and suppliers, as well as those who are considering applying toparticipate in the program should be aware of the new rule and of upcoming changes to the Medicareenrollment process.BackgroundCR 6310 implements regulatory changes found in the CY 2009 Medicare Physician Fee Schedule final rulewith comment (CMS-1403-FC). Significant changes are summarized below.Effective date of Medicare billing for physicians, certain non-physician practitioners, and Physicianand Non-Physician Practitioner Organizations• Carriers and A/B MACs will establish the effective date of Medicare billing privileges (see 42 CFR424.520(d)) for physicians, non-physician practitioners, and physician or non-physician practitionerorganizations. Physicians, non-physician practitioners and physician and non-physician practitionerorganizations will no longer be allowed to establish retrospective Medicare effective billing dates.• Carriers and A/B MACs will establish an effective date of Medicare billing privileges for the followingindividuals and organizations: physicians, physician assistants, nurse practitioners, clinical nursespecialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers,clinical psychologists, registered dietitians or nutrition professionals, and physician and non-physicianpractitioner organizations (e.g., clinics/group practices).• The effective date of Medicare billing privileges for the individuals and organizations identified above isthe later of the date of filing or the date they first began furnishing services at a new practice location.Note: The date of filing for Internet-based Provider Enrollment, Chain and Ownership System (PECOS)applications for these individuals and organizations is the date that the contractor received an electronicversion of the enrollment application and a signed certification statement that were both processed tocompletion.• The individuals and organizations identified above may, however, retrospectively bill for services when:• The supplier has met all program requirements, including state licensure requirements; and• The services were provided at the enrolled practice location for up to—o 30 days prior to their effective date if circumstances precluded enrollment in advance ofproviding services to Medicare beneficiaries; oro 90 days prior to their effective date if a Presidentially-declared disaster under the Robert T.Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§5121-5206 (Stafford Act)precluded enrollment in advance of providing services to Medicare beneficiaries.Timeframes for reporting changes of information• Physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurseanesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, registereddietitians or nutrition professionals, and organizations (e.g., group practices) consisting of any of thecategories of individuals identified in this paragraph; the following changes must be reported within 30days:• A change of ownership;• A final adverse action; or• A change in practice location.• If an individual or organization identified above does not comply with the reporting requirementsrelating to, respectively, final adverse actions and practice location changes, the supplier may beassessed an overpayment back to the date of the final adverse action or change in practice location.Home Health & Hospice May 1, 2009 5Medicare A Newsline Vol. 16, No. 8

Application rejections and denials for physician and certain non-physician practitioner applications• Carriers and A/B MACs will deny, rather than reject, incomplete applications submitted by physicians,non-physician practitioners, and physician or non-physician practitioner organizations.• This change will allow the individuals and organizations identified above to preserve their effective dateof filing by submitting a corrective action plan or an appeal and submitting the missinginformation/documentation to allow the carrier or A/B MAC to adjudicate the enrollment application tocompletion.Revocation effective dates• A revocation based on a: (1) Federal exclusion or debarment, (2) felony conviction, (3) licensesuspension or revocation, or (4) determination that the provider or supplier is no longer operational, iseffective with the date of the exclusion, debarment, felony conviction, license suspension or revocation,or the date that CMS or its contractor determined that the provider or supplier is no longer operational.• Any physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurseanesthetist, certified nurse-midwife, clinical social worker, clinical psychologist, registered dietitian ornutrition professional, organization (e.g., clinic/group practices) consisting of the individuals previouslyidentified, or Independent Diagnostic Testing Facility (IDTF) who/that is revoked from the Medicareprogram must, within 60 calendar of the effective date of the revocation, submit all claims for items andservices furnished.Requirements for maintaining ordering and referring documentation• Carriers or A/B MACs may revoke the billing privileges of any provider or supplier that fails to complywith Medicare’s ordering and referring documentation requirements as specified in 42 CFR 424.5216(f).• Such revocation is also possible in cases where the physician or non-physician practitioner fails tomaintain written ordering and referring documentation for seven (7) years from the date of service.• Off-site or electronic storage of the ordering and referring documentation described in 42 CFR§424.516(f) is not precluded, as long as these records are readily accessible and retrievable.Other changes• Final adverse action is defined.Additional InformationThe official instruction (CR 6310) issued to your carrier, FI, and A/B MAC, regarding this change may beviewed at http://www.cms.hhs.gov/transmittals/downloads/R289PI.pdf on the CMS Web site.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.Home Health & Hospice May 1, 2009 6Medicare A Newsline Vol. 16, No. 8

Internet-Based Medicare Enrollment is Available in All States and the District ofColumbia for Medicare Provider and Supplier OrganizationsIt's Fast, Secure, and Easy to UseNow there is a better way for provider and supplier organizations to enroll in Medicare or make a change totheir Medicare enrollment information. The Centers for Medicare & Medicaid Services (CMS) announcesthe availability of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to providerand supplier organizations. They may use Internet-based PECOS to enroll in Medicare, make a change intheir Medicare enrollment information, view their existing Medicare enrollment information, voluntarilywithdraw from the Medicare program, or check on the status of an Internet-submitted Medicare enrollmentapplication.Internet-based PECOS is already available to physicians and non-physician practitioners in all 50 states andthe District of Columbia. (CMS expects to make Internet-based PECOS available to suppliers of durablemedical equipment, prosthetics, orthotics, and supplies (DMEPOS) in the future.)FastBy submitting an initial Medicare enrollment application through Internet-based PECOS, a provider orsupplier organization's enrollment application can be processed as much as 50 percent faster than by paper.This means that it will take less time to enroll or make a change in an existing enrollment record.For information about the types of changes that enrolled Medicare provider and supplier organizations mustreport, go to the “Downloads” section of the Medicare provider/supplier enrollment page:www.cms.hhs.gov/MedicareProviderSupEnrollSecureInternet-based PECOS meets all required Government security standards in terms of data entry, datatransmission, and the electronic storage of Medicare enrollment information. Only individuals whoseidentities have been verified by CMS and who have been approved by a provider or supplier organization'sAuthorized Official may use Internet-based PECOS on behalf of that provider or supplier organization. ThePECOS User IDs and passwords that these individuals establish will protect the access to the given provideror supplier organization's Medicare enrollment information. PECOS users should change their passwordsfrequently-at least once a year. By safeguarding their User IDs and passwords, PECOS users will be takingan important step in protecting the provider or supplier organization's Medicare enrollment information.CMS does not disclose Medicare provider or supplier enrollment information to anyone except whenauthorized or required to do so by law.Easy to UseInternet-based PECOS is a scenario-driven application process with front-end editing capabilities and builtinhelp screens. The scenario-driven application process ensures that provider and supplier organizationscomplete and submit only the information necessary to facilitate the action they wish to take. The CMSExternal User Services (EUS) Help Desk (1-866-484-8049) is available and staffed to respond to questionsabout using Internet-based PECOS, such as navigating through the screens, and to receive reports ofsystems problems as noted by users.Home Health & Hospice May 1, 2009 7Medicare A Newsline Vol. 16, No. 8

PECOS will guide the user through each of these processes. (Internet-based PECOS enables the user toprint a copy of the enrollment application, if desired. We recommend this be done so the provider orsupplier organization has a copy for its records.)As part of the enrollment application submittal process, the AO of the provider or supplier organizationmust sign and date the 2-page Certification Statement that the user will print from Internet-based PECOS.The user must mail the signed and dated Certification Statement, along with any required supporting paperdocumentation, to the designated Medicare contractor. The Medicare contractor will not begin processingthe application that was submitted over the Internet until it has received the signed and dated CertificationStatement.Limitations of Internet-based PECOSAt this time, Internet-based PECOS is unable to handle changes of ownership applications from providerand supplier organizations. Therefore, changes of ownership must be submitted using the paper Medicareenrollment application (CMS-855) process. Internet-based PECOS will be able to accommodate changes ofownership at a future date.Additional InformationSeveral documents about Internet-based PECOS for provider and supplier organizations will soon beavailable in the “Downloads” section of the Medicare provider/supplier enrollment Web page:www.cms.hhs.gov/MedicareProviderSupEnrollInstructions on Utilizing ANSI X12 837 Institutional CAS segments for MedicareSecondary Payer (MSP) Part A Claims—RescindedThe Centers for Medicare & Medicaid Services (CMS) has issued notification that the Medicare LearningNetwork (MLN) Matters article entitled, “Instructions on Utilizing ANSI X12 837 Institutional CASsegments for Medicare Secondary Payer (MSP) Part A Claims,” which was published in the March 1, 2009,Home Health & Hospice Medicare A Newsline has been rescinded. This MLN Matters article and otherCMS articles can be found on the CMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM6275 Revised Related Change Request (CR) #: 6275Related CR Release Date: December 19, 2008 Effective Date: July 1, 2009Related CR Transmittal #: R63MSP Implementation Date: July 6, 2009Note: On March 27, 2009, the Centers for Medicare & Medicaid Services (CMS) rescinded CR 6275 andreplaced it with CR 6426. As a result, this article is replaced by article MM6426, which is available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6426.pdf on the CMS Web site. TheMM6426 article can also be found in this Newsline, immediately following this article.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.Home Health & Hospice May 1, 2009 9Medicare A Newsline Vol. 16, No. 8

Instructions on Utilizing 837 Institutional Claim Adjustment Segments (CAS) forMedicare Secondary Payer (MSP) Part A Claims (This CR Rescinds and FullyReplaces CR 6275)The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare LearningNetwork (MLN) Matters article. This MLN Matters article and other CMS articles can be found on theCMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM6426 Related Change Request (CR) #: 6426Related CR Release Date: March 27, 2009 Effective Date: July 1, 2009Related CR Transmittal #: R66MSP Implementation Date: July 6, 2009Provider Types AffectedProviders submitting claims to Medicare contractors (fiscal intermediaries (FIs), Medicare administrativecontractors (MACs), and/or regional home health intermediaries (RHHIs)) for services provided toMedicare beneficiaries.What You Need to KnowCR 6426, from which this article is taken, alerts your Medicare Part A contractors (FIs, MACs, and RHHIs)and their associated systems to the changes they will need to follow when calculating MSP paymentamounts from incoming American National Standards Institute (ANSI) ASC X12N 837 4010-A1 claimstransactions. It specifically addresses their use of data reported in ANSI ASC X12N 837 institutional CASsegments for Medicare Secondary Payer (MSP) Part A Claims.CR 6426 only affects providers submitting Part A claims. It is important for such providers to code theCAS segments of their claims accurately so that Medicare will make the correct MSP payments. See the“Background” and “Additional Information” sections of this article for further details regarding thesechanges.BackgroundThe MSP provisions apply to situations where Medicare is not the beneficiary’s primary insurance.Medicare’s secondary payment for Part A MSP claims is based on:• Medicare-covered charges, or the amount the physician (or other supplier) is Obligated to Accept asPayment in Full (OTAF), whichever is lower;• What Medicare would have paid as the primary payer; and• The primary payer(s) payment.The Health Insurance Portability and Accountability Act (HIPAA) requires that Medicare, and all otherhealth insurance payers in the United States, comply with the Electronic Data Interchange (EDI) standardsfor health care as established by the Secretary of Health and Human Services. The X12N 837implementation guides have been established as the standards of compliance for claim transactions and theimplementation guides for each transaction are available at http://www.wpc-edi.com on the Internet.Home Health & Hospice May 1, 2009 10Medicare A Newsline Vol. 16, No. 8

This article is to remind you to include CAS segment related group codes, claim adjustment reason codesand associated adjustment amounts on your MSP 837 claims you send to your Medicare contractor.Medicare contractors need these adjustments to properly process your MSP claims and for Medicare tomake a correct payment. This includes all adjustments made by the primary payer, which, for example,explains why the claim’s billed amount was not fully paid.The instructions detailed by CR 6426 are necessary to ensure:• Medicare complies with HIPAA transaction and code set requirements;• Providers code for the CAS segments claims to reflect any adjustments made by primary payers; and• MSP claims are properly calculated by Medicare contractors (and their associated shared systems) usingpayment information derived from the incoming 837 Institutional claim.Adjustments made by the payer are reported in the CAS segment on the 835 electronic remittance advice(ERA) or on hardcopy remittance advices. Providers must take the CAS segment adjustments (as found onthe 835 ERA) and report these adjustments on the 837 (unchanged) when sending the claim to Medicare forsecondary payment.Note: If you are obligated to accept, or voluntarily accept, an amount as payment in full from theprimary payer (a.k.a. your contractual obligation), you must identify this amount as Value Code 44 inthe 2300 HI Value Information. This amount is also known as the Obligated to Accept as Payment inFull (OTAF) amount. Details of the MSP payment provisions may be found in the CMS MedicareSecondary Payer Manual (CMS Pub. 100-05) and in the federal regulations at 42 CFR 411.32 and411.33.Additional InformationYou can find the official instruction (CR 6426) issued to your FI, RHHI, or MAC by visitinghttp://www.cms.hhs.gov/transmittals/downloads/R66MSP.pdf on the CMS Web site. You will find theupdated Medicare Secondary Payer (MSP) Manual, (CMS Pub 100-05) Ch. 5 (Contractor PrepaymentProcessing Requirements), §40.7.3.2 (Medicare Secondary Payment Part A Claims Determination forServices Received on 837 Institutional Electronic or Hardcopy Claims Format) as an attachment to that CR.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents. CPT only copyright 2008 American Medical Association.Home Health & Hospice May 1, 2009 11Medicare A Newsline Vol. 16, No. 8

New Common Working File (CWF) Medicare Secondary Payer (MSP) Type forWorkers' Compensation Medicare Set-aside Arrangements (WCMSAs), to StopConditional Payments—RevisedThe Centers for Medicare & Medicaid Services (CMS) has issued a revision to the Medicare LearningNetwork (MLN) Matters article entitled, “New Common Working File (CWF) Medicare Secondary Payer(MSP) Type for Workers' Compensation Medicare Set-aside Arrangements (WCMSAs), to StopConditional Payments,” which was published in the February 1, 2009, Home Health & Hospice Medicare ANewsline. This MLN Matters article and other CMS articles can be found on the CMS Web site at:http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM5371 Revised Related Change Request (CR) #: 5371Related CR Release Date: March 20, 2009 Effective Date: July 1, 2009Related CR Transmittal #s: R1703CP, Implementation Date: July 6, 200965MSPNote: This article was revised on March 20, 2009, to reflect a revised transmittal related to CR 5371. TheCR was changed to clarify some of the requirements. The CR release date, transmittal numbers (see above),and the Web address for accessing that transmittal were changed. All other information remains the same.Provider Types AffectedPhysician, providers and suppliers who bill Medicare contractors (carriers, including durable medicalequipment Medicare administrative contractors (DME MACs), fiscal intermediaries (FIs), includingregional home health intermediaries (RHHIs), and Part A/B Medicare administrative contractors (A/BMACs)) for services related to workers’ compensation liability claims.What You Need to KnowIn order to prevent Medicare’s paying primarily for future medical expenses that should be covered byworkers’ compensation Medicare set-aside arrangements (WCMSA), CR 5371, from which this article istaken, provides your Medicare contractors with instructions on the creation of a new MSP code inMedicare’s claims processing systems. With the creation of the new MSP code, CMS will have thecapability to discontinue conditional payments for diagnosis codes related to such settlements.BackgroundA Workers’ Compensation Medicare Set-aside Arrangement (WCMSA) is an allocation of funds from aworkers’ compensation (WC) related settlement, judgment or award that is used to pay for an individual’sfuture medical and/or future prescription drug treatment expenses related to a workers’ compensation injury,illness or disease that would otherwise be reimbursable by Medicare. The CMS has a review process forproposed WCMSA amounts and updates its CWF system in connection with its determination regarding theproposed WCMSA amount. For additional information regarding WCMSAs, visithttp://www.cms.hhs.gov/WorkersCompAgencyServices on the CMS Web site.The CMS has determined that establishing a new MSP code in its systems, which identifies situations whereCMS has reviewed a proposed WCMSA amount, will assist Medicare contractors in denying payment foritems or services that should be paid out of an individual’s WCMSA funds. The creation of a new MSPcode specifically associated with the WCMSA situation will permit Medicare to generate an automateddenial of diagnosis codes associated with the open WCMSA occurrence.Home Health & Hospice May 1, 2009 12Medicare A Newsline Vol. 16, No. 8

When denying a claim because of these edits, your Medicare contractor will notify the beneficiary usingMedicare Summary Notice (MSN) message 29.33 - Your claim has been denied by Medicare because youmay have funds set aside from your settlement to pay for your future medical expenses and prescriptiondrug treatment related to your injury(ies).In addition, Medicare will use Reason Code 201, Group Code PR, and Remark Code MA01, on outboundclaims and/or remittance advice transactions when Medicare denies claims based on the WCMSA presence.Also, on 271 inquiry reply transactions, Medicare will reflect the WCMSA on the 271 response with “EB”followed by the qualifier WC.Additional InformationYou can find the official instruction (CR 5371) issued to your Medicare contractor in two transmittals:http://www.cms.hhs.gov/Transmittals/downloads/R1703CP.pdf andhttp://www.cms.hhs.gov/Transmittals/downloads/R65MSP.pdf on the CMS Web site.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.Payment for Maintenance and Servicing of Certain Oxygen Equipment as a Result ofthe Medicare Improvements for Patients and Providers Act (MIPPA) of 2008The Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare LearningNetwork (MLN) Matters article. This MLN Matters article and other CMS articles can be found on theCMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM6404 Related Change Request (CR) #: 6404Related CR Release Date: March 20, 2009 Effective Date: July 1, 2009Related CR Transmittal #: R461OTN Implementation Date: July 6, 2009Provider Types AffectedSuppliers submitting claims to Medicare contractors (regional home health intermediaries (RHHIs), and/ordurable medical equipment Medicare administrative contractors (DME MACs)) for oxygen servicesprovided to Medicare beneficiaries.Provider Action NeededThis article is based on CR 6404 which provides additional instructions regarding maintenance andservicing of oxygen concentrators and transfilling equipment resulting from implementation of Section144(b) of the MIPPA. Earlier instructions pertaining to the MIPPA changes for oxygen equipment wereHome Health & Hospice May 1, 2009 13Medicare A Newsline Vol. 16, No. 8

issued as part of CRs 6297 and 6296 and the MLN Matters articles for these CRs are available athttp://www.cms.hhs.gov/MLNMattersArticles/downloads/mm6297.pdf andhttp://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6296.pdf , respectively, on the CMS Website.BackgroundSection 144(b) of the MIPPA repeals the transfer of ownership provision established by the DeficitReduction Act (DRA) of 2005 for oxygen equipment and establishes new payment rules and supplierresponsibilities after the 36 month payment cap. Section 144(b) of MIPPA mandates payment forreasonable and necessary maintenance and servicing of oxygen equipment furnished after the 36-monthrental cap. The 36-month cap applies to stationary and portable oxygen equipment furnished on or afterJanuary 1, 2006; therefore, the 36-month cap may end as early as January 1, 2009, for beneficiaries usingoxygen equipment on a continuous basis since January 1, 2006.CMS has determined that, for services furnished during calendar year 2009, it is reasonable and necessary tomake payment for periodic, in-home visits by suppliers to inspect certain oxygen equipment and providegeneral maintenance and servicing after the 36-month rental cap. These payments only apply to equipmentfalling under HCPCS codes E1390, E1391, E1392, and K0738, and only when the supplier physicallymakes an in-home visit to inspect the equipment and provide any necessary maintenance and servicing.Payment may be made every 6 months, beginning 6 months after the 36-month rental cap (as early as July 1,2009, in some cases), and the allowed payment amount for each visit is equal to the lesser of the supplier’sactual charge or the 2009 fee for code K0739, multiplied by 2, for the state in which the in-home visit takesplace.Key Points• Medicare contractors will pay claims with dates of service from July 1, 2009, through December 31,2009, for maintenance and servicing for oxygen concentrators no more often than every 6 monthsbeginning 6 months after the end of the 36th month of continuous use when billed with one of thefollowing HCPCS codes and modifiers:• E1390MS;• E1391MS; or• E1392MS.• In addition to payment for maintenance and servicing for stationary oxygen concentrators (HCPCScodes E1390 or E1391) Medicare contractors will pay claims with dates of service from July 1, 2009,through December 31, 2009, for maintenance and servicing for portable oxygen transfilling equipment(HCPCS code K0738) no more often than every 6 months beginning 6 months after the end of the 36thmonth of continuous use. HCPCS code K0738 must be billed with the HCPCS modifier “MS” to obtainsuch payment.• Medicare contractors will not pay for maintenance and servicing of both a portable oxygen concentrator(E1392MS) and portable oxygen transfilling equipment (K0738MS).• If maintenance and servicing is billed for a column I code, additional payment for the maintenance andservicing of any of the column II codes shall not be made:Column IE1390 MSE1391 MSE1392 MSK0738 MSColumn IIE1391 MS, E1392 MSE1390 MS, E1392 MSE1390 MS, E1391 MS, K0738 MSE1392 MSHome Health & Hospice May 1, 2009 14Medicare A Newsline Vol. 16, No. 8

• For the oxygen equipment codes E1390, E1391, E1392, and K0738, billed with the modifier “MS”,Medicare contractors will make maintenance and servicing payments for covered services equal to thelesser of the supplier’s actual charge or 2 units of K0739 every 6 months.• Medicare contractors will deny claims for maintenance and servicing of oxygen equipment when billedwith the HCPCS codes E0424, E0439, E0431, E0434, E1405 or E1406 and the “MS” modifier.Additional InformationIf you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.The official instruction, CR 6404, issued to your Medicare DME MAC, and/or RHHI regarding this changemay be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R461OTN.pdf on the CMS Web site.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.News from CMS for Home Health ProvidersDurable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) SupplierAccreditation—RevisedThe Centers for Medicare & Medicaid Services (CMS) has issued a revision to the Special Edition (SE)Medicare Learning Network (MLN) Matters article entitled, “Durable Medical Equipment, Prosthetics,Orthotics and Supplies (DMEPOS) Supplier Accreditation,” which was published in the April 1, 2009,Home Health & Hospice Medicare A Newsline. This Special Edition MLN Matters article and other CMSarticles can be found on the CMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: SE0903 Revised Related Change Request (CR) #: N/ARelated CR Release Date: N/A Effective Date: March 1, 2009Related CR Transmittal #: N/AImplementation Date: N/ANote: This article was revised on March 19, 2009, to change the Web links that were not working to accessthe DMEPOS Quality Standards and the list of CMS-approved deemed accreditation organizations. Allother information is unchanged.Provider Types AffectedAll providers and suppliers that furnish Medicare Part B durable medical equipment (DME), prostheticdevices, prosthetic or orthotic items, and medical supplies to Medicare beneficiariesHome Health & Hospice May 1, 2009 15Medicare A Newsline Vol. 16, No. 8

Provider Action NeededSTOP – Impact to YouDMEPOS (durable medical equipment, prosthetics, orthotics and supplies) providers and suppliers enrolledin the Medicare Part B program are required to obtain accreditation by September 30, 2009.CAUTION – What You Need to KnowIn order to retain or obtain a Medicare Part B billing number, all DMEPOS providers and suppliers (exceptfor exempted professionals and other persons as specified by the Secretary of the Department of Health andHuman Services as noted below in this article) must comply with the Medicare program’s supplier standardsand quality standards and become accredited. A DMEPOS supplier’s Medicare Part B billing privilegeswill be revoked on October 1, 2009, if the DMEPOS supplier fails to obtain accreditation by September 30,2009.GO – What You Need to DoDMEPOS providers and suppliers that have not yet done so should contact an accreditation organization(AO) right away to obtain information about the accreditation process and submit an accreditationapplication to the AO of their choosing. Suppliers can find a list of the deemed accrediting organizations athttp://www.cms.hhs.gov/MedicareProviderSupEnroll/Downloads/DeemedAccreditationOrganizations.pdfon the CMS Web site.BackgroundSection 302 of the Medicare Modernization Act of 2003 (MMA) added a new paragraph 1834(a)(20) to theSocial Security Act (the Act) that required the Secretary to establish and implement quality standards forsuppliers of DMEPOS. All suppliers that furnish such items or services set out at subparagraph1834(a)(20)(D) as the Secretary determines appropriate must comply with the quality standards in order toreceive Medicare Part B payments and to receive or retain a provider or supplier number.Covered Items and ServicesPursuant to subparagraph 1834(a)(20)(D) of the Act, the covered items and services are defined in Section1834(a)(13), Section 1834(h)(4) and Section 1842(s)(2) of the Act. The covered items and services include:• Durable Medical Equipment (DME);• Medical supplies;• Home dialysis supplies and equipment;• Therapeutic shoes;• Parenteral and enteral nutrient, equipment and supplies;• Blood products;• Transfusion medicine; and• Prosthetic devices, prosthetics, and orthotics.Non-Covered Items• Medical supplies furnished by home health agencies;• Drugs used with DME (inhalation drugs and drugs infused with a DME pump);• Implantable items and;• Other Part B drugs:• Immunosuppressive drugs• Anti-emetic drugs.Home Health & Hospice May 1, 2009 16Medicare A Newsline Vol. 16, No. 8

DMEPOS Quality StandardsThe quality standards, published athttp://www.cms.hhs.gov/MedicareProviderSupEnroll/Downloads/DMEPOSAccreditationStandards.pdf onthe CMS Web site, are separated into two sections and have three appendices as follows:• Section I includes the business standards that apply to all suppliers and focus on standards foradministration, financial management, human resource management, consumer services, performancemanagement, product safety and information management.• Section II contains service standards, including intake, delivery and setup, training and instruction ofthe beneficiary and/or their caregiver and follow-up service.• Appendix A addresses respiratory equipment, supplies and services.• Appendix B addresses manual wheelchairs and power mobility devices, including complexrehabilitation and assistive technology.• Appendix C addresses custom fabricated and custom fitted orthoses, prosthetic devices, external breastprostheses, therapeutic shoes and inserts and their accessories and supplies, and custom-made somatic,ocular and facial prostheses.Accreditation Deadline for DMEPOS SuppliersThe Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) required all DMEPOSsuppliers to meet quality standards for Medicare accreditation by September 30, 2009.Who Needs Accreditation?The September 30, 2009, accreditation deadline applies to all Medicare Part B enrolled providers andsuppliers of durable medical equipment, medical supplies, home dialysis supplies and equipment,therapeutic shoes, parenteral/enteral nutrition, transfusion medicine and prosthetic devices, prosthetics andorthotics. The accreditation deadline also applies to pharmacies, pedorthists, mastectomy fitters, orthopedicfitters/technicians and athletic trainers.As of March 1, 2008, new DMEPOS providers and suppliers submitting an enrollment application to theNational Supplier Clearinghouse (NSC), except those eligible professionals and other persons mentionedbelow, must be accredited prior to submitting the application. The NSC shall reject the enrollmentapplication unless the DMEPOS supplier demonstrates an approved accreditation.Who is Exempt?MIPPA stated that certain eligible professionals and other persons do not have to be accredited bySeptember 30, 2009, unless the Secretary determines that the quality standards are specifically designed toapply to such professionals and persons. In addition, those providers that were accredited prior to theenactment of MIPPA (July 15, 2008) will not have to undergo a re-accreditation process.The eligible professionals that are exempt from the September 30, 2009, accreditation deadline include thefollowing practitioners:• Physicians (as defined in Section 1861(r) of the Act);• Physical Therapists;• Occupational Therapists;• Qualified Speech-Language Pathologists;• Physician Assistants;• Nurse Practitioners;Home Health & Hospice May 1, 2009 17Medicare A Newsline Vol. 16, No. 8

• Clinical Nurse Specialists;• Certified Registered Nurse Anesthetists;• Certified Nurse-Midwives;• Clinical Social Workers;• Clinical Psychologists;• Registered Dietitians; and• Nutritional professionals.Additionally MIPPA allows the Secretary to specify “other persons” that are exempt from meeting theSeptember 30, 2009, accreditation deadline unless the Secretary determines that the quality standards arespecifically designed to apply to such other persons. At this time, these “other persons” are only defined asthe following practitioners:• Orthotists;• Prosthetists;• Opticians; and• Audiologists.Accreditation ProcessThe accreditation process takes an average of 6-7 months but may take up to 9 months to complete for aMedicare enrolled or new DMEPOS supplier that submits a complete application to an accreditingorganization (AO) and has no deficiencies to correct post onsite-survey.Pre-application Process• A DMEPOS supplier that wishes to become accredited should contact the AOs and obtain informationabout each organization’s accreditation process.• The supplier should review the information and choose the organization to which it will apply.• The AO will assist the supplier to determine what changes will be required to meet the accreditationstandards (e.g., modify existing services, practices, developing appropriate policies and procedures,develop an implementation plan, timeline, and training employees).• The supplier should apply for accreditation after the changes are in place or during implementation.Application Review and On-site Survey• The supplier submits a completed application to the AO with all the supporting documentation.• The AO reviews the application and documentation (verify licensures, organizational chart, etc.).• The on-site surveys are conducted minimally every 3 years and are unannounced.• The AO will determine whether to accredit the supplier based on the submitted data and the results ofthe on-site survey.Key PointsAll Medicare Part B enrolled DMEPOS providers and suppliers are required to obtain accreditation bySeptember 30, 2009.Home Health & Hospice May 1, 2009 18Medicare A Newsline Vol. 16, No. 8

DMEPOS suppliers who submitted a completed application to an accrediting organization on or beforeJanuary 31, 2009, will have their accreditation decision (either full accreditation or denied accreditation)on or before the September 30, 2009, deadline.DMEPOS suppliers submitting applications to an accrediting organization after January 31, 2009, may ormay not have their accreditation decision by the September 30, 2009, deadline.It takes an average of 6-7 months but could take as long as 9 months for a DMEPOS supplier to completethe accreditation process. Accordingly, DMEPOS suppliers should contact an accreditation organizationright away to obtain information about the accreditation process and submit an application.A DMEPOS supplier’s Medicare Part B billing privileges will be revoked on October 1, 2009, if theDMEPOS supplier fails to obtain accreditation by September 30, 2009.Note: The current delay in the DMEPOS Competitive Bidding Program has no impact on theSeptember 30, 2009, accreditation deadline.Accreditation Frequently Asked Questions (FAQs)1. Do the accrediting organizations have enough capacity to get everyone who applies at least 9months before September 30, 2009, accredited by the deadline?Yes. The AOs have increased surveyor staffing anticipating the additional workload. A DMEPOSsupplier should choose an AO based upon their deemed status, policies, procedures and the philosophyof the organization. CMS encourages suppliers to ask the AOs questions, such as, how long it takes tobecome accredited from application to accreditation decision. The time to become accredited can takeup to 9 months for some organizations.2. Who are the approved DMEPOS accrediting organizations?In November 2006, CMS approved (deemed) 10 national accreditation organizations that will accreditproviders and suppliers of DMEPOS as meeting new quality standards under Medicare Part B. Most ofthe accreditation organizations are authorized to accredit all major supplier types, and most will be ableto accredit both national and local suppliers, as well as mail order companies. A list of the CMSapproveddeemed accreditation organizations and information about the types of suppliers eachaccrediting organization is approved to accredit and how to contact a deemed accrediting organization isposted athttp://www.cms.hhs.gov/MedicareProviderSupEnroll/Downloads/DeemedAccreditationOrganizations.pdf onthe CMS Web site.3. Is accreditation transferable upon merger, acquisition or sale of a supplier?Accreditation cannot be transferred upon merger, acquisition or sale of a supplier. As specified in 42CFR 424.57 (c) (3), CMS, the NSC and the accrediting organization must be notified when a newDMEPOS location is opened.Home Health & Hospice May 1, 2009 19Medicare A Newsline Vol. 16, No. 8

4. If I have just recently received a survey by an accreditor, will I be subject to a site visit by arepresentative of the National Supplier Clearinghouse (NSC)?These actions are independent of one another. The accreditor checks quality standards. The NSC sitevisit concerns enforcing supplier standards. In many cases a new supplier will receive a site survey bythe AO and a site visit by the NSC.5. Is information transferred between the accreditor and NSC?Transfer of information between these two entities concerning their findings does occur. The NSCneeds to know if a supplier is accredited prior to issuing an enrollment number, thus they will need toverify the accreditation status.6. Will the accreditation survey efforts be coordinated with reenrollment efforts?Not at the present time. A supplier must meet both the NSC supplier standards and the accreditationrequirements on a continuous basis. We are not changing reenrollment dates and timeframes to matchsurvey timeframes.Additional InformationIf you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.There is additional information on the accreditation process athttp://www.cms.hhs.gov/MedicareProviderSupEnroll/03_DeemedAccreditationOrganizations.asp#TopOfPageon the CMS Web site.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.News from CMS for Hospice ProvidersHospice Cap Calculations Letters and Administrative AppealsThe Centers for Medicare & Medicaid Services (CMS) has provided the following Medicare LearningNetwork (MLN) Matters article. This MLN Matters article and other CMS articles can be found on theCMS Web site at: http://www.cms.hhs.gov/MLNMattersArticlesMLN Matters Number: MM6400 Related Change Request (CR) #: 6400Related CR Release Date: April 3, 2009 Effective Date: July 1, 2009Related CR Transmittal #: R1708CP Implementation Date: July 6, 2009Home Health & Hospice May 1, 2009 20Medicare A Newsline Vol. 16, No. 8

Provider Types AffectedHospice providers submitting claims to Medicare contractors (fiscal intermediaries (FIs), Part A/B Medicareadministrative contractors (A/B MACs), and/or regional home health intermediaries (RHHIs)) for servicesprovided to Medicare beneficiaries.Provider Action NeededThis article is based on CR 6400 which requires Medicare contractors to send each of their providers a letterwhich serves as a determination of program reimbursement, regardless of whether or not they haveexceeded a cap. The letter you receive will include the inpatient and aggregate cap calculation results.Additionally, it will include appeals language in every determination of program reimbursement letter. Ifyou have exceeded the cap, the letter will include a demand for repayment.BackgroundThe law governing payment for hospice care subjects hospice payments to two statutory caps:• A cap on payments for inpatient days, described in Section 1861(dd)(2)(A)(iii) of the Social SecurityAct; and• An aggregate cap on total payments, described in Section 1814(i)(2)(A)-(C).These statutory caps limit total hospice payments during a cap year. Payments in excess of either cap mustbe refunded. Currently, after the end of the cap year, the applicable contractor (RHHI, FI, or A/B MAC)computes both cap amounts, and determines the amount of program reimbursement for each hospiceprovider they serve.Important Information:The latest hospice cap amount for the cap year ending October 31, 2008, is $22,386.15. The hospice cap isdiscussed further in the Medicare Claims Processing Manual (CMS Pub. 100-04, Chapter 11 - ProcessingHospice Claims, §80.2) which is available at http://www.cms.hhs.gov/manuals/downloads/clm104c11.pdfon the CMS Web site. Your contractor (RHHI, FI, or A/B MAC) will issue a letter to notify you of theresults of the contractor’s cap calculations and to serve as your determination of program reimbursement. Ifthere is a cap overpayment, there will be an accompanying demand for repayment.Administrative Appeals:As indicated in section 418.311 of 42 CFR, if you believe that your payments have not been properlydetermined, you may request a review from the applicable contractor if the amount in controversy is $1,000or more, but less than $10,000, or from the Provider Reimbursement Review Board (PRRB) if the amount incontroversy is $10,000 or more. Appeal requests must be in writing and be filed within 180 days from thedate of the determination. Your appeal rights are discussed further in the Medicare Claims ProcessingManual (CMS Pub. 100-04, Chapter 11 - Processing Hospice Claims, §80.3), which is attached to CR 6400.Additional InformationThe official instruction, CR 6400, issued to your RHHI, FI or A/B MAC regarding this change may beviewed at http://www.cms.hhs.gov/Transmittals/downloads/R1708CP.pdf on the CMS Web site.If you have questions regarding this issue, refer to the “Contact Us” page of our Web site and select “PhoneUs” to call the Provider Contact Center.Disclaimer: This article was prepared as a service to the public and is not intended to grant rights or impose obligations. Thisarticle may contain references or links to statutes, regulations, or other policy materials. The information provided is onlyintended to be a general summary. It is not intended to take the place of either the written law or regulations. We encouragereaders to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of theircontents.Home Health & Hospice May 1, 2009 21Medicare A Newsline Vol. 16, No. 8

CMS Proposes Medicare Hospice Fiscal Year 2010 Wage IndexProposal Includes Physician Narrative for Certification of IllnessThe Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update the MedicareHospice Wage Index for fiscal year (FY) 2010.Payments to Medicare participating hospices are estimated to decrease by approximately 1.1 percent in FY2010. The decrease in the hospice payments is the net result of a 3.2 percent reduction in payments due tothe phase-out of a temporary adjustment used in calculating the wage index, partially offset by an estimated2.1 percent increase in the hospital market basket indicator of costs.The elimination of this adjustment with a 2-year phase-out would result in more accurate payments andsaves Medicare $2.9 billion over five years. The phase-out would include a 75 percent reduction for FY2010 and ultimately eliminate it in FY 2011. As such, hospice expenditures are estimated to be about $13billion in 2010 for more than 3,000 for-profit and not-for-profit hospices across the country.The Medicare Payment Advisory Commission (MedPAC) reports that through 2015, hospice expendituresare projected to grow at a rate that outpaces those projected for hospitals, skilled nursing facilities, physicianservices or home health care.In the Medicare Hospice Wage Index FY 2009 final rule, CMS laid out a plan to phase-out the budgetneutrality adjustment factor (BNAF) over a three year period, with the first BNAF reduction of 25 percent inthe fiscal year 2009 wage index. With the passage of the American Recovery and Reinvestment Act,Congress suspended the BNAF reduction set for 2009. However, the legislation did not affect FYs 2010and 2011. CMS plans to reduce the BNAF by 75 percent in FY 2010 and ultimately eliminate it in FY2011.The BNAF was implemented in 1997 as part of an effort to change from an outdated wage index to a morecurrent and accurate method for determining hospice payments. In order to minimize disruption to servicesthis special adjustment was applied.This proposed regulation would bring the Medicare hospice wage index more in line with that used forhome health agencies, while maintaining the fiscal integrity of Medicare and allowing continued access toservices for its beneficiaries. Both hospices and home health agencies are home-based benefits, whichcompete in the same labor markets.The rule also proposes to adopt a MedPAC recommendation that would increase accountability in thephysician hospice certification and recertification process. MedPAC found an increasing proportion ofhospice patients with stays exceeding 180 days and significant variation in hospice length of stay.Therefore, CMS is proposing that hospice physicians who certify or recertify a beneficiary as terminally illwrite a short narrative on the certification form. The narrative would briefly describe the clinical evidencesupporting a life expectancy of six months or less.Home Health & Hospice May 1, 2009 22Medicare A Newsline Vol. 16, No. 8

BackgroundThe Medicare hospice benefit is intended to assist terminally ill patients, with a prognosis of six months orless if the disease runs its normal course, to remain in their homes. The focus of care shifts from curative topalliative care for relief of pain and symptom management. The law requires that hospice physicians certifythat the patient is terminally ill, with a life expectancy of six months or less, and periodically recertify thatthe patient continues to be terminally ill.Payment is made to a hospice for each day that an individual elects the benefit. Payment rates are adjustedto reflect local differences in area wage levels using a hospice-specific wage index, which is based onhospital wage data. Overall aggregate payments to a hospice are subject to a statutorily prescribedaggregate cap amount.The number of Medicare-certified hospices has increased significantly since 1997, up by over 70 percent.The number of Medicare beneficiaries in hospice care has also grown rapidly from just over 400,000 in1998 to close to one million in 2007.Proposed Rule DetailsThis proposed rule also solicits comments on a number of potential policy changes for the future. In orderto increase accountability in the recertification process, the rule seeks comment on requiring a physician ornurse practitioner to visit every hospice patient after 180 days on the benefit, and every benefit periodthereafter.This proposed rule also solicits comments on broader payment reform, such as alternate methods tocalculate the hospice aggregate cap.This proposed rule will be published in the April 24, 2009, Federal Register. Comments are due 60 daysafter publication by June 22, 2009. A link to the proposed rule is available at:http://www.federalregister.gov/OFRUpload/OFRData/2009-09417_PI.pdfNews from Cahaba for Home Health and Hospice ProvidersReminder of Claim Adjustments, Reopenings, and Appeal RequestsThe following serves as a reminder that will help providers in determining whether to submit a claimadjustment, a reopening request, or an appeal request.Claim AdjustmentsSubmitting adjustments are the most efficient way to add, delete or change an item or service on apreviously processed claim. However, an adjustment cannot be made to charges that were medicallydenied. Instead, you must request an appeal. An adjustment and an appeal request cannot be submitted asone request. If you wish to appeal a medically denied charge(s), your adjustment cannot be submitted untila final appeal decision is made. For information on how to adjust a claim via direct data entry (DDE), referHome Health & Hospice May 1, 2009 23Medicare A Newsline Vol. 16, No. 8

to the “Claims Corrections” section of the Fiscal Intermediary Standard System (FISS) Reference Guide,which can be viewed on our Web site at:https://www.cahabagba.com/rhhi/education/materials/fiss_correct.pdfAdjustments may be made to claims that include medically denied charges; however, the denied chargescannot be adjusted (deleted or changed). For example, an adjustment can be submitted to add physicaltherapy visits, even though the skilled nursing services are medically denied. This type of adjustment canbe submitted electronically or via DDE.Reopenings to Claims Denied Due to Unanswered Additional Development Requests (ADRs)Claims that are selected for prepayment review receive an Additional Development Request (ADR) notice.If the requested ADR documentation is not received by Cahaba within the time frame specified, the claim isautomatically denied for insufficient information. If a valid and timely appeal request is submitted with theADR documentation, within the timeframe specified for an appeal, a reopening will be done instead of anappeal. A valid request for an appeal must be received before this type of reopening is done. If a reopeningis done, and services remain denied, you still have first level appeal rights. For additional information, referto the Centers for Medicare & Medicaid Services (CMS) Medicare Claims Processing Manual, (CMS Pub.100-04), Ch. 34 §10.1 or the Medicare Learning Network (MLN) Matters article MM4147 entitled “MMA –Reopenings and Revisions of Claim Determinations and Decisions.”In addition, a claim cannot be reopened if it is already in the appeals process. A clerical error reopening isfor minor errors and omissions; however, these are usually submitted as adjustments.AppealsA redetermination (1st level of appeal) can be requested when a party is dissatisfied with an initialdetermination where items or services are not covered or ordered, because they are not reasonable andnecessary, were not intermittent, constituted custodial care, the patient was not homebound, services weredenied as not being ordered, or if the party disputes the liability of the denied or noncovered items orservices. Only the appealed items or services will be reviewed. Any changes (adding, deleting or changingitems or services) to the claim must be submitted as an adjustment request, after an appeal decision has beenmade. Services that have been medically reviewed and denied cannot be deleted from the claim. Whenrequesting an appeal, submit all medical records that apply to the items or services being appealed.The appeal request for a redetermination must be received within 120 days from the date of the initialdetermination notice (i.e., date of the remittance advice).Mail appeal requests to:Cahaba GBAMedicare A RedeterminationP.O. Box 9242Des Moines, IA 50306-9242For details about submitting ADRs, refer to the “Additional Development Request (ADR) Process”information on our Web site.Home Health & Hospice May 1, 2009 24Medicare A Newsline Vol. 16, No. 8

Availability of the Provider Contact Center (PCC)Medicare is a continuously changing program, and it is important that we provide correct and accurateanswers to your questions. To better serve the provider community, the Centers for Medicare & MedicaidServices (CMS) allows the provider contact centers the opportunity to offer training to our customer servicerepresentatives (CSRs). Listed below is the date and time the home health and hospice PCC (1-877-299-4500 and 1-866-539-5592) will be closed for training. We will continue to notify you of future CSRtraining dates in the Home Health & Hospice Medicare A Newsline.CSR Training DateMay 21, 2009Time1:15—3:45 p.m. Central Time (CT)Stay Informed About Medicare InformationOne of Cahaba’s primary means of communication with our providers is through Cahaba’s E-mailNotification Service (Listserv). The Listserv is a free email notification service that provides you withprompt notification of Medicare news including policy, benefits, claims submission, claims processing andeducation events. Subscribing for this service means that you will receive information as soon as it isavailable, and plays a critical role in ensuring you are up-to-date on all Medicare information.When considering whether you should subscribe to Cahaba’s Listserv, remember the following: It’s free. There is no cost to subscribe or to receive information. You only need a valid e-mail address to subscribe. Multiple people/e-mail addresses from your facility can subscribe. We recommend that all staff(clinical, billing, and administrative) who interact with Medicare register individually. This willhelp to facilitate the internal distribution of critical information and eliminates delays in getting thenecessary information to the right person. This is Cahaba’s primary means of sharing important information with you in a timely manner.To subscribe to the Cahaba’s E-mail Notification Service, go tohttps://www.cahabagba.com/part_a/whats_new/email_service.htm and click on the ‘Subscribe Now’ link.After you complete the form and click on “Sign Up for News”, you will receive an email message from“cahaba_news Confirmation (from Lyris ListManager)”. You must reply to this message to confirm yoursubscription.Current Listserv SubscribersThe E-mail Notification Service Web page includes the option for current listserv subscribers to changetheir email address. This allows providers to keep their subscription to the listserv current and accurate. Tochange information about your organization or to update the Medicare A topics that you wish to receiveHome Health & Hospice May 1, 2009 25Medicare A Newsline Vol. 16, No. 8

news about, you need to unsubscribe and then re-subscribe to the E-mail Notification Service. Additionally,the listserv software product we use automatically quits mailing to email addresses that return as inactive orincorrect after five attempts.System Availability During the Memorial Day HolidayWhile we celebrate the Memorial Day holiday with our families, our offices will be closed on Monday, May25, 2009. Our data center has informed us that the Fiscal Intermediary Standard System (FISS) and accessto the ELGA and ELGH eligibility screens will not be available on May 25. In addition, the system will notcycle that night, which means that claims will not be sent to the Common Working File (CWF) on May 25,2009. Medicare Remittance Advices, Electronic Remittance Advices (ERAs), Medicare paper checks, andElectronic Funds Transfers (EFTs) will not be produced Monday night.News from Cahaba for Home Health ProvidersReminder of Physician Signature Requirements for Home Health ServicesCahaba’s Medical Review department has seen an increase in the use of stamped physician signatures onhome health plans of care and verbal orders. As a reminder to home health providers stamped signaturesare not acceptable on any medical record.Medicare will accept hand written, electronic signatures or facsimiles of original written or electronicsignatures. If using an electronic or facsimile, the home health provider is responsible for obtaining theoriginal signature of the physician, if an issue surfaces that would require verification. If using an electronicsignature, all such entries must be appropriately authenticated and dated.For additional information, refer to the Centers for Medicare & Medicaid Services (CMS) Medicare BenefitPolicy Manual (CMS Pub. 100-02) Ch. 7, §30.2.7 and §30.2.8 on the CMS Web site.Home Health & Hospice May 1, 2009 26Medicare A Newsline Vol. 16, No. 8

News from Cahaba for Hospice ProvidersMedicare ForumDo you have a Medicare question or topic that you would like addressed in the Home Health & HospiceMedicare A Newsline? If so, fax it to the Provider Outreach and Education (POE) department at 515-471-7584, or e-mail it to ianewsline@cahabagba.com. Please include your facility’s name and provider number,your name and telephone number. Responses to the inquiries received in this e-mail box will be providedonly through the Medicare Forum article, if appropriate. If you need an immediate response to a question,please contact a Provider Contact Center for assistance. Refer to the “Contact Us” page of our Web site andselect “Phone Us” to call a Customer Service Representative (CSR). We also welcome your comments orsuggestions on this publication and other Cahaba customer service activities.Q1. I would like a little clarification regarding when a hospice patient is living in a skilled nursingfacility and that is their declared residence and they die. What would be the appropriatedischarge reason code; 40 expired at home or 41 expired at medical facility? If there issomething that I could print out for reference that would be very helpful.I would be billing to Medicare at the routine home care level of care.A1. The Centers for Medicare & Medicaid Services (CMS) as well as the National Uniform BillingCommittee (NUBC) do not provide a definition of what is considered a patient’s place of residence inregard to the patient status codes. Therefore, because the patient status codes 40 (expired at home),and 41 (expired in a medical facility) are not used to determine reimbursement or coverage, wesuggest that you use the code you believe to be the most appropriate.Home Health & Hospice May 1, 2009 27Medicare A Newsline Vol. 16, No. 8

Cahaba Learning CornerMay 2009 Education EventsTo register for educational events, go to the “Calendar of Educational Events” page on our Web site.Select the event title for registration instructions.‣ “Save Time & Money: Avoiding Hospice Billing Errors Ask the Contractor Teleconference(ACT)” WebinarDate: May 19, 2009Time: 1:00 a.m. – 2:00 p.m. Central Time (CT)Registration Deadline: May 14, 2009Intended Audience: This Webinar is intended for hospice billers, financial staff andadministrators.Description: The ACT will be presented as a Webinar, and concentrate on the most commonhospice billing errors and how to resolve them and ways to prevent the errors from occurring in thefuture. Providers are encouraged to submit questions in advance, which will be responded toduring the event.‣ “Online Courses” are computer-based and can be launched from the convenience of your owndesk. All courses are free and open to anyone.Course TitleAdjusting and Canceling ClaimsAdvanced Hospice BillingAppeals ProcessBasics of ICD-9-CM Coding for HomeHealth CliniciansBeginner Hospice BillingBeginner Home Health BillingCERT (Comprehensive Error Rate Test)Checking Claims StatusComprehending Medicare ClaimsProcessingDescriptionLearn how to adjust or cancel claims.Learn about advanced hospice billing topics.Learn about the Medicare appeals process.Learn the basics ICD-9-CM coding.Learn the basics of hospice billing.Learn the basics of home health billing.Learn about the CERT Program.Learn how to use the Fiscal Intermediary StandardSystem (FISS) to check the status of your claims.Learn about Medicare claims processing.Home Health & Hospice May 1, 2009 28Medicare A Newsline Vol. 16, No. 8

Cahaba GBA Learning Corner‣ “Online Courses” (continued)Course TitleMedicare Coding (Insight into)Medicare Cost Report (Introduction to)Medical Review (Getting a view of)Medicare Secondary PayerOverview of MedicareProvider EnrollmentVerifying Beneficiary EligibilityDescriptionLearn the basics about Medicare coding.Learn the basics about the Medicare Cost ReportLearn the basics of the Medical review process.Learn the basics of Medicare Secondary Payer.Learn the basics about the Medicare program.Learn about provider enrollment and how to apply.Learn how to identify various eligibilityinformation by using ELGA and ELGH.Please note these courses were designed specifically for providers served by Cahaba. You can findadditional national courses under the Medicare Learning Network.‣ Didn’t find what you were looking for? Visit our Web site—it provides a variety of valuableinformation and is continuously updated. In addition, subscribe to the Cahaba E-mail NotificationService to receive the most current home health and hospice Medicare information.Home Health & Hospice May 1, 2009 29Medicare A Newsline Vol. 16, No. 8