DME
MAC Jurisdiction C Frequently Asked Questions (FAQs)
Claim Submission FAQs Archive
Question: Do we still need to use UPINs or Legacy provider numbers on a claim, or can we just use NPI numbers?
Answer: Claims may be submitted with the NPI only; though it is currently acceptable to submit claims with the UPIN and/or NPI number(s) in blocks 17a and b. If submitting the NPI only in block 17b, verify the validity of the physician's NPI utilizing the NPI Registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. When effective, it is the goal of CMS to have all suppliers and providers submitting all claims with the NPI only.
Question: If a beneficiary had an initial oxygen CMN, but there was a 60 day break in service, how can we transmit the new initial oxygen CMN without having it rejected? (it needs to come on paper)
Answer: Whenever there is a new initial CMN for an item that is already on file with Medicare, it will be necessary to request a reopening via mail or fax including a copy of the new CMN and request that we correct the records.
Question: Why are accessories denying when the wheelchair itself is paying?
Answer: If the base equipment is on file and approved to pay, accessories are often automatically payable if they meet Medicare guidelines. There are several scenarios in which accessories may be denied for an approved piece of base equipment.
- Accessories submitted on a separate claim from the base equipment; the accessories may process before the base equipment is set.
- Accessories that require modifiers which are omitted from the claim.
- Inappropriate accessories billed with the incorrect base (e.g., manual accessory billed with power base).
If a denial for an accessory to equipment on file is identified and the denial explanation is unclear, contact the customer service department for further guidance.
Question: Do I need to put a KX modifier on accessories for power wheelchairs?
Answer: Yes, the KX modifier is required on the base and the accessories. This requirement also applies to hospital bed bases and accessories (e.g., trapeze bar). Please review the LCD of each policy to ensure that the appropriate documentation requirements are met.
Question: My E1390 paid but the E0431 denied for no CMN. Can you adjust the claim?
Answer: It is necessary to submit the initial/recertification CMN for both the concentrator and the portable oxygen to avoid unnecessary denials. If this denial is received, please resubmit the claim and include the completed CMN information with the claim, this may be submitted electronically.
Question: Do we have to have an original "pen and ink" signature on prescriptions and CMNs?
Answer: Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen and ink" document. (Reference: CMS Manual System, Pub. 100-8, Medicare Program Integrity Manual, Chapter 3, section 3.4.1.1.B.)
Question: Will I need a new supplier number to submit claims to CIGNA Government Services?
Answer: No. Your supplier billing numbers will remain the same, so there is no need to obtain a new number if you have an active supplier number.
Question: What changes are required for electronic claim submitters?
Answer: CIGNA Government Services will communicate changes through our Web site. As of the publication date of this article, we know that EDI users will have to review their claim submission software to ensure that the proper contractor code is being utilized after the transition date. See the separate article in this newsletter for more EDI billing information.
Question: Will I need to re-enroll to send my transactions to CIGNA Government Services?
Answer: Yes, but only if you live in the states of Virginia and West Virginia. You should be receiving information shortly regarding the transition of these states from Jurisdiction B to DME MAC Jurisdiction C .
Question: I currently bill for beneficiaries in Virginia and West Virginia. Can I use Express Plus to submit my claims?
Answer: No. The Express Plus software product currently in use at Jurisdiction B is not compatible for submission of claims to Jurisdiction C. If you are a current user of Express Plus, you are advised to request and begin using Pro-32 as your billing software or consult a Certified Vendor to determine a product best suited to your business needs.
Question: Will I need to test with CIGNA Government Services before I start submitting electronic claims to them?
Answer: If you already submit claims to Palmetto GBA, you will not need to test before submitting claims.
Question: Will the allowed amounts be different when CIGNA takes over?
Answer: Reimbursement (pricing) rates for items billed to the DME MAC will not change with the implementation of CIGNA Government Services. The current rates should still be applicable.
Question: Will CIGNA provide a supplier manual?
Answer: Yes, you will have access to the CGS' supplier manual on our Web site. We will be sending a CD with a copy of the manual to suppliers the last week of April.
Question: Why are my electronic claims being rejected now?
Answer: On October 29, 2007 CIGNA Government Services began editing electronic claims for NPI Crosswalk validity. If the information on file with the National Plan and Provider Enumeration System (NPPES) does not match the information on file with the National Supplier Clearinghouse, electronic claims will reject until the necessary record corrections are made. Please review the following website for additional information on NPI: http://www.cms.hhs.gov/NationalProvIdentStand/
Question: Why is my maintenance and service being recouped after it was paid for years?
Answer: Maintenance and Service payments are allowed after 15 paid rental months. Many suppliers are receiving overpayment requests because the Medicare records do not show 15 paid months. A common reason for missing rental payment records may be attributed to previously paid rentals that had to be refunded due to consolidated billing or other payment errors causing overpayments. Please review the article titled Maintenance and Servicing Denials (07.10.07) at the following link for instructions on correcting records for maintenance and servicing: http://www.cignagovernmentservices.com/jc/pubs/news/archive/07/index.html for details
Question: Why isn’t a new capped rental period automatically begun when we bill a KH modifier?
Answer: Break in service claims require additional information in order for a new capped rental to begin. In addition to submitting a claim with the KH modifier, it is necessary to indicate the reason a new capped rental is beginning; when the previous medical need ended; and include the medical necessity of the new item. This information may be included in the electronic claim narrative or attached to paper claims (if paper claims may be submitted per the Administration Simplification Compliance Act/ASCA).
Question: Why are claims still denied when the narrative contains the information needed to process?
Answer: Generally if a claim is denied and notes are included on the claim, the information submitted was insufficient. Please review the Medicare Remittance Notice for details of which information was omitted. If the Medicare Remittance Notice Remark Codes are missing or difficult to understand, please check the claim status through our Interactive Voice Response (IVR) unit for a more detailed explanation of the denial. Please note that it is necessary to review the status of the claim line level to get full details. An IVR flow chart and script may be viewed at the following link: http://www.cignagovernmentservices.com/jc/help/contact/contactinfo.html. If, however, the information indicated on the remittance notice was present at submission, please contact customer service at 866.270.4909 for guidance.
Question: How long will it take my NPI to be updated with the National Plan and Provider Enumeration System (NPPES)?
Answer: The records are updated in NPPES immediately. Please allow a few days for the Medicare records to reflect the changes.
Question: Which items require spanned dates?
Answer: The items below require date spans when submitting claims to the Durable Medical Equipment Medicare Approved Contractor:
- Diabetic testing supplies (test strips, lancets, and calibration chips)
- Continuous passive motion device (CPM)
- Parenteral and enteral nutrition
- Parenteral and enteral administration kits
- External infusion pump supplies
Note: Do not span dates for any other durable medical equipment claims.
Question: Which items may be submitted with more than one month’s supply?
Answer: For most items that are provided on a recurring basis, including but not limited to DME accessories or supplies, Nebulizer drugs, urological supplies, ostomy supplies at home, the general rule is that suppliers may dispense no more than a 3 month supply at any one time. When billing more than one month’s supply for items not requiring date spans include narrative of months supplied on the claim. The exceptions to the 3 month maximum rule are:
- Surgical dressings
- Enteral and parenteral nutrients and supplies
- Immunosuppressive drugs
- Oral Anti-cancer Drugs
- Oral Antiemetic Drugs
- Ostomy supplies provided in a nursing facility
For these items, only a one month quantity of supplies may be dispensed.
Please review the Policy Article titled, Dispensing DMEPOS Items:
Quantity Limits, Updated June 2007 at http://www.cms.hhs.gov/mcd/cpt_license.asp?type=article&page=results_index.asp&from='articlecontractor'&contractor_name=TrustSolutions%20(77012,%20DME%20PSC)&contractor_number=121&article_id=43028&article_version=2&letter_range=4&retired=&basket=
article:43028:2:Dispensing+DMEPOS+Items%3D%3D++Quantity+Limits++December+2006:DME+PSC:TrustSolutions+%2877012%29 for
further details.
Question: How are upgrades billed appropriately with GK, GL, and GZ modifiers?
Answer: GK and GL modifiers are used on claims for upgraded DMEPOS items to allow for automatic down-coding and to avoid unnecessary redetermination requests. The GZ modifier is used when an ABN has not been obtained for the upgraded item and the beneficiary requested the upgrade.
An upgrade is defined as an item that goes beyond what is medically necessary under Medicare’s coverage requirements. An item can be considered an upgrade even if the physician has signed an order for it. All upgraded items must be billed on the same claim form in sequential order as described below.
Supplier collects additional charge for upgrade:
An appropriate ABN must be collected prior to dispensing item(s). If an ABN is obtained, the supplier bills the HCPCS code for the item that is provided (but that does not meet coverage criteria) with a GA modifier on one claim line and the HCPCS code for the item that meets coverage criteria with a GK modifier on the next claim line. (Note: The codes must be billed in this specific order on the claim.)
Example of billing if upgrade is prescribed and ABN is properly obtained for the equipment that exceeds Medicare criteria:
- E0147NUGA (Extra heavy-duty, multiple breaking system, variable wheel resistance walker)- Upgraded item
- E0143NUGK (Folding, wheeled, adjustable or fixed height walker)- Medicare medically necessity guidelines met
Example of billing if upgrade is prescribed and ABN is properly obtained for the equipment that exceeds Medicare criteria and KX modifier is required and met per the medical policy (LCD):
- E0265RRKHGA (Total electric bed with rails and mattress)- Upgraded item
- E0250RRKHKXGK (Fixed height hospital bed with rails and mattress)- Medicare medically necessity guidelines met
Example of billing if the upgraded item is identified with the same HCPCS code as the item prescribed by a physician; but upgraded option is requested by the beneficiary with a proper ABN on file (this example includes KX also).
- E0250RRKHGA (Fixed height hospital bed with rails and mattress)- Upgraded item
- E0250RRKHKXGK (Fixed height hospital bed with rails and mattress)- Medicare medically necessity guidelines met
Supplier provides upgrade without additional charge:
Supplier voluntary upgrades, no charge to the beneficiary, do not require an ABN to be secured. There are two options for this type of upgrade to be filed.
Example of billing if the upgrade is prescribed or the upgrade is provided without additional charge for supplier’s convenience. Only the HCPCS code of the item meeting Medicare’s medical necessity would be billed with a GL modifier.
- E0143NUGL (Folding, wheeled, adjustable or fixed height walker) - Medicare medically necessity guidelines met and no charge for upgraded item.
Example of billing if the upgrade is not prescribed by a physician; but is requested by the beneficiary.
- E0147NUGZ (Extra heavy-duty, multiple breaking system, variable wheel resistance walker)- Beneficiary-requested upgraded item
- E0143NUGK (Folding, wheeled, adjustable or fixed height walker) - Medicare medically necessity guidelines met.
The submitted charge for all items would be listed as the supplier’s retail charge for each item. For further details on the billing of upgraded items, please review the Jurisdiction C DME MAC Policy Article titled, Use of GK & GL Modifiers on Claims for Upgrades Effective April 2007 (A44196). The article may be accessed at the following link: Upgrade Policy Article. You may also view additional guidance on billing upgrades in the Jurisdiction C DME MAC Supplier Manual in Chapter 6 found at www.cignagovernmentservices.com/jc.
