Breaking Down The PHE Rules
From The Desk Of Ronda Buhrmester, VGM Sr Director of Reimbursement
You have taken care of your patients, now it's time to get the claims paid! As more information is being released on the COVID-19 public health emergency (PHE), we are getting a better understanding with regards to getting claims reimbursed especially in the respiratory area.
Let's break down the latest release as it relates to in-person encounters (F2F), clinical indications for coverage, the standard written order requirements, claim instructions, and diagnosis coding.
Starting with the diagnosis coding, follow the normal guidelines outline in the medical policies to append the appropriate ICD-10 diagnosis code. If the patient is being treated for COVID-19 related illness, then use the following guidelines based on dates of service.
For claims with dates of service before April 1, 2020, suppliers and providers should enter two ICD-10 codes on the claim. The first code entered should be used to describe the clinical diagnosis (pneumonia, bronchitis etc.). The second code entered should be B97.29 (OTHER CORONAVIRUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE).
For claims with dates of service on or after April 1, 2020, suppliers and providers should enter ICD-10 code U07.1 (COVID-19) on the claim.
Claim instructions have finally been released for submitting the oxygen claims that require a CMN (CMS-484). Suppliers have not been able to submit oxygen claims (would front-end reject) which also meant no reimbursement for oxygen equipment and services because section B required detailed information that could not be completed due to the temporary suspension of the oxygen LCD & NCD during the PHE. The new direction is that the CMS-484 CMN will not be enforced at this time. According to the DMACs, their system has been set up to accept oxygen claims without a CMN. If a supplier has a completed CMN or can get the CMN completed, the claim can still be submitted with a CMN. If an oxygen order is all that you have from the practitioner, then submit the claim without the CMN.
Either way, submit the oxygen claims with standard modifiers (RR, KX) and now include the CR modifier along with a narrative in the NTE 2300 or 2400 segment with "COVID-19".
The same instruction applies to the DIF for enteral infusion pumps requiring the DIF 10125 form.
For all HCPCS codes, suppliers should continue to submit claims appending the appropriate modifiers (including KX, if applicable) as well as the CR modifier with a narrative in the NTE segment (2300/2400) with "COVID-19".
If you are using the CMS-1500 claim form, please follow the same claim instructions.
Throughout the PHE, we all have been trying to wrap our heads around the guidelines surrounding the coverage guidelines outlined within the medical policies (NCD & LCD).
According to the most recent information released, for claims with a date of service March 1, 2020 through the duration of the PHE, the following NCDs and LCDs that have temporarily suspension:
Home Oxygen (NCD 240.2)
Infusion Pumps (NCD 280.14)
Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4)
Intrapulmonary Percussive Ventilator (NCD 240.5)
Oxygen and Oxygen Equipment (L33797);
Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718);
Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611)
Respiratory Assist Devices (L33800);
Mechanical In-exsufflation Devices (L33795)
High Frequency Chest Wall Oscillation (L33785)
Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous Glucose Monitors (CGM) are not enforced
External Infusion Pumps (L33794)
What does this mean? If an item is needed under the waived enforcement, that item still needs to be reasonable and necessary. The medical record still needs to have information to show the medical need, it’s the enforcement of the specific details that do not need to be met.
All other medical policies not listed above, the coverage criteria does need to be met as outlined within the specific medical policy. However, the medical need can be determined by a clinician (i.e. nurse, RT, PT, OT) where they would indicate the necessary coverage within the patients' medical record.
With that, a treating practitioner must still order the DMEPOS item/equipment.
This also means a standard written order (SWO) is required for all items for claim submission. (Please note PMDs still have specific policy requirements to be met.)
In the end, proving medical necessity is important, we need to continue to be good stewards of our industry. I highly encourage our members to follow the medical policies as close as possible taking each referral case by case. There may be situations where only minimal information is available. In these cases, document with the patients file exactly what has occurred and track the patient for future reference.
This is all temporary as we are working through the COVID-19 PHE. At the end of this emergency, the enforcement of the clinical indications for coverage apply.
Join me on Tuesday, May 12th at 3pm CST (4pm EST, 1pm PST) for a webinar that will continue to break down the PHE rules as it relates to DMEPOS. Use the link below to register.
This is our time to SHINE! Thank you for all you are doing.