Section 144(b) of MIPPA took effect on January 1, 2009, and repeals the requirement for you to transfer title to oxygen equipment to the beneficiary after the 36 month payment cap mandated by the Deficit Reduction Act of 2005.  Section 144(b) of MIPPA also establishes new payment rules and supplier responsibilities following the 36 month payment period.  See MLN Matters number SE0840 for additional information about these new rules.  This listserv message provides specific instructions for submitting claims for oxygen contents and replacement of oxygen equipment.

REPLACEMENT OF OXYGEN EQUIPMENT

New HCPCS Modifier for Replacement of DME

Effective January 1, 2009, the following modifiers was added to the Healthcare Common Procedure Coding System (HCPCS):

RA – Replacement of a DME item;

This modifier is to be used on claims for replacement of oxygen equipment with dates of service on or after January 1, 2009.  HCPCS modifier RP, which was discontinued effective December 31 2008, remains in effect for claims with dates of service prior to January 1, 2009.

• If oxygen equipment is replaced because the equipment has been in continuous use by the patient for the equipment’s reasonable useful lifetime or is lost, stolen, or irreparably damaged, the patient may elect to obtain a new piece of equipment.  Irreparable damage refers to a specific incident of damage to equipment such as equipment falling down a flight of stairs as opposed to equipment that is worn out over time.  In these situations, a new 36-month rental period and new reasonable useful lifetime is started on the date that the new, replacement item is furnished.   Claims for the replacement of oxygen equipment for the first month of use only are billed using the HCPCS code for the new equipment and either the RA or RP HCPCS modifier depending on the date that the equipment is furnished.

• You must include on the claim for the first month of use a narrative explanation of the reason why the equipment was replaced and supporting documentation must be maintained in your files.  For example, if equipment is stolen, you should keep a copy of the police report in your files.  For lost or irreparably damaged equipment, you should maintain any documentation that supports the narrative account of the incident.  For reasonable useful lifetime replacements, the narrative explanation should include the date that the beneficiary received the equipment being replaced.

• When submitting claims electronically for replacement of oxygen equipment, you may use, for the narrative explanation, loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ASC X12, version 4010A1 professional electronic claim format.  If you are billing using the Form CMS-1500 paper claim, you may report this information in item 19 of the claim form.

• If you are a home health agency submitting claims electronically for replacement of oxygen equipment, you may use, for the narrative explanation, loop 2300, segment NTE (billing note) of the ASC X12, version 4010A1 institutional electronic claim format.  If you are a home health agency billing using the UB-04 paper claim, you may report this information in Form Locator 80 (Remarks).

• A new certificate of medical necessity (CMN) is required in situations where oxygen equipment is replaced because the equipment has been in continuous use by the patient for the equipment’s reasonable useful lifetime or is lost, stolen, or irreparably damaged.  New testing, however, is not required unless it is necessary in order to meet existing medical review guidelines for oxygen and oxygen equipment.  You should continue to follow the existing guidelines requiring recertification CMNs for all situations in which oxygen equipment is being replaced.   The most recent qualifying value and testing date should be entered on the CMN.

• As is the case for all DME items, you must maintain proof-of-delivery documentation in your files for replacement oxygen equipment.  In addition, for equipment that is being replaced because it has been in continuous use by the beneficiary for the reasonable useful lifetime and the beneficiary has elected to obtain new equipment, you must also have proof-of-delivery documentation in your files for the item being replaced that documents that the oxygen equipment has been in use for at least 5 years.

Change in Oxygen Equipment during the Reasonable Useful Lifetime Period

• The reasonable useful lifetime for stationary or portable oxygen equipment begins when the oxygen equipment is first delivered to the beneficiary and continues until the point at which the stationary or portable oxygen equipment has been used by the beneficiary on a continuous basis for 5 years.  Computation of the reasonable useful lifetime is not based on the age of the equipment.

• If there is a change in oxygen equipment modalities (e.g., from a concentrator to a stationary liquid oxygen system) prior to the end of the reasonable useful lifetime period, this does not result in the start of a new reasonable useful lifetime period or a new 36 month payment period.  In addition, if you have to replace oxygen equipment that is not functioning properly prior to the end of the reasonable useful lifetime period, this does not result in the start of a new reasonable useful lifetime period or a new 36 month payment period.  Finally, if the beneficiary switches to a new supplier and new equipment prior to the end of the reasonable useful lifetime period, this does not result in the start of a new reasonable useful lifetime period or a new 36 month payment period.

• A beneficiary may elect to obtain new oxygen equipment at the end of the 5 year reasonable useful lifetime period in these situations.

Clarification of Policy Regarding Continuous Use of Oxygen and Oxygen Equipment

• The instructions pertaining to payments for capped rental items during a period of continuous use now apply to the monthly payment amounts for oxygen and oxygen equipment and the portable oxygen equipment add-on payments.

• A period of continuous use allows for temporary interruptions in the use of the equipment.  For breaks in need (beneficiary no longer needs or uses the equipment) of less than 60 days plus the days remaining in the last paid rental month, the period of continuous use does not start over and so the count of continuous months picks up where it left off before the break.  For example, if the last paid rental month is month #31 and there is a 50 day break in need, the next paid rental month would be month #32.

• If, however, there is a break in need more than 60 days plus the days remaining in the last paid rental month, and the need for the equipment resumes at a later date, a new period of continuous use, a new 36-month payment period, and a new reasonable useful lifetime period would begin provided that you have submitted the following:

• New medical necessity documentation (i.e., a new CMN and retesting) for oxygen and oxygen equipment and/or portable oxygen equipment;

AND

• A narrative explanation describing the reason for the interruption which shows that medical necessity in the prior episode ended.  When submitting claims electronically for replacement of oxygen equipment, you may use, for the narrative explanation, loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ASC X12, version 4010A1 professional electronic format.  If you are billing using the Form CMS-1500 paper claim, you may report this information in item 19 of the claim form.  If you are a home health agency submitting claims electronically for replacement of oxygen equipment, you may use, for the narrative explanation, loop 2300, segment NTE (billing note) of the ASC X12, version 4010A1 institutional electronic claim format.  If you are a home health agency and are billing using the UB-04 paper claim, you may report this information in Form Locator 80 (Remarks).  Suppliers and home health agencies are not to use modifier RA on these claims.

PLEASE NOTE: If medical necessity for the equipment continues during a break in billing/Part B payment (e.g., the beneficiary is hospitalized for 70 days but continues to use oxygen equipment during the hospital stay), this DOES NOT constitute a break in need, and therefore, a new period of continuous use DOES NOT begin.  In these situations, the count of continuous months picks up where it left off before the break.

OXYGEN CONTENTS

Payment for Oxygen Contents (General Policy)

• If you furnished liquid or gaseous oxygen equipment during the 36-month rental period, you are responsible for furnishing the oxygen contents used with the oxygen equipment for any period of medical need following the 36-month rental cap for the remainder of the reasonable useful lifetime of the equipment.

• In these situations, you can bill for and receive a monthly payment for furnishing oxygen contents (see chart below).

Payment for Oxygen Contents (When Monthly Payments May Begin)

• Payment for both oxygen contents used with stationary oxygen equipment and oxygen contents used with portable oxygen equipment is included in the 36 monthly payments for oxygen and oxygen equipment (stationary oxygen equipment payment) made for codes E0424, E0439, E1390, or E1391.  Beginning with dates of service on or after the end date of service for the month representing the 36^th payment for code E0424, E0439, E1390, or E1391, you may bill on a monthly basis for furnishing oxygen contents (stationary and/or portable), but only in accordance with the following chart:

• You may not bill for stationary oxygen contents if the beneficiary uses a stationary concentrator and you may not bill for portable oxygen contents if the beneficiary uses a portable concentrator or transfilling equipment.

PLEASE NOTE: The descriptors for HCPCS codes E0441 through E0444 reflect older policies and regulations and need to be revised to reflect current policies and regulations.  For now, each of these four codes represents monthly delivery of either stationary or portable oxygen contents.  The language in parentheses in the descriptors for each of these codes should be disregarded.

• If the beneficiary began using portable gaseous or liquid oxygen equipment (E0431 or E0434) more than one month after they began using stationary oxygen equipment, monthly payments for portable gaseous or liquid oxygen contents (E0443 or E0444) may begin following the stationary oxygen equipment payment cap AND prior to the end of the portable equipment payment cap (code E0431 or E0434).  As long as the beneficiary is using covered gaseous or liquid portable oxygen equipment, payments for portable oxygen contents may begin following the stationary oxygen equipment payment cap.  This will result in a period during which monthly payments for E0431 and E0443, in the case of a beneficiary using portable gaseous oxygen equipment, or E0434 and E0444, in the case of a beneficiary using portable liquid oxygen equipment, overlap.  In these situations, after the 36-month portable oxygen equipment payment cap for E0431 or E0434 is reached, monthly payments for portable oxygen contents (E0443 or E0444) would continue.

• If the beneficiary began using portable gaseous or liquid oxygen equipment (E0431 or E0434) following the 36-month stationary oxygen equipment payment period, payments may be made for both the portable equipment (E0431 or E0434) and portable contents (E0443 or E0444).

• In all cases, separate payment for oxygen contents (stationary or portable) would end in the event that a beneficiary receives new stationary oxygen equipment and a new 36-month stationary oxygen equipment payment period begins (i.e., in situations where stationary oxygen equipment is replaced because the equipment has been in continuous use by the patient for the equipment’s reasonable useful lifetime or is lost, stolen, or irreparably damaged).  Again, the monthly payment for stationary oxygen equipment includes payment for both stationary and portable oxygen contents.  Therefore, under no circumstances can you receive both the monthly stationary oxygen equipment payment and payment for either stationary or portable oxygen contents.

Proof-of-Delivery Requirements for Oxygen Contents

• Following the stationary oxygen equipment payment cap, you may bill for oxygen contents (stationary and/or portable in accordance with the chart above) on the anniversary date of the oxygen equipment billing.

For example, if the 36^th month of continuous use of the stationary oxygen equipment begins on March 11^th and ends on April 10^th, you may begin billing for monthly oxygen contents that the beneficiary will use after the cap on April 11^th.

• For subsequent months, you do not need to deliver the oxygen contents every month in order to continue billing for the contents on a monthly basis.  A maximum of 3 months of oxygen contents can be delivered at one time.  In these situations, the delivery date of the oxygen contents does not have to be the DOS (anniversary date) on the claim.  However, in order to bill for contents for a specific month, you must have previously delivered quantities of oxygen that are sufficient to last for one month following the date of service on the claim.  You are required to have proof-of-delivery for each actual delivery of oxygen, but as discussed above, this may be less often than monthly.

For example, if you deliver 30 oxygen tanks on April 11^th and the beneficiary only uses 15 tanks from April 11^th through May 10^th and 15 tanks from May 11^th through June 10^th, you may bill for contents on April 11^th and again on May 11^th for contents delivered on April 11^th that were used for two months.

Now Available to Order! The Expanded Benefits Brochure (January 2009). This tri-fold brochure provides health care professionals with an overview of Medicare’s coverage of three preventive services: the initial preventive physical examination (IPPE), also known as the Welcome to “Medicare Physical” Exam or the “Welcome to Medicare” visit, ultrasound screening for abdominal aortic aneurysms, and cardiovascular screening blood tests. To view, download and print this brochure, please go to the CMS Medicare Learning Network (MLN) at http://www.cms.hhs.gov/MLNProducts/downloads/Expanded_Benefits.pdf. To order free of charge, visit http://www.cms.hhs.gov/MLNProducts/, scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

The ABC’s of Providing the Initial Preventive Physical Examination Quick Reference Information (January 2009 Resource). This resource tool is now available in either a two-sided laminated chart or in a tear off pad. It can be used by Medicare fee-for-service physicians and qualified non-physician practitioners as a guide when providing the initial preventive physical examination (IPPE) (also known as the “Welcome to Medicare” Physical Exam or the “Welcome to Medicare” Visit). The two-sided reference identifies the components and elements of the IPPE; provides eligibility requirements, procedure codes to use when filing claims, FAQs, and suggestions for preparing patients for the IPPE; and lists references for additional information. To view, download and print this resource, please go to the CMS Medicare Learning Network (MLN) at http://www.cms.hhs.gov/MLNProducts/downloads/MPS_QRI_IPPE001a.pdf. To order free of charge the laminated chart or tear off pad, visit http://www.cms.hhs.gov/MLNProducts/, scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

The revised publication titled Inpatient Rehabilitation Facility Prospective Payment System Fact Sheet (October 2008), which provides information about Inpatient Rehabilitation Facility Prospective Payment System rates and classification criterion, is now available in print format from the Centers for Medicare & Medicaid Services Medicare Learning Network. To place your order, visit http://www.cms.hhs.gov/MLNGenInfo/ , scroll down to “Related Links Inside CMS” and select “MLN Product Ordering Page.”

Electronic Prescribing (E-Prescribing) Incentive Program: New Educational Product is Now Available!

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a new Medicare Learning Network educational resource has been posted to the Electronic Prescribing (E-Prescribing) Incentive Program section page on the PQRI webpage:

2009 Electronic Prescribing Incentive Program Made Simple- This Fact Sheet provides detailed information on how to participate in the 2009 Electronic Prescribing (E-Prescribing) Incentive Program by reporting the E-Prescribing measure.

To access this new educational product, as well as all available E-Prescribing educational resources, visit http://www.cms.hhs.gov/PQRI on the CMS website and click on the Electronic Prescribing Incentive Program tab. Once on the E-Prescribing page, scroll down to the “Downloads” section and click on the “2009 Electronic Prescribing Incentive Program Made Simple” link.

Medicare Part B Competitive Acquisition Program (CAP) – Reminder about CAP Claims Submission Deadlines and Unused CAP Drugs

The following is a reminder about upcoming CAP deadlines.  It is very important that physicians who participated in the CAP during 2008 understand and comply with these deadlines because failure to do so will affect physicians’ ability to be reimbursed.

CAP Drugs Administered During 2008

• All CAP drug claims must be submitted on or before January 30, 2009.  CAP drug claims and corresponding physicians’ drug administration claims must have a date of service on or before December 31, 2008.
• CAP drugs that have not been administered by December 31, 2008 are the property of the Approved CAP Vendor.
• Do not submit CAP claims for dates of service after December 31, 2008 because they will be denied.
• CAP claims submitted by the Approved CAP Vendor for dates of service after December 31, 2008 will also be denied.

CAP Drugs NOT Administered by December 31, 2008

• CAP physicians must return any unused CAP drugs to the Approved CAP Vendor by February 28, 2009.
• CAP drugs are the property of the Approved CAP Vendor. Therefore, physicians who have not returned these drugs to the Approved CAP Vendor on or before February 28, 2009 will be liable for the cost of drugs.
• Please note that CAP physicians may contact the Approved CAP Vendor to discuss the option of purchasing unused CAP drugs.

Emergency Restocking of CAP Drugs for Dates of Services on or before December 31, 2008

• When permitted under the emergency restocking provision, physicians may submit a prescription order for a CAP drug to replace what they used from their own stock. Physicians may request replacement drugs ONLY if the date of service is on or before December 31, 2008, AND the corresponding drug administration claim has been submitted on or before January 30, 2009.
• Physicians must request replacement drugs by January 30, 2009.
• The Approved CAP Vendor will not send replacement products under the CAP emergency restocking provision (J2 modifier claims) after February 28, 2009.
• CAP physicians who have not submitted a prescription order and a request for replacement drugs under the emergency restocking provision as described above will not be able to bill Medicare under the ASP system for the CAP drugs that they administered on or before December 31, 2008 from their private stock.

For more information

Physicians who participated in the CAP during 2008 are encouraged to contact the Approved CAP Vendor and reconcile their inventories as soon as possible.  Contact information for the Approved CAP Vendor, BioScrip, is available on their website at www.bioscrip.com.

Additional information on the 2009 CAP Postponement is available on the Centers for Medicare and Medicaid Services website at: http://www.cms.hhs.gov/CompetitiveAcquisforBios/01_overview.asp .

RTI’s 24 month contract includes two phases.  The first phase consists primarily of reviewing the relevant literature and policy materials and compiling stakeholder input.  The second phase involves conducting analyses utilizing administrative and clinical assessment data. CMS will be reporting on the first phase in a Report to Congress which is due June 2009.  The RTI analysis will continue through 2009 with a final report to CMS by late 2010.

Comments should be limited.  Longer written comments may be submitted via e-mail to IRFReporttoCongress@cms.hhs.gov.  If possible, comments should be submitted to CMS in writing in advance of the Special ODF. If you have any questions please feel free to contact Julie Stankivic at (410) 786-5725.

Physician Quality Reporting Initiative (PQRI) Updates

Frequently Asked Questions

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that updates to many of the Frequently Asked Questions (FAQS) on the Physician Quality Reporting Initiative (PQRI) are now available on the PQRI webpage.  A number of FAQs have been revised, while many new FAQS have been added to the system. The purpose of the FAQs is to provide detailed answers to common questions regarding the PQRI program. Among the various FAQs included in this update are several related to the 2007 PQRI data re-run. The FAQs may be found in the “Related Links Inside CMS” section of the PQRI webpage at http://www.cms.hhs.gov/pqri/ on the CMS website.

New Educational Products for 2009 PQRI Now Available

The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that two new educational resources have been posted to the PQRI webpage on the CMS website.

2009 PQRI Fact Sheet: What’s New for the 2009 PQRI- This Fact Sheet provides an overview of the 2009 PQRI and highlights the changes from the 2008 PQRI program.

2009 PQRI Made Simple – Reporting the Preventive Care Measures Group- This Tip Sheet provides quick, easy to understand instructions on how to satisfactorily participate in the 2009 PQRI for those who wish to report quality data using claims for the Preventive Care Measures Group.

To access these new, and all, available educational resources, visit http://www.cms.hhs.gov/PQRI on the CMS website and click on the Educational Resources tab. Once on the Educational Resources page, scroll down to the “Downloads” section and click on the “2009 PQRI Fact Sheet: What’s New for the 2009 PQRI” and the “2009 PQRI Made Simple- Reporting the Preventive Care Measures Group” links.

Notification of Error in Attachment D to Chapter 8 of the “OASIS Implementation Manual”

Section D (4) (c) (3) of Attachment D in the “OASIS Implementation Manual” contains an error. Currently, this section of the document incorrectly lists the Neuro 3-Stroke diagnosis group. The correct diagnosis group is Neuro 1-Brain Disorders and Paralysis. Case Scenario #4 also incorrectly assigns a diagnosis from the Neuro 3-Stroke diagnosis group. The correct diagnosis assignment in Scenario #4 should be from the Neuro 1- Brain Disorders and Paralysis diagnosis group.  Revisions to the above section of Attachment D, to include revisions to the associated Case Scenario #4, will be posted in the near future.  Questions related to Attachment D should be sent to: AskOasisAttachD@cms.hhs.gov.

“Attachment D” to Chapter 8 of the “OASIS Implementation Manual” is currently posted in the “Downloads” section of the “OASIS B1 User Manual website: http://www.cms.hhs.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp.

CMS Updates End Stage Renal Disease (ESRD) PC Pricer

The Centers for Medicare & Medicaid Services (CMS) has updated the PC Pricer web page at http://www.cms.hhs.gov/PCPricer/02e_ESRD_Pricer.asp#TopOfPage to include the updated ESRD PC Pricer with the rates for 2009.  The PC Pricer is located in the Downloads section of the web page.

Flu Shot Reminder

It’s seasonal flu time again! If you have Medicare patients who haven’t yet received their flu shot, you can help them reduce their risk of contracting the seasonal flu and potential complications by recommending an annual influenza and a one-time pneumococcal vaccination.  Medicare provides coverage of flu and pneumococcal vaccines and their administration. – And don’t forget to immunize yourself and your staff. Protect yourself, your patients, and your family and friends. Get Your Flu Shot – Not the Flu.

Remember - Influenza vaccine plus its administration are covered Part B benefits.  Note that influenza vaccine is NOT a Part D covered drug.

Health care professionals and their staff can learn more about Medicare’s coverage of the influenza vaccine and other Medicare Part B covered vaccines and related provider education resources created by CMS, by reviewing Special Edition MLN Matters article SE0838 http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0838.pdf on the CMS website.

Nursing jobs in the intensive care unit, emergency room and pediatrics will always be staples of the profession, but changes to the evolving health care system will also determine which nursing specialties will grow at an accelerated pace.

Read more at NurseZone.com: http://www.nursezone.com/Nursing-News-Events/more-news.aspx?ID=18834

Additional paperless processes are also being designed for the future, such as on-line applications and on-line payment.  More information will be provided as those phases move towards implementation.

For questions or more information please contact the Nursing Commission at 360-236-4709 or nursing@doh.wa.gov.

• To see NCQAC’s power point presentation related to the new paperless system for license renewal, download this PowerPoint presentation:  paperless-licensing-0309.ppt
• Attached is the list of confirmed sites for the March 24th Paperless Licensing Video Announcement.  If you wish to attend you may do so at one of these sites.  NOTICE: THE MARCH 27 VIDEO ANNOUNCEMENT HAS BEEN CANCELLED : Paperless Licensing Video Announcement Confirmed Sites (Excel format file)
  

From this web page, you will be able to access and peruse the Medicare FFS program topics in order to keep abreast of policy and operational updates specific to Advanced Practice Nurses and Physician Assistants.

One of the educational resources featured on this webpage is the “Advanced Practice Nurse/Physician Assistant Web-Based Training Program” – this interactive web-based training program provides definitions of the Advanced Practice Nursing/Physician Assistant provider types; outlines the qualifications of the Advanced Practice Nursing/Physician Assistant provider types; describes collaboration/supervision requirements for Advanced Practice Nursing/Physician Assistant Medicare reimbursements; lists the Medicare billing requirements for Advanced Practice Nursing and Physician Assistants; and identifies links to Medicare manuals and other resources.

This web page is updated on a regular basis, so check it often for timely and reliable information from MLN.

For more information, visit the web page at www.cms.hhs.gov/MLNProducts/70_APNPA.asp on the CMS website.

http://www.fda.gov/cdrh/safety/heparin-healthcare-update.html

Medical errors drive hospital costs up and while many seek ways to reduce these mistakes, not all fully understand their financial effects.

A new review suggests that current statistics on medical mistakes might not be comprehensive because they do not factor in all inpatient costs or include readmissions and patient care for the 90 days following surgery.

Read full article at NurseZone.com: http://www.nursezone.com/nursing-news-events/more-news.aspx?ID=18145