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Correct Coding – RT and LT Modifier

Until now, suppliers billing for bilateral DME devices including therapeutic shoes for patients with diabetes, diabetic inserts, custom AFOs or custom foot orthoses, have been able to submit electronic claims by indicating the total quantity and using the RTLT modifier on a single line OR by using RT on one line and LT on another, noting half the quantity on each.

Beginning March 1, 2019, such claims MUST be submitted using two separate lines, using the RT and LT modifier on each. Units of service (UOS) should be “1″ on each line for shoes and for AFOs; it should be up to “3″ on each line, for prefabricated or custom diabetic inserts. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and / or LT modifier or with RTLT on a single claim line, will be rejected as incorrect coding.

Suppliers who have been submitting codes for bilateral devices using one line are advised to start billing on two separate lines NOW and not wait until March 1.

As always, each claim line should also include the modifier KX to indicate that all required compliance documentation is on file. When billing L3000 for custom foot orthotic devices, the GY modifier should be used to indicate that the item is statutorily excluded and cause the claim to deny.

For a link to the Medicare carrier website and Policy Articles, see:

https://med.noridianmedicare.com/web/jadme/policies/dmd-articles/2018/correct-coding-rt-and-lt-modifier-usage-change

Helpful Links Using the Medicare DME Portals

Each of the DME MACs have created webpages that offer podiatrists and other DME suppliers access to useful Medicare information.  The “Portals” requires individual registration and uses a personal log-in.  They offer different levels of accessibility and also protects patient personal health information.  Presently Jurisdictions A and D are serviced by Noridian; Jurisdictions B and C are serviced by CGS.

Podiatrists are encouraged to register for the Portals corresponding to the region(s) where their patients reside and to also create access for appropriate staff members.  Some of the things that are certain to prove useful include: Medicare Beneficiary Identifier (MBI) lookup,  info about the Interactive Voice Response (IVR) for checking status of claims, and redetermination.

 

Noridian Medicare Portal (NMP)

Jurisdiction A, Jurisdiction D.

https://www.noridianmedicareportal.com/web/nmp/home

CGS Medicare Portal (myCGS)

Jurisdiction B, Jurisdiction C. 

https://www.cgsmedicare.com/jc/mycgs/pdf/mycgs_registrationguide.pdf

 

Medicare Beneficiary Identifier (MBI) Look Up Tool

A new Medicare Beneficiary Identifier (MBI) replaced the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.

In the past, the HICN was based on a person’s social security number.  Every person with Medicare has been assigned an MBI and has been mailed a new Medicare card.  The MBI is confidential like the SSN and should be protected as Personally Identifiable Information.  The biggest reason for the new MBI is to fight medical identity theft for people with Medicare.

The MBI provides podiatrists and other DME suppliers information need to enter using the telephone key pad when using the IVR and is based only on the information you enter. 

Use this tool to convert the patient’s MBI to the corresponding numbers on your telephone key pad. 

https://cgsmedicare.com/medicare_dynamic/jb/mbiconverter.aspThe Medicare Beneficiary Identifier (MBI) Lookup Tool is an option for providers/suppliers if they are not able to obtain the MBI from the patient.

Noridian DME: Jurisdiction A, D

https://med.noridianmedicare.com/web/jadme%20/topics/nmp/end-user-manual/mbi-lookup-tool

CGS: Jurisdiction B, C

https://cgsmedicare.com/parta/pubs/news/2018/05/cope7584.html

 

Medicare Interactive Voice Response (IVR)

The Centers for Medicare & Medicaid Services (CMS) requires providers to utilize the Interactive Voice Response (IVR) System to check the status of claims.  The Interactive Voice Response (IVR) system requires you to enter your patient’s name and Medicare number during the beneficiary validation process.   The IVR will validate the beneficiary information.

 

Noridian: Jurisdictions A, D

https://med.noridianmedicare.com/web/jeb/contact/ivr

CGS: Jurisdictions B, C

To use the IVR, please call: 877.299.7900

 

Submitting Redeterminations Through the Medicare Portal

When AFO claims are denied and given reason code “M3”, it’s because of “Same or similar”, meaning that Medicare is only covering one device, prefabricated or custom, per side, every five years.  Claims to treat a different diagnosis with a different device, can generally be covered, even after initial denial, if appealed as a “Redetermination”.  Redetermination can be done either by faxing in a form and supporting documentation or via the Portal.  Its recommended that suppliers use the Portal, and not fax, as it provides assurance that all forms are received.  

 

Noridian: Jurisdictions A, D

https://www.noridianmedicareportal.com/

CGS: Jurisdictions B, C

https://cgsmedicare.com/articles/cope25316.html

 

Documentation Identification Tool

CGS has created the Documentation Identification Tool to assist you in submitting the different types of documentation needed to support your claim. Simply select the type of documentation you are submitting from our list of items below. Then print the pre-designed divider sheet and place it in front of the document(s) that will be submitted for review.

The documentation identification tool standardizes the process so you no longer need to create your own divider sheets for your documentation.

https://www.cgsmedicare.com/jc/help/documentation_identification_tool.html

 

Jurisdiction A is serviced by Noridian Healthcare Solutions   and includes Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont.

Jurisdiction B is serviced by CGS   and includes Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.

Jurisdiction C is serviced by CGS   and includes Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, West Virginia and the US Virgin Islands.

Jurisdiction D is serviced by Noridian Healthcare Solutions   and includes Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington and Wyoming,

 

Medicare DME Reimbursement Increases in 2019

Good news!
On January 1, 2019, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $146.42
Prefabricated, Heat Molded Inserts (A5512): pair $59.72
Custom Milled Inserts (A5514): pair $89.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $325.36
Depth Shoes w/3 pr. Custom Molded Inserts: $413.78
Custom Molded Shoes w/offset heels and rocker bottoms: $656.62
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61, Floor $904.29
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22, Floor $1808.58

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME19-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

AFO DENIALS BASED ON “SAME OR SIMILAR”

The DME MACs have recently begun strictly enforcing a long-existing policy, “Same or Similar.” This situation has resulted in suppliers more frequently receiving denials for DME, indicated on EOBs with reason code “M3.”

Medicare dictates that AFOs can be dispensed only once, per side, every five years. The “Same or Similar” policy states that a beneficiary cannot get another AFO device for the same limb within this period unless the AFO is lost, stolen, or irreparably damaged or the patient has a new diagnosis, resulting in the need for a new type of device.

AFOs considered to be within the same or similar category include both custom fabricated and off-the-shelf including:

L1900, L 1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2106, L2108, L2112, L2114, L2116, L 2126, L2128, L2132, L2134, L2136, L4350, L4360, L4361, L4370, L4386, L4387, L4396, L4397, L4398, L4631.

For example, a patient receiving a CAM Boot (L4386) in 2017 for a stress fracture on the left foot would likely be rejected for a Custom Fabricated Hinged AFO (L1970) should he or she require one for Posterior Tibial Tendinosis of the left foot in 2019.

Details of the policy can be found at https://med.noridianmedicare.com/web/jadme/policies/lcd/active.

The rule is not provider-specific, meaning that if a patient received an AFO from another provider or supplier within the past five years that was billed to Medicare, the claim for a “same or similar” device may be denied.

What to do about it

Providers can easily discover whether their patient has received a device within the past five years by enrolling in their respective DME MAC Jurisdiction’s Provider Portal. Information on enrolling in the provider portals is available on each DME MAC Homepage.

APMA urges its members not to use the NMBI (National Medicare Beneficiary Identifier) and to continue to use the patient’s Social Security-linked number as there are cases in which the provider portal either will not recognize the NMBI or cannot properly perform a “Same or Similar” inquiry. This issue has been brought to the attention of CMS contractors. Once this issue is resolved, APMA will notify our members.

Once enrolled in a DME MAC carrier’s portal, it will take a minute or less to determine what, if any, devices your patient has received in the last five years. The provider portal will provide you with information regarding the date, HCPCS codes, and name of the supplier who provided the previous device.

The Noridian Provider Portal will only provide “Same or Similar” information regarding services provided in Regions A and D, while MyCGS will only provide “Same or Similar” Information for services provided in Regions B and C.

APMA suggests that providers confirm their patient’s legal address history. This information will minimize any possibility that services were provided previously in a different DME MAC Jurisdiction.

APMA urges members to save any information received on the provider portal. Be sure your chart documentation includes the above information and, if dispensing another AFO for the same side within five years, the fact that a new device is required for one of the several reasons stipulated in the LCD. These reasons include, but are not limited to: The device was lost, stolen, irreparably damaged (due to a one-time event); a different diagnosis; change in anatomy (e.g., amputation, significant weight loss or gain) resulting in the previous device being unusable by the patient; or a different physiologic need (e.g., previous device was for a non-weight-bearing situation and the new device is for a weight-bearing situation).

Suppliers may still initially receive a “Same or Similar” rejection. However, a properly documented progress note including the above information may be used to successfully appeal (Redetermination) a “Same or Similar” rejection.

Providers may obtain the redetermination form from their DME MAC Website and/or provider portal. Once this form is downloaded and completed, you may scan the form (or complete and save it online) and then upload the form and other pertinent information, including response letter and your chart documentation, directly onto the DME MAC provider portal.

By using the provider portal, you may avoid fax transmission errors and be instantly assured that the information submitted has been received by the DME MAC. You may also follow the appeals process via the provider portal and read any comments made by the nurse reviewer. While a redetermination must be completed within a 90-day period (once received by the carrier), it will typically take only 30 days using the provider portal.

Providers may wish to obtain a properly executed ABN, should your search of the provider portal result in a potential “Same or Similar” scenario. A properly executed ABN should be specific as to why your services (new device) may not be covered. Information to include in the ABN should include the name of the device dispensed, date of service, name of supplier, and that any new device may result in a “Same or Similar” rejection.

Recent communication between APMA and the DME MAC Medical Directors seems to indicate that the DME MACs are interested in developing new edits to substantially reduce the number of “Same or Similar” rejections.

This situation is fluid, and APMA urges members to monitor APMA.org for future developments.

Reference: APMA.org

SafeStep representatives can help you:

  • Register for Medicare portal
  • Easily check patient eligibility prior to prescribing AFOs
  • Submit claims for redetermination (appeal) either via Medicare carrier website or via fax.

Contact us at info@safestep.net or 866.712.STEP

MIPS DRIVES SUCCESS BY PROMOTING FALL RISK ASSESSMENT, FITTING SHOES, ORTHOSES & AFOS

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit quality measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increased to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when balance AFOs, payable by Medicare, should be prescribed.

DON’T BE HIT WITH MIPS PENALTIES: DOWNLOAD THE LATEST MIPS FALL RISK ASSESSMENT TOOL HERE

MIPS quality measures 154, falls risk assessment and 155, falls, plan of care, address falls being the leading cause of injuries for older adults. One in four Americans aged 65 and over falls each year. By identifying people with gait instability, podiatrists can reduce this risk and make fall prevention a valuable part of their practice.

Physicians should annually, ask every patient, 65 and over, whether they have fallen in the past year. If so, they should follow-up by asking how many times and if the patient suffered an injury. Patients who have fallen two or more times or once with injury are defined to be at high risk.

These patients should be evaluated using a fall risk assessment form available from SafeStep.
Gait, strength and balance are assessed by having patients perform a “Timed Up and Go Test”. Patients stand, walk 10 feet, turn around and sit down. If TUG takes more than 12 seconds, there’s a good chance such conditions as: muscle weakness, difficulty walking or unsteadiness on feet are present.

MIPS 154 also requires assessing another contributing factor to falling including:
• a review of medications, or
• asking if the patient has had an eye exam in the past year, or
• reviewing other possibly contributing medical conditions, or
• determining the presence of postural hypotension.

Patients should be provided with a Plan of Care that includes balance, strength and gait training instructions, advice about vitamin D and information about home fall hazards. To make it easy, when using the assessment form available from SafeStep, simply tear off and give the patient a sheet that’s part of it.

When patients have NOT fallen two or more times or once with injury, submit MIPS quality measure 154 using CPT code 1101F.

If patients at high risk for falls are evaluated and provided a plan of care, consider billing E&M code 99213. Also submit codes 3288F and 1100F for MIPS 154 and 0518F for MIPS 155.
When there is fall risk, based on gait assessment, consider prescriptions for balance footwear, foot orthotics and possibly balance AFOs.

SafeStep has available, for free, copies of a Fall Risk Assessment form that assists in satisfying the MIPS fall prevention requirements. Medicare compliance documentation for AFOs can be best assured by using SafeStep’s WorryFree DME program.

Medicare DME Reimbursement Increases in 2018

Good news!
On January 1, 2018, Medicare increased the amount it pays for diabetic shoes, Moore Balance Brace and Arizona custom AFOs.

While the amounts paid may vary slightly by state, the National Fee Schedule is as follows:
Depth Shoes (A5500): pair $143.12
Prefabricated, Heat Molded Inserts (A5512): pair $58.38
Custom Molded Inserts (A5513): pair $87.12
Depth Shoes w/3 pr. Prefab, Heat Molded Inserts: $318.26
Depth Shoes w/3 pr. Custom Molded Inserts: $404.48
Custom Molded Shoes w/offset heels and rocker bottoms: $570.38
Arizona AFO, Standard (L1940, L2330, L2820): each – Ceiling $1178.61 Floor $883.96
Moore Balance Brace (L1940, L2330, L2820): pair – Ceiling $2357.22 Floor $1767.92

For a complete listing of updated DME allowables, including prefabricated and custom ankle-foot orthoses, visit:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule-Items/DME18-A.html?DLPage=1&DLEntries=10&DLSort=2&DLSortDir=descending

MIPS DRIVES SUCCESS BY PROMOTING CDFE AND SHOE FITTING IN 2018

Failure to submit Medicare MIPS quality measures will cost physicians tens of thousands of dollars. In 2018, podiatrists have to submit qualify measures all year and not for just a 3-month window, like in 2017. Also, the penalty for not submitting increases to 5% of Medicare payments. However, podiatrists should appreciate that performing MIPS measures may also allow billing for office visits and will increase awareness of when shoes and inserts, payable by Medicare, should be prescribed.

MIPS quality measures 126 and 127, diabetic foot exam including evaluation of footwear, address the association of neuropathy with diabetic foot ulceration. Properly fit shoes have been demonstrated to significantly reduce the likelihood of foot ulceration in patients with diabetes. By identifying people who qualify for shoes paid for by Medicare, podiatrists can make shoe fitting a valuable part of their practice.
Podiatrists should annually perform an ulcerative risk assessment on every patient with diabetes. A CDFE should include testing for loss of protective threshold using a 10-gram monofilament plus at least one of the following neurological exams including feeling vibration using a tuning fork, pinprick sensation, or ankle reflexes. Testing should also look for vascular, dermatological and structural findings. The foot should be sized using a standard measuring device, and the patient counseled on appropriate footwear based on risk categorization.

Patients with Medicare and diabetes who are identified to be at increased risk for ulceration should be fit with shoes and inserts. Shoe fitting will be most successful when patients are recommended models based on the consideration of what’s referred to as the 4 S’s of shoe fitting: Size, Shape, Stability & Style.

When patients with diabetes are given a comprehensive diabetic foot exam and provided a plan of care, which may include prescribing shoes, consider billing E&M code 99213. Also, submit codes G8404 for MIPS 126 and G8410 for MIPS 127.

SafeStep has available, for free, copies of a CDFE form that assists in satisfying the MIPS diabetic foot examination requirements. Medicare compliance documentation for diabetic shoe-fitting can be best assured by using SafeStep’s WorryFree DME program.

To access SafeSTep training and webinars, visit:

DME Training

Free Webinar Instructionals

New Billing Codes for Plantar Fascia Night Splints, Pneumatic and Non-pneumatic Walking Casts

Medicare now differentiates between off-the-shelf and custom fitted type prefabricated AFOs including pneumatic and non-pneumatic walkers and plantar fascia night splints.

Traditionally used codes reflect the custom fitted version and the allowable amounts for both are currently the same.  For devices traditionally billed using L4360, L4386 and L4396, new codes reflecting the off-the-shelf definition most likely apply.

Click below to read entire article:

NEW BILLING CODES FOR PLANTAR FASCIA NIGHT SPLINTS, 150127

Increased Medicare DME Reimbursement for 2015

Good news!! On January 1, 2015, the Medicare fee schedule for diabetic shoes, Moore Balance Brace and Arizona custom AFOs increased. While the amount reimbursed by each DME MAC may vary slightly, the National Fee Schedule allowables are as follows:

Depth Shoes (A5500) $141.14
Prefabricated, Heat Molded Inserts (A5512) $57.58
Custom Molded Inserts (A5513) $85.92

Depth Shoes w/ 3 pr. Prefab, Heat Molded Inserts $313.88
Depth Shoes w/ 3 pr. Custom Molded Inserts $398.90
Custom Molded Shoes w/ Custom Molded Inserts $586.42

Arizona AFO, Standard (L1940, L2330, L2820) $1162.23
Moore Balance Brace (L1940, L2330, L2820) $1162.23

For a complete listing of updated DME prices, including prefabricated and custom ankle foot orthoses, go to:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html.

Effect of Sequestration on DME

Questions and AnswersQuestion: Does the 2% payment reduction under sequestration apply to the payment rates reflected in Medicare fee-for-service fee schedules or does it only apply to the final payment amounts?

Answer: Payment adjustments required under sequestration are applied to all claims after determining the Medicare payment including application of the current fee schedule, coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments. All fee schedules, Pricers, etc., are unchanged by sequestration; it’s only the final payment amount that is reduced.

Question: How is the 2% payment reduction under sequestration identified on the electronic remittance advice (ERA) and the standard paper remittance (SPR)?

Answer: Claim adjustment reason code (CARC) 223 is used to report the sequestration reduction on the ERA and SPR.

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