Heritage Medical

PECOS Letter

Dear Dr.

As an orthotic and prosthetic facility that appreciates your past referrals and hopes to continue to be able to offer care to your patients, we wanted to make you aware of a situation that will affect your ability to make referrals for Medicare patients.

Recently, CMS (The Centers for Medicare and Medicaid Services) began the process of implementing new
regulations that require all referring physicians to be enrolled in Medicare through the Provider Enrollment,
Chain and Ownership System (PECOS) in order to be eligible to refer their Medicare patients for DMEPOS and other services.

Starting on January 4, 2010, if you have not enrolled through PECOS, you will no longer be able to refer patients for durable medical equipment, orthotics, prosthetics, supplies and eventually clinical laboratory and radiological services.

In order to avoid this situation, you need to re-enroll with Medicare through the PECOS system. You can find information on PECOS and how to enroll at the CMs website www.cms.hhs.gov/MedicareProviderSupEnroll.

For additional information, you can also access the CMS MedLearn Matters article at
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6421.pdf (see page 3 under Key Points.)

Please be assured that we regret any additional work that this new Medicare requirement may impose on your very busy practice. Unfortunately, unless you re-enroll with Medicare through the PECOS system, neither our office nor any other O&P facility will be able to provide care to your Medicare patients effective January 4.

We appreciate your previous referrals and sincerely hope that we will be able to continue to serve you and your patients in the future.

Sincerely,

Compliance Standards for Consignment Closets and Stock and Bill Arrangements

Effective September 8, 2009

SUBJECT: Compliance Standards for Consignment Closets and Stock and Bill Arrangements

I. SUMMARY OF CHANGES: The purpose of this change request is to define and prohibit certain
arrangements where an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather, owned by a physician, non-physician practitioner or other health care professional for the purpose of distribution, commonly referred to as a consignment closet and/or stock and bill arrangement.

In addition, this change request will instruct physicians, non-physician practitioners or other health care professional’s practices that use of consignment closets and/or stock and bill arrangements (as defined above) must be in compliance with current standards.

NEW / REVISED MATERIAL
EFFECTIVE DATE: *September 8, 2009
IMPLEMENTATION DATE: September 8, 2009
Disclaimer for manual changes only: The revision date and transmittal number apply only to red
italicized material. Any other material was previously published and remains unchanged. However, if this
revision contains a table of contents, you will receive the new/revised information only, and not the entire
table of contents.

II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED

R/N/D CHAPTER / SECTION / SUBSECTION / TITLE
R 10/Table of Contents
N 10/21/.8/Consignment Closets and Stock and Bill Arrangements

III. FUNDING:
SECTION A: For Fiscal Intermediaries and Carriers: N/A
SECTION B: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

IV. ATTACHMENTS:
Business Requirements
Manual Instruction
*Unless otherwise specified, the effective date is the date of service.

Download CMS Compliance Standards

Devices Used for Edema or Ulcer Healing

July 30, 2009

From CMS

HCPCS Code A9283 - DEVICES USED FOR EDEMA OR ULCER HEALING

HCPCS code A9283 (Foot pressure off loading / supportive device, any type, each) was developed to describe various devices used for the treatment of edema or for a lower extremity ulcer or for the prevention of ulcers.

When products are used solely to treat edema or ulcers or to prevent an ulcer of the lower extremity, suppliers should code them based on the patient's condition.

For example, walking boots are coded L4360 and L4386 when they are used as a brace for the treatment of orthopedic conditions. However, if walking boots are used solely for the prevention or treatment of a lower extremity ulcer or edema reduction, they shall be coded A9283.

When using code A9283, there is no separate billing using addition codes. Replacement liners for devices billed with A9283 must be billed with code A9270 (noncovered item or service).

The instructions in the Ankle-Foot, Knee-Ankle-Foot Orthoses LCD, Documentation Requirements section, concerning the use of the GY modifier no longer apply and will be deleted in a future revision of the policy.

CMS Revises Orthopedic Footwear LCD

Orthopedic Footwear LCD
Revision Effective Date: 10/01/2009
HCPCS CODES AND MODIFIERS:

Added: GY modifier.
Revised: KX modifier.
DOCUMENTATION REQUIREMENTS:

Added: GY modifier instructions.
Policy Article
Revision Effective Date: 10/01/2009
CODING GUIDELINES:
Revised: RT/LT modifier instructions.
Changed: SADMERC to PDAC.

More info, click here.

The revised information is contained in the Documentation Section and outlines the use of additional modifiers to indicate that an item is statutorily noncovered or not medically necessary and whether or not a waiver of liability statement (i.e., Advance Beneficiary Notice of Noncoverage or ABN) is on file for an expected medical necessity denial.

Proper use of the KX modifier expedites claim processing. Currently, an absent modifier causes a claim denial. However, increasing numbers of claims are submitted without the modifier resulting in a growing appeals volume. If the patient meets the criteria for use of the KX modifier but the supplier forgets to include it on the claim line, currently the supplier may request a reopening of the claim. This procedure requires manual intervention by the DME MAC and is responsible for a substantial workload for the contractor.

Effective with these LCD revisions, the contractors will use the presence of a KX, GA, GZ or GY modifier to indicate whether the coverage criteria are or are not met. The DME MACs are implementing system edits that will now reject a claim line if the supplier does not include one of these modifiers as specified in each of these LCDs. If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier. Requesting a reopening to correct a claim that is missing one of these modifiers will no longer be an available option.

Since the KX modifier has a differing definition depending on the LCD requirements, suppliers should review the revised LCDs carefully to understand the proper use of the KX, GA, GZ or GY modifiers for each policy.

Over the coming months, other LCDs that include use of the KX modifier will be updated to incorporate instructions for the use of the GA, GZ or GY modifiers.

IMPORTANT CHANGE - KX, GA, GZ and GY Modifiers - New Uses

Many policies use the KX modifier to indicate compliance with specified coverage criteria. The following LCDs have revised instructions on modifier use. Refer to each policy for detailed guidance.

• Automatic External Defibrillators
• Cervical Traction Devices
• Commodes
• Epoetin
• Home Dialysis Supplies and Equipment
• Positive Airway Pressure Devices
• Respiratory Assist Devices
• Therapeutic Shoes for Persons with Diabetes

The revised information is contained in the Documentation Section and outlines the use of additional modifiers to indicate that an item is statutorily noncovered or not medically necessary and whether or not a waiver of liability statement (i.e., Advance Beneficiary Notice of Noncoverage or ABN) is on file for an expected medical necessity denial.

Proper use of the KX modifier expedites claim processing. Currently, an absent modifier causes a claim denial. However, increasing numbers of claims are submitted without the modifier resulting in a growing appeals volume. If the patient meets the criteria for use of the KX modifier but the supplier forgets to include it on the claim line, currently the supplier may request a reopening of the claim. This procedure requires manual intervention by the DME MAC and is responsible for a substantial workload for the contractor.

Effective with these LCD revisions, the contractors will use the presence of a KX, GA, GZ or GY modifier to indicate whether the coverage criteria are or are not met. The DME MACs are implementing system edits that will now reject a claim line if the supplier does not include one of these modifiers as specified in each of these LCDs. If a claim line is rejected, the supplier may resubmit the claim line with the appropriate modifier. Requesting a reopening to correct a claim that is missing one of these modifiers will no longer be an available option.

Since the KX modifier has a differing definition depending on the LCD requirements, suppliers should review the revised LCDs carefully to understand the proper use of the KX, GA, GZ or GY modifiers for each policy.

Over the coming months, other LCDs that include use of the KX modifier will be updated to incorporate instructions for the use of the GA, GZ or GY modifiers.

MORE THERAPEUTIC SHOE INFO

Download Therapeutic shoe update CMS

Upcoming DME MAC Seminar for O&P Providers in Cherry Hill, NJ

REGISTER HERE

REGISTRATION DEADLINE IS
AUGUST 14, 2009

SEPTEMBER 2, 2009
IS THE SEMINAR IN CHERRY HILL, NJ

Program Agenda

Time	Description
7:30am - 9:00am	Registration / Exhibits Open
8:30am	Breakfast Begins In General Session Room
9:00am - 10:00am	Welcome and Introduction / Keynote Speaker Amy Capece, Manager, Provider Outreach & Education CMS
10:00am - 10:15am	Morning Break / Exhibits
10:15am - 11:30am	Concurrent Breakout Sessions The Basics - Not Just for Beginners Medicare News You Can Use - DME MAC Updates & Hot Topics DME MAC Cyber Session - Going Green CERT and DME - What DMEPOS Suppliers Need to Know! Introduction to the Recovery Audit Contractor (RAC)
11:30am - 1:00pm	Lunch Begins In General Session Room / Speaker Paul J. Hughes, M.D. - Jurisdiction A Medical Director
1:00pm - 2:15pm	Concurrent Breakout Sessions Getting It Right the First Time - Clues to Troubleshooting DME MAC Claims O & P Troubleshooting - Detecting the Truth Reopenings and Appeals - Revealing the Differences Get Ready for DMEPOS Competitive Bidding NSC & Me: How to Secure My Medicare Billing Privileges
2:15pm - 2:30pm	Afternoon Break / Exhibits
2:30pm - 4:00pm	Concurrent Breakout Sessions Getting It Right the First Time - Clues to Troubleshooting DME MAC Claims Medicare News You Can Use - DME MAC Updates & Hot Topics Repairs and Replacements - Knowing the Facts Makes a Difference CERT and DME - What DMEPOS Suppliers Need to Know! Introduction to the Recovery Audit Contractor (RAC)

DME MAC Jurisidiction A upcoming shows/meetings

Trade Shows/Special Events

Events at which DME MAC Jurisdiction A will be exhibiting and/or presenting information. Keep checking this page for updates.

• 2009 AOPA National Assembly - Washington State Convention & Trade Center
  September 20-23, 2009, Seattle, Washington
  
  
• Medtrade - Georgia World Congress Center
  October 13-15, 2009, Atlanta, GA
  
  
• The New England Chapter American Academy of Orthotists and Prosthetists (NEAAOP) 2009 Scientific Symposium - The Radisson Hotel Manchester
  October 14-16, 2009, Manchester, NH
  
  
• POPS Annual Meeting - Holiday Inn Hotel and Conference Center
  November 2, 2009, New Cumberland, PA
  
  
• New Jersey American Academy of Orthotists and Prosthetists (NJAAOP) Annual Meeting - Bally’s Hotel and Casino
  November 11-13, 2009, Atlantic City, NJ
  
  
• Jersey Association of Medical Equipment Suppliers (JAMES) Annual Conference - Ocean Place Resort & Spa
  November 18-19, 2009, Long Branch, NJ

Source

Update from CMS

July 01, 2009

Therapeutic Shoes - Withdrawal of Policy Article

A revision of the Therapeutic Shoes for Persons with Diabetes Policy Article was recently released. The effective date was listed as August 1, 2009. That version of the Policy Article is being withdrawn. The current version of the Policy Article which has an effective date of October 1, 2008 remains in effect until a new revised Policy Article is published.

LCD and Policy Article Revisions - Therapeutic Shoes

Therapeutic Shoes for Persons with Diabetes
     LCD
     Revision Effective Date: 08/01/2009
     CMS NATIONAL COVERAGE POLICY:
         Added: Benefit Policy Manual reference.
     HCPCS CODES AND MODIFIERS:
         Added: GY modifier.
     DOCUMENTATION REQUIREMENTS:
         Revised: Instructions for certification statement to indicate that it must be completed by the certifying physician.
         Revised: Instructions concerning KX modifier to refer to the Policy Article.
         Clarified: Information documenting that KX modifier requirements have been met must be in the records of the certifying physician.
         Added: Instructions for use of GY modifier.

     Policy Article
     Revision Effective Date: 08/01/2009
     NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
         Clarified: Documentation of qualifying conditions must be in the medical records of the certifying physician. (This requirement has always been included in the national policy. The 08/01/2009 effective date does not apply.)
     CODING GUIDELINES:
         Clarified: Definitions of A5512 and A5513.
         Revised: Billing instructions for the RT and LT modifiers.
         Added: Statement that custom fabricated inserts do not require PDAC Coding Verification Review. 

Download Therapeutic shoe update CMS

Accreditation Date Rapidly Approaching!

Impact to You
DMEPOS suppliers enrolled with the National Supplier Clearinghouse (NSC) are required to obtain accreditation by September 30, 2009.

What You Need to Know if You Choose Not to Become Accredited
In order to obtain or retain your Medicare Part B billing privileges, all DMEPOS suppliers (except for exempted professionals and other persons as specified by the Secretary of the Department of Health and Human Services as noted below in this article) must comply with the Medicare program’s supplier standards and quality standards and become accredited. These standards can be found in 42 CFR 424.57 or on page 36 & 37 of the CMS 855S. A DMEPOS supplier’s Medicare Part B billing privileges will be revoked on or after October 1, 2009, if the DMEPOS supplier fails to obtain accreditation unless the DMEPOS supplier submits a voluntary termination to the NSC by September 30, 2009.

What You Need to Do if You Choose Not to Become Accredited
For those DMEPOS suppliers who choose not to become accredited at this time, they will need to submit an amended CMS-855S application which reflects their voluntary termination. This will prevent the supplier from being revoked and subsequently barred from the Medicare program, as cited in 42 CFR Section 424.535(c). For pharmacies that choose not to become accredited but wish to remain a DMEPOS supplier in order to continue to bill Medicare for drugs and biologicals only, an amended CMS 855S will have to be completed. In addition to updating their application, the supplier must ensure that they have checked the appropriate boxes in Section 2 (C) to reflect which drugs and biologicals they will provide to beneficiaries. Providers and suppliers can find the latest version of CMS 855S at http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf on the Centers for Medicare & Medicaid Services (CMS) website.