dmerc medicare advisory · comments and suggestions are welcome. please direct them to...

Comments and suggestions are welcome. Please direct them to Communications Specialistsin the Professional Relations department at the address listed above or www.pgba.com.

DMERCMEDICARE ADVISORY

Palmetto Government Benefits Administrators, LLC

Summer 1999 Issue 29Page 99-33

New MexicoNorth Carolina

OklahomaPuerto Rico

South CarolinaTennessee

TexasVirgin Islands

AlabamaArkansasColoradoFlorida

GeorgiaKentuckyLouisiana

Mississippi

Durable Medical Equipment Regional Carrier PO Box 100141 Columbia SC 29202-3141

MEDICARE

Palmetto Government Benefits Administrators, LLC

NEW MEDICAL POLICY

RESPIRATORY ASSIST DEVICES

A new Respiratory Assist Devices (RAD) DMERCRegional Medical Review Policy (RMRP) is published with the manual revisions accompany-ing this Advisory. Its effective date of implementation is for dates of service on or afterOctober 1, 1999.

The Health Care Financing Administration (HCFA)proposed that the policy on Respiratory AssistDevices be effective October 1, 1999. Beforeimplementing this policy, however, there will be an

open meeting in the nearfuture at HCFA inBaltimore to discuss the appropriate DME payment category for res-piratory assist deviceswith bi-level pressurecapability and with the backup rate feature.Please watch for the Federal Register notice of themeeting. HCFA hopes that all interested partiesincluding the physician community, the suppliercommunity and beneficiaries will be in attendanceand that there will be a full discussion of theassignment of these devices into the capped rentalpayment category. It is HCFA's view that thesedevices are excluded from the class of itemsrequiring frequent and substantial servicing in

Accessories used with CPAP devices........... 35AFO/KAFO/Ankle Positioning Splint............. 36Claim filing reminder...................................... 47CMN Completion........................................... 49Cover letters.................................................. 35 External Infusion Pump................................. 37Fee Changes................................................. 52Fee Update....................................................53Get Hooked on the Web................................45HCPCS Helpline........................................... 45HCPCS code J7506 fee clarification............. 54Heated Humidifier.......................................... 35Hospital Beds

Physician information sheet...................... 43

Immunosuppressive drugs............................ 37New HCPCS code K0534............................. 34New Product Classification............................56NSC Change of Address............................... 55OIG Special Fraud Alerts...............................46Ombudsmen

New Ombudsmen..................................... 55Addresses/territories................................. 68

Oral Anti-cancer drug correction....................54Oral Anti-emetic drugs.................................. 38PACES software/Y2K Compliant................... 48Portable Oxygen............................................38Prompt Payment Interest rate correction...... 46Region C Directory....................................... 69

Respiratory Assist DevicesNew Medical policy....................................33

Supplier Reinstatement Actions.....................62Supplier Sanctions.........................................60Voluntary Refunds..........................................50

Overpayment Refund form........................51Web site overview..........................................70Workshop Wizard.......................................... 63Team Tips...................................................... 65Y2K Toll-free help line................................... 47Year 2000 and Your PC.................................48

IN THIS ISSUE

WWeebb ssiittee WWeebb ssiittee

SSurveey oon bbaacckkSSurveey oon bbaacckk

ccooveer!!ccooveer!!

Summer 1999 DMERC Medicare Advisory

accordance with Section 1834(a)(3) of the Social Security Act. HCFAwill be accepting written comments on the appropriateness of theDME payment category for respiratory assist devices with bi-levelpressure capability and with the backup rate feature. Additionalinformation on providing comments has been published in theFederal Register. Comments should be mailed to the followingaddress:

Health Care Financing AdministrationDivision of Community Post-Acute CareAttn: Joel KaiserC5-06-277500 Security BoulevardBaltimore, MD 21244-1850

Comments may also be submitted electronically to the followinge-mail address:

[email protected]

E-mail comments must include the full name, address, and affiliation (if applicable) of the sender, and must be submitted to thereferenced address in order to be considered. All comments mustbe incorporated in the e-mail message because we may not be able toaccess attachments.

A special DMERC bulletin will be issued some time after the public meeting and prior to October 1, 1999, and will contain thedetermination of the payment category for each code and all applica-ble billing instructions.

NEW MEDICAL POLICY

Respiratory Assist Devices

(continued)

For dates of service on or after October 1, 1999, another HCPCScode has been established:

K0534: Respiratory assist device, bi-level pressure capability, withbackup rate feature, used with invasive interface, e.g., tracheostomytube (intermittent assist device with continuous positive airwaypressure device)

K0534 describes a bi-level pressure device used with an invasiveinterface. For dates of service on or after October 1, 1999, E0453used with an invasive interface should be billed to the DMERC usingHCPCS code K0534.

Accessories used with the K0534 will have the same utilizationparameters as are described in the RAD RMRP for accessory HCPCScodes K0187 - K0189.

NEW HCPCS CODE

RAD: K0534

Summer 1999 DMERC Medicare Advisory 5

ACCESSORIES USED WITHCPAP DEVICES

The Respiratory Assist Devices Regional Medical Review Policydescribes usual maximal amounts of accessories (HCPCS codesK0183-K0189) used with respiratory assist devices HCPCS codesK0532 and K0533 which are expected to be medically necessarywithin a period of time. Since these are the same accessories usedwith CPAP devices (HCPCS code E0601), for dates of service on orafter October 1,1999, the published amounts for these accessorieswill apply to their use with CPAP devices as well.

HEATED HUMIDIFIER

New HCPCS Code

A new HCPCS code has been established for a heated humidifier thatis used with a CPAP device (HCPCS code E0601) or a respiratoryassist device (HCPCS code K0532, K0533, or K0534):

K0531 - Humidifier, heated, used with positive airway pressure device

This HCPCS code is effective for dates of service on or after October1, 1999. HCPCS code K0531 is in the Inexpensive or RoutinelyPurchased (IRP) DME payment category.

Published clinical evidence has not demonstrated that a heatedhumidifier provides a significant benefit compared to a nonheatedhumidifier. Therefore, if a K0531 humidifier is provided for usewith a covered CPAP device or a covered respiratory assist device,payment will be based on the allowance for the least costly medically appropriate alternative, HCPCS code K0268 (nonheatedhumidifier). This is a continuation of current DMERC policy.

COVER LETTERS Suppliers should remind physicians of their responsibility to properly and conscientiously complete Certificates of MedicalNecessity. It is the physician's responsibility to determine both themedical necessity and utilization of all health care services, includingDME, prostheses, orthoses and supplies used in the home setting.The physician should ensure that the information relating to the ben-eficiary's condition is correct. Suppliers may use cover letters toremind the physician of these responsibilities - to review the answersto Section B of the CMN for accuracy, and also to assure that ade-quate notes are entered into the patient's chart to corroborateanswers supplied on the CMN. Future DMERC audits may requirecopies of relevant portions of the patient's chart to ultimately estab-lish the existence of medical necessity, as represented on CMNs sub-mitted with claims.


POLICY REVISION

AFO/KAFO/AnklePositioning Splint

A revision of the Ankle-Foot and Knee-Ankle-Foot Orthoses policy isincluded in the accompanying Supplier Manual update. Thisrevised policy will become effective for dates of service on or afterOctober 1, 1999. The basic elements of the AFO/KAFO policy havenot changed. Some of the minor changes include:

♦ Adding HCPCS codes for all additions to AFOs to the HCPCS section for completeness,

♦ Adding definitions for prefabricated and custom fabricated orthoses,

♦ Adding definitions and coding guidelines distinguishing AFOs from foot orthoses,

♦ Distinguishing AFOs used in ambulatory patients from those used in nonambulatory patients for coding and coverage purposes,

♦ Placing Coverage and Payment information from the current AFO/KAFO policy in a subsection titled "AFOs and KAFOs used in ambulatory patients,"

♦ Adding a statement that socks used in conjunction with orthoses are noncovered (effective for dates of service on or after October 1, 1999),

♦ Specifying codes for custom fabricated orthoses in the Coding Guidelines section,

♦ Incorporating information that had been previously published about HCPCS code L2860 into the Coding Guidelines section,

♦ Adding statements to the Documentation section about using the ZY modifier when billing for noncovered uses of AFOs (effective for dates of service on or after October 1, 1999).

The revised policy also incorporates and updates all the information from the current policy on Recumbent Ankle PositioningSplints. Therefore the Recumbent Ankle Positioning Splint policy asa separate policy will be deleted when the revised AFO/KAFO policybecomes effective (i.e., dates of service on or after 10/1/99). Some ofthe changes relating to recumbent ankle positioning splints include:

♦ Updating the HCPCS codes because all of the codes in the current Recumbent Ankle Positioning Splint policy have either been previously converted to L codes or eliminated,

♦ Clarifying definitions and coverage statements relating to ankle positioning splints,

♦ Placing Coverage and Payment information from the Recumbent Ankle Positioning Splint policy in a subsection titled "AFOs used in nonambulatory patients,"

♦ Adding statements to the Documentation section about use of the ZY modifier when billing for noncovered uses of AFOs

(effective for dates of service on or after October 1, 1999).

Summer 1999 DMERC Medicare Advisory Page 37

IMMUNOSUPPRESSIVE DRUGS

Pancreas Transplant

As the result of a revision to the Medicare Coverage Issues Manual,Section 35-82, coverage of immunosuppressive drugs is beingextended to include patients who meet all of the following criteria:

♦ The patient receives a Medicare-covered whole organ pancreas transplant on or after July 1, 1999, and

♦ The patient has had a prior Medicare-covered kidney transplant because of diabetic nephropathy, and

♦ The patient was enrolled in Medicare Part A at the time of bothtransplants and is enrolled in Medicare Part B at the time thatthe drugs are dispensed, and

♦ The drugs are medically necessary to prevent or treat rejectionof the organ transplants in the particular patient, and

♦ The drugs are furnished within 36 months after discharge fromthe hospital following the pancreas transplant.

Immunosuppressive drugs will be denied as noncovered if they areused following a whole organ pancreas transplant that was notsimultaneous with or preceded by a kidney transplant for diabeticnephropathy. Coverage of immunosuppressive drugs already existsand will continue for patients who have had a pancreas transplantsimultaneous with a Medicare-covered kidney transplant because inthese situations coverage is based on the kidney transplant. BecauseMedicare does not cover transplantation of partial pancreatic tissueor islet cells, if these tissues are transplanted subsequent to aMedicare-covered kidney transplant, coverage of immunosuppressivedrugs will be limited to those furnished within 36 months after hos-pital discharge following the kidney transplant.

Refer to the Immunosuppressive Drugs policy in the Region CDMERC DMEPOS Supplier Manual for more information onCoverage and Payment Rules, Coding Guidelines, andDocumentation requirements. On the DMERC Information Form(DIF), in question #5, which asks for the organ that has been trans-planted most recently, enter the statement "whole organ pancreastransplant subsequent to Medicare-covered kidney transplant" if this

The Regional Medical Review Policy on External Infusion Pumps hasbeen included in the accompanying manual revisions. The followingchanges were made:

♦ Coverage and Payment Rules have been reformatted to improve clarity

♦ Liposomal amphotericin B (HCPCS code J0286) is now covered for patients who have had significant toxicity to standard amphotericin and are unable to complete that course of therapy or for those patients who have significantly impaired hepatic function.

♦ Flolan (epoprostenol, HCPCS code J1325) will additionally be covered for those patients with pulmonary hypertension secondary to a connective tissue disease.

POLICY UPDATED

External Infusion Pump


For beneficiaries with initial dates of service on or after October 1,1999, Medicare will cover only a stationary oxygen system if theoxygen test was conducted during sleep and all coverage criteria aremet. Portable oxygen systems for beneficiaries tested during sleepwill be denied as not medically necessary.

PORTABLE OXYGEN

Effective for dates of service on or after January 1, 1999, theDMERCs will begin processing claims for oral anti-emetic drugs dis-pensed by a pharmacy when they are used in conjunction with intra-venous cancer chemotherapeutic regimens. (If these drugs are dis-pensed by the ordering physician, they are billed to the local carrier.If they are dispensed in an outpatient hospital facility, they are billed to the local intermediary.) Special Q HCPCScodes (Q0163-Q0181) have been established to bill for these drugsin this situation. The HCPCS codes are:

Q0163 Diphenhydramine hydrochloride 50mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosageregimen

Q0164 Prochlorperazine maleate 5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hourdosage regimen

Q0165 Prochlorperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hourdosage regimen

Q0166 Granisetron hydrochloride 1mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen

Q0167 Dronabinol 2.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute

ORAL ANTI-EMETICDRUGS

correctly describes the patient's situation. Initial claims forimmunosuppressive drugs related to a pancreas transplant subse-quent to a kidney transplant must be filed hard copy. Subsequentclaims in these situations may be filed electronically.

IMMUNOSUPPRESSIVE DRUGS

Pancreas Transplant(continued)


for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0168 Dronabinol 5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute foran IV anti-emetic at the time of chemotherapy treat-ment, not to exceed a 48 hour dosage regimen

Q0169 Promethazine hydrochloride 12.5mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hourdosage regimen

Q0170 Promethazine hydrochloride 25mg, oral, FDA approvedprescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0171 Chlorpromazine hydrochloride 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0172 Chlorpromazine hydrochloride 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0173 Trimethobenzamide hydrochloride 250mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0174 Thiethylperazine maleate 10mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0175 Perphenazine 4mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0176 Perphenazine 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treat ment, not to exceed a 48 hours dosage regimen

Q0177 Hydroxyzine pamoate 25mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time

ORAL ANTI-EMETICDRUGS(continued)


of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0178 Hydroxyzine pamoate 50mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0179 Ondansetron hydrochloride 8mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Q0180 Dolasetron mesylate 100mg, oral, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 24 hour dosage regimen

Q0181 Unspecified oral dosage form, FDA approved prescription anti-emetic, for use as a complete therapeutic substitute for an IV anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen

Oral anti-emetic drugs billed with HCPCS codes Q0163-Q0181 arecovered only if all of the following criteria are met:

1) The drug has been approved by the Food and DrugAdministration (FDA) for use as an anti-emetic, and

2) The drug has been ordered by the treating physician aspart of a cancer chemotherapy regimen, and

3) The drug is used as a full therapeutic replacement for an intravenous anti-emetic drug that would otherwise have been administered at the time of the chemotherapy treatment, and

4) The initial dose of the oral anti-emetic drug is administered within 2 hours of the administration of thechemotherapy drug.

If all of the above criteria are met, the quantity of oral anti-emeticdrugs covered for each episode of chemotherapy cannot exceed theinitial loading dose plus 48 hours of therapy. However, for the drugsgranisetron (Q0166) and dolasetron (Q0180), the quantity of drugs covered for each episode of chemotherapy is limited to the initial loading dose plus 24 hours of therapy.

Criterion 3 is not met when the chemotherapy drug is an oral drugor when the chemotherapy drug is administered intravenously in the home setting because the type and dosage ofchemotherapy drugs administered in these situations do not requireintravenous anti-emetic drugs.

Oral anti-emetic drugs which do not meet all of the criteria describedabove are noncovered under Section 1861(s)(2)(T) of the SocialSecurity Act.



The supplier may bill for only a single course of oral anti-emeticdrugs at a time and the quantity of drugs billed using HCPCS codesQ0163-Q0181 must not exceed the 24 or 48 hours of therapy specified above.

Documentation:

Order: The supplier must have a detailed written order for thedrug which has been signed and dated by the treating physician.There must be a statement on the order which indicates that theoral anti-emetic drug is a full therapeutic replacement for an intra-venous anti-emetic drug as part of a cancer chemotherapy regimen.The patient's cancer diagnosis must be entered on the order by thephysician. This order must be available to the DMERC on request.The supplier may bill using HCPCS code Q0163-Q0181 only if theyhave a written order with the specified attestation.

HCFA-1500 (12/90) claim form: The supplier must enter an ICD-9diagnosis code corresponding to the patient's cancer diagnosis on each claim.

HCPCS code Q0181 is a miscellaneous code which may be usedonly when all the requirements of the policy are met, but the drugadministered does not have a specific HCPCS code (Q0163-Q0180).Claims for HCPCS code Q0181 must be accompanied by the nameof the drug, the dosage strength dispensed, the number of tablets and frequency of administration during the cov-ered time period (24-48 hours) as specified on the order. Thisinformation should be entered in the HAØ record of an electronicclaim or attached to a hard copy claim.

Two Separate Oral Anti-Emetic Benefits:

The coverage of oral anti-emetic drugs described above (i.e., as afull therapeutic substitute for an intravenous anti-emetic at the timeof chemotherapy treatment) and billed using HCPCS codes Q0163-Q0181 is distinct from coverage of oral anti-emetic drugs (billedusing HCPCS code K0415) which are related to the administration of oral anti-cancer drugs.



Dear Physician:

The following is a summary of the Durable Medical Equipment Regional Carrier's (DMERC's) RegionalMedical Review Policy (RMRP) upon which Medicare bases reimbursement decisions for some of theequipment physicians might order for patients. It describes the equipment, its usual clinical indications, Medicare's coverage criteria for reimbursement, and the adjudication criteria for claims.

The DMERC strongly believes that the physician is still the "Captain of the Ship." Palmetto GovernmentBenefits Administrators (Palmetto GBA) requires a physician's order before reimbursing any item.Sometimes Palmetto GBA requires a Certificate of Medical Necessity (CMN) and extra documentation.

While this may inconvenience physicians with additional paperwork, it is only through physician cooper-ation that Medicare can provide beneficiaries with the appropriate equipment and supplies they need.Physicians are also helping to protect the Medicare Trust Fund from abusive and fraudulent claims for items that are not medically necessary or physician-ordered. Funds lost to unnec-essary utilization of and fraudulent claims for DME come from the same Part B Medicare Fund fromwhich physicians are reimbursed for their own services.

The following Physician Information Sheet (PHYIS) is only a summary of the RMRP published in theDMERC Region C DMEPOS Supplier Manual. The definitive and binding coverage policy will always bethe RMRP itself, which reflects national Medicare policy, and upon which actual claims adjudication is based. The Physician Information Sheet is intended only as an effort to educate thephysician community on conditions of coverage for items of durable medical equipment, prostheses,orthoses, and supplies when ordered for the care of Medicare beneficiaries.

If more detailed information is desired, the physician is encouraged to obtain a copy of the RMRP fromthe supplier servicing your patient, or directly from the Region C DMERC office of Professional Relationsat (803) 735-1034, ext. 35707 or 35745.

Paul D. Metzger, M.D.Medical DirectorRegion C DMERC Palmetto Government Benefits Administrators, LLCColumbia, SC


HOSPITAL BEDS

PHYSICIAN INFORMATION SHEET

Description of Equipment:

An ordinary bed (not a hospital bed) is one which is typically sold as furniture. It consists of a frame,box spring and mattress. The frame is a fixed height from the floor and has no head or leg elevationadjustments. An ordinary bed will accommodate most transfers to a chair, wheelchair or standing posi-tion. If needed, it can almost always be adjusted to accommodate these transfers. The need for a par-ticular height from the floor would rarely by itself justify the need for a hospital bed.

Hospital beds allow the patient's position to be changed at the head and foot of the bed, as well as thedistance of the bed frame from the floor. Hospital beds may be:

♦ Totally Manual and of Fixed Height, having manual (a cranking mechanism) head and leg elevation adjustments, but no height adjustment;

♦ Totally Manual and with Variable Height, having additionally, manual height adjustment;

♦ Semi-Electric, having electric head and leg adjustment, but still manual height adjustment;

♦ Total Electric, having electric head and leg adjustment, plus electric height adjustment.

Indications for Hospital Beds:

Fixed Height (One or more of the following):

♦ A patient who requires positioning of the body in ways not feasible with an ordinary bed, for thealleviation of pain.

♦ A patient who requires the head of the bed to be elevated more than 30 degrees most of the timedue to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Pillows or wedges should first have been considered.

♦ A patient who requires traction equipment which can only be attached to a hospital bed.

Variable Height (In addition to one of the above):

♦ The patient requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

Semi-Electric:

♦ In addition to the above indications, the patient requires frequent or immediate changes in body position.

Total Electric: (Not covered by Medicare):

The additional feature allowing for motorized adjustment of the height of the bed frame from the floor isstrictly for the convenience of the caregiver. While the caregiver may have true limitations in his/herability to minister to the patient, the laws upon which Medicare national payment policy is based do notallow for consideration to be extended to the patient's caregiver. Therefore, this added feature is not covered. However, this does not mean that the more basic (semi-electric) feature of thebed will be denied. If the indications for a semi-electric bed are met, then payment will be made byMedicare at the level of a semi-electric bed.


Comment:

It is rarely necessary for a patient to require changes from one type of hospital bed to another (e.g., vari-able height to semi-electric) once, in the judgment of the physician, a particular level of bed has beenordered. It is inconceivable that a patient should "progress" from a higher to a lower level bed (e.g.,semi-electric to a variable height). Medicare should not pay for two beds, when the needs of the patientcould have been anticipated based on the clinical condition originally judged to require a hospital bed.

DOCUMENTATION:

The supplier of your patient's equipment must submit a Certificate of Medical Necessity (CMN) with theclaim in order to obtain Medicare reimbursement. Section B of the CMN contains questions pertainingto the medical necessity of the equipment which may not be completed by the supplier. The physician oranother health care clinician involved in the care of the patient may complete Section B, BUT ONLY THEPATIENT'S PHYSICIAN MAY SIGN THE CMN, INDICATING THAT HE/SHE HAS REVIEWED SECTION BOF THE CMN FOR ACCURACY AND COMPLETENESS. In addition, the physician should review SectionA to affirm that this is the appropriate patient, and Section C to ascertain that this is the equipment thathas been ordered, and that the supplier's charges and expected Medicare reimbursement have beenentered onto the form for the physician's review.

The physician's medical record of the patient must contain documentation substantiating that thepatient's condition meets the above coverage criteria and the answers given in Section B of the CMN.These records may be requested by the DMERC to confirm concurrence between the medical record andthe information submitted to the DMERC.

Paul D. Metzger, M.D. Medical DirectorRegion C DMERC Palmetto Government Benefits Administrators, LLCColumbia, SC


Effective May 1, 1999, the HCPCS Helpline Representatives at theStatistical Analysis Durable Medical Equipment Regional Carrier(SADMERC) will be available to answer your coding questions from 9:00 am - 4:00 pm EST Monday through Friday withextended hours on Wednesday. Our Helpline will remain open until6:00 pm EST on Wednesday. Please also note that our Helplineremains open throughout the lunch hours. We received your com-ments on our customer survey regarding the desire for extended hours to accommodate our West Coast customers. TheSADMERC is always looking for ways to improve service to our customers. If you have suggestions, please feel free to contact usthrough our web site address, Helpline or in writing. In addition toassisting with proper HCPCS code recommendations, the representatives are able to address your fee schedule requests.Please note we are not able to assist customers with allowables foritems not on a fee schedule (e.g. reasonable charge, individually considered).

Questions and inquiries regarding HCPCS code usage and fee schedule allowances should be directed to:

www.pgba.com/palmetto/main.nsf/allframesets/oth_sadm.htmlor

HCPCS Helpline(803) 736-6809

or

SADMERC/HCPCS UnitP.O. Box 100143

Columbia, South Carolina 29202-3143

HCPCS HELPLINESADMERC

GET HOOKEDON THE WEB

The SADMERC strives to the stay on the cutting edge of technology. Our latest effort to better serve our customers is ourweb site. If you're connected, it's easy to access up to date SADMERC information. Located on our site are all HCPCS advisory articles that are available through the DMERC Advisoriesand speciality publications such as the Required DocumentationList for Coding Verification reviews. Also located on our web site isa copy of all product classification lists, frequently asked questions and any pertinent related links such as the HCFA feeschedule for HCPCS codes.

The site also permits you to give us feedback. We want to knowwhat you think of our site and any additional information you wouldlike to see. To give us feedback, just click on the feedback buttonlocated on all screens. Please remember that the SADMERC cannot address coverage or any claims information.These are questions to direct to your DMERC. The web site strivesto better serve our customers by giving them 24-hour access toHCPCS information. Our address on the internet is:

www.pgba.com/palmetto/main.nsf/allframesets/oth_sadm.html


OIG SPECIAL FRAUD ALERTS In January of this year, the Office of Inspector General (OIG) issueda Special Fraud Alert in an effort to promote voluntary compliance inthe health care industry and assist providers in their complianceefforts. The Alert addressed potential problem areas with regard tophysician certification in the provision of medical equipment andsupplies and home health services. Among other things, this newlyissued Special Fraud Alert addressed: (1) the importance ofphysician certification for Medicare; (2) how improper physiciancertifications foster fraud; and (3) potential consequences forknowingly signing a false or misleading certification, or signing withreckless disregard for the truth.

Special Fraud Alerts are intended for widespread dissemination tothe health care provider community, as well as those charged withadministering the Medicare and Medicaid programs. It is the OIG'sintention to publish future Special Fraud Alerts in this same manneras a regular part of their dissemination of such information.

Medicare recognizes the physician as the key figure in determiningappropriate utilization of all medical services. Payment for certainnon-physician services, such as medical equipment and supplies, areconditional on the existence of a physician's order or certificate ofmedical necessity which must be kept on file by the supplier. TheOffice of Evaluation and Inspections has undertaken a series ofstudies to look at the role of the physician in certifying these non-physician services.

The first report is about physicians' perceptions of the certificationprocess for durable medical equipment, prosthetics, orthotics andsupplies. The second report looks at the relationship between thephysician and the patient and its effect on the certification ofmedical equipment and supplies.

These reports can be accessed at:

www.dhhs.gov/progorg/oig/frdalrt/index.htm

PROMPT PAYMENT

Interest rate correction

The prompt interest rate published in the Spring 1999 DMERCMedicare Advisory (page 18) was incorrect.

The prompt interest rate is 5.00 percent. The rate applies to cleanpaper and electronic claims that have not paid by the 30th day afterhaving been received by Palmetto Government BenefitsAdministrators. This rate was effective January 1, 1999, and endsJune 30, 1999.


As part of its continuing efforts to help healthcare plans andproviders prepare their computer systems for the Year 2000, theHealth Care Financing Administration has launched a new toll-freetelephone line, 1-800-958-HCFA (1-800-958-4232).

"We are doing what we can to help the people and institutions thatdeliver healthcare services get ready for the Year 2000," HCFAAdministrator Nancy-Ann DeParle said. "While HCFA is responsiblefor the financing of health care for our beneficiaries, continuity ofcare depends on far more than our own Medicare payment systems.It depends on doctors, hospitals, plans and other service providersmaking sure that their equipment will work, so that they can be paidand medical records will beproperly handled.

"While most providers are aware of the challenge, there are stillmany who have to take action to prepare their computer systems forthe Year 2000," DeParle said. "That is why we are taking our roleseriously to help them prepare for the millennium."

The toll-free telephone line, along with upcoming managedcare conferences, are part of the agency's ongoing efforts to provideinformation on the Y2K computer date change to all healthcareproviders.

HCFA has also posted materials about Y2K readiness, including aprovider checklist, on the agency's web site:

www.medicare.gov/y2k.

Callers to 1-800-958-HCFA (1-800-958-4232) will be able to getanswers to Y2K questions that relate to medical supplies, theirfacilities and business operations as well as referrals for morespecific billing information. The toll-free line will also update callerson HCFA's Y2K policies and provide general assistance to helpcallers prepare their own computer systems for the millennium.

"HCFA's foremost concern has been, and continues to be, assuringthat our more than 70 million Medicare and Medicaid beneficiariescontinue to receive the health care services they need," DeParle said."That is why we are addressing the Year 2000 issues in our systemswhile engaging in an unprecedented effort to raise awareness andprovide information to states and private sector individuals andorganizations that serve them."

Y2K TOLL-FREEHELP LINE

Please remember that cyclophosphamide and methotrexate are cov-ered under two separate Medicare medical policies, the Oral Anti-Cancer policy and Immunosuppressive Drug policy. When billing asoral anti-cancer drugs, NDC numbers and an order are required.When billing as immunosuppressive drugs, HCPCS codes and theDMERC Information Form (DIF) are required.

CLAIM FILING REMINDER


PACES SOFTWARE

Y2K Compliant

Over the past several years, Palmetto GBA has distributed severalcommercial software products to support the needs of our DMERCelectronic submitters. The low-cost claims data entry product dis-tributed and supported by Palmetto GBA is called "PACES." Thisproduct is Year 2000 ready.

In addition to "PACES," Palmetto GBA has distributed several com-mercial communications packages for the convenience of our cus-tomers. These packages include:

♦ Advantis Passport for DOS, Version 1, Release 2.2-H (CSI access)

♦ Advantis Passport for Windows 3.x Version 1, Release 3.1 (CSI access)

♦ Advantis Passport for Windows 95/NT, Version 1, Release 3.2, Level A (CSI access)

♦ ProComm communications software, Version 2.4.3 (DOS)

It is likely that these products will continue to function smoothlysubsequent to the millennium. However, to confirm the Year 2000viability of these products, or to upgrade to the version suggested by the vendors who supply these products, please consult the web sites listed below.

The Year 2000 ready versions of ProComm are 4.6 and 4.7. Forupgrade information about ProComm products, visit:

www.quarterdeck.com.

There is no Year 2000 ready DOS version of Advantis. The Year2000 ready version of Advantis Passport for Windows 3.x andAdvantis Passport for Windows 95/NT is Version 2, Release 1.LC. Toconfirm the Year 2000 viability of IBM (Advantis Passport) products, or to upgrade to the version suggested by the vendor whosupplies these products, please consult IBM. Information is avail-able from their website at:

www.IBM.com

PALMETTO GOVERNMENT BENEFITS ADMINISTRATORS, LLC,HAS NOT VERIFIED THE CONTENTS, NOR IS IT THE SOURCE,OF THE YEAR 2000 STATEMENTS REGARDING IBM OR PRO-COMM PRODUCTS MENTIONED IN THIS ARTICLE.

YEAR 2000 ANDYOUR PC

As mentioned in the previous article, “PACES,” Palmetto GBA’s low-cost data entry software, is Year 2000 ready.

Although “PACES” will run on non-compliant hardware, it is impera-tive that all users take the responsibility to ensure that their hard-ware is Y2K compliant. There are several ways to determine if your personal computer is Y2K compliant.

To test your PC yourself, follow these steps:

1. Set the date on your PC to December 31, 1999 and the time to 23:59 p.m.


2. Turn off your PC.3. Reboot your PC after a five-minute wait.4. When your machine boots up, the date and time should

read January 1, 2000, at (approximately) 12:04 a.m.5. If the date and time on your PC does not read January 1,

2000, at (approximately) 12:04 a.m., your software may not function on and after this date.

6. Check with your hardware vendor, whether or not your PC passes this simple test, to verify the Y2K validity of your hardware.

To review lists of PCs that are considered Y2K compliant, you maywish to consult the Web site at www.nstl.com, which provides lists ofY2K compliant personal computers and Y2K compliance testing soft-ware.

Finally, perhaps the most important precaution to ensure Y2K com-pliant hardware is to contact your hardware vendor or personal computer manufacturer. These entities can verify the com-pliance of your personal computer and peripheral hardware compo-nents.

YEAR 2000 ANDYOUR PC

(continued)

CMN COMPLETIONPHYSICIAN OBLIGATION

When a physician bills for his/her services, including examination, diagnosis and treatment, any cost associated withpaperwork is considered part of the charges made for his/her professional services. If a patient needs an item of durable medical equipment orthotics, prosthetics and supplies (DMEPOS),the completion of an order or Certificate of Medical Necessityis a service to the patient rather than the supplier. This view isshared by the Health Care Financing Administration and theAmerican Medical Association.

Section 4152 of the Omnibus Reconciliation Act of 1990 requires aphysician to complete a CMN or an order for DMEPOS items pre-scribed. The language in the statute does not authorize physicians to separately charge the patient or supplier for completing the certificates. Allegations of physicians charging sup-pliers for completing CMNs will be investigated under one or moreof the following principles:

� As potential kickback situations under Section 1128B (b) of the Social Security Act; and/or

� As false representation with respect to the physician's actual charge for professional services furnished on or near the date of his/her DMEPOS order for the beneficiary; and/or

� As a potential assignment violation on assigned claims for professional services on or near the date he/she orders DMEPOS for the beneficiary; or

� As a potential charge limit violation on unassigned claims for professional services on or near the date he/she ordered DMEPOS for the beneficiary.

Send information regarding improper payments issued to the physi-cian to the Anti-Fraud Unit (address on page 76). Include all perti-nent information in the referral, such as physician name, beneficiaryname, health insurance claim number and proof of payment made.


The Office of the Inspector General (OIG), working with theDepartment of Justice and the Health Care FinancingAdministration, has developed two initiatives to help combat fraudand abuse and to encourage providers and suppliers to comply withrules and regulations of Federal health care programs. Both initia-tives are designed to ensure that providers and suppliers refundinappropriately received Medicare monies. These two initiatives are Compliance Program Guidances and CorporateIntegrity Agreements.

♦ Compliance Program Guidances provide guidance and recommendations to providers/suppliers in developing effective internal controls to meet program requirements of Federal, State, and private health programs. These Guidances describe the fundamental elements of a compliance program. Currently, Compliance Program Guidances have been published for hospitals, home health agencies, clinical laboratories and third- party medial billing companies. OIG will issue compliance program guidance for additional entities in the future.

♦ Corporate Integrity Agreements (CIAs) are entered into between a health care provider/supplier and OIG as part of a global settlement of a fraud investigation. Under the CIA, which can be for a period ranging from three to five years, the provider/supplier is required to undertake specific compliance obligations, such as designating a compliance officer, undergoing training, and auditing. The provider/supplier must report compliance activities on an annual basis to OIG, which is responsible for monitoring the agreements.

When returning voluntary refund checks, suppliers can ensure thatthe monies will be credited timely and accurately by correct comple-tion of the attached Overpayment Refund Form. If a supplier has a CIA, he/she should indicate that fact in the space pro-vided for OIG reporting requirements on the Overpayment RefundForm.

VOLUNTARY REFUNDS


FEE CHANGES Effective for claims processed on or after July 1, 1999, for dates ofservice on or after January 1, 1999, HCPCS code E0457 (Chestshell (Cuirass)) will be processed as a inexpensive routinely purchased item. The fee schedule allowances for HCPCS codeE0457 are listed below. Since E0457 (Chest shell (Cuirass)) is usedas a supply with HCPCS code E0460 (Negative pressure ventilator; portable or stationary), the Health Care FinancingAdministration (HCFA) has changed the payment category from fre-quently serviced to inexpensive and routinely purchased.

The payment category published in the 1999 Region C DMEPOS FeeSchedule Catalog for HCPCS code E0731 - Form fitting conductive garment for delivery of TENS or NMES form, post mastectomy has changed from supply to inexpensive and routinely purchased.

1999 Fee Schedule Changes

L8015 - Payment Revision

The fees published in the 1999 Fee Schedule Catalog for HCPCScode L8015 - External breast prosthetics garment, with mastectomy form, post mastectomy have been revised. These feesare effective immediately for dates of service on or after January 1, 1999.

L8015

PAYMENT REVISION

E0731 - Change in Payment Category


The following DMEPOS Drug fees were effective for claims processedon or after April 1, 1999, with dates of service on or after January 1,1999. Fee changes are shaded. In addition, fees for Oral Anti-Emetic Drugs, HCPCS codes Q0163 - Q0180 are provided.

FEE UPDATE

NOTE: The Region C Drug Fee Schedule is updated quarterly. The unit of measure for the fee amounts notedcorresponds to the unit of measure noted in the code descriptions published in the 1999 HCPCS coding manual.Please be sure to report the same unit of measure in the Days/Unit field (Item 24g) of the HCFA-1500 (12-90)claim form as is listed in your HCPCS manual. For example, if the HCPCS manual lists one unit as 50 mg, besure to report 50 mg as one unit on the claim form. If you administered 100 mg, you would list two units on theclaim form.

The Region C Drug Fee Schedule is based on the lesser of the median average wholesale price (AWP) of the genericforms or the lowest brand name product AWP.


FEE UPDATE(continued)

Oral Anti-Cancer Drug Fees

The following Oral Anti-Cancer Drug fees were effective for claimsprocessed on or after April 1, 1999, with dates of service on or afterJanuary 1, 1999. Fee changes are shaded.

Currently the following Oral Anti-Cancer drugs meet the require-ments for coverage under OBRA '93.

Unlike other drugs billable to the DMERC, these oral anti-cancerdrugs are not submitted with HCPCS codes. Oral anti-cancer drugsare billed using the National Drug Code (NDC) number.

ORAL ANTI-CANCERDRUG CORRECTION

The NDC numbers for the 5-FU prodrug, Capecitabine, trade name:Xeloda, manufactured by Roche and published in the Spring 1999DMERC Medicare Advisory (page 13), are incorrect. The correctNDC numbers are as follows:

00004-1100-22 Capecitabine, 150 mg, oral, 1 tab per unit00004-1100-51 Capecitabine, 150 mg, oral, 1 tab per unit00004-1100-13 Capecitabine, 150 mg, oral, 1 tab per unit

00004-1101-51 Capecitabine, 500 mg, oral, 1 tab per unit00004-1101-16 Capecitabine, 500 mg, oral, 1 tab per unit00004-1101-13 Capecitabine, 500 mg, oral, 1 tab per unit

Note: The listing of a HCPCS drug code along with its allowable does not constitute coverage.

HCPCS CODE J7506 FEE CLARIFICATION

The 1999 Region C DMEPOS Fee Schedule Catalog listed the feefor HCPCS code J7506 as $3.03. This amount was incorrect. Dueto the change in nomenclature for this code, the correct fee is $0.02.The verbiage for HCPCS J7506 previously read "Prednisone, anydosage, 100 tablets (various)". It currently reads "Prednisone, oral,per 5 mg." Please ensure your days/units are billed correctly. Thatis, if you provide 100 5 mg tablets, your days/units should reflect100.


A graduate of Tennessee State University, Ronjaearned a Bachelor of Science degree in speechcommunication and theatre, as well as a Master of Arts degree in interpersonal/health communication from the University of Kentucky.Before joining Palmetto GBA, Ronja worked as aninstructor of public speaking, sociology, and computer courses. Her communication and education experience will serve her well in assisting Tennessee sup-pliers with billing and policy issues.

A native of Tennessee, Ronja is pleased to be working in Nashville.Having presented Medicare information at several conferences,Ronja is looking forward to conducting future Palmetto GBA work-shops as well as educational onsite visits with her Tennessee suppliers.

NEW OMBUDSMEN

Oklahoma/Arkansas Eric Kast is the new ombudsman for Oklahoma andArkansas. He comes to the DMERC with four yearsexperience in the durable medical equipment (DME) industry. Eric’s professionalexperience includes Medicare reimbursement forinfusion and DME services. Eric earned hisBachelor of Arts and Master of Arts degrees in jour-nalism/public relations from the University ofOklahoma.

After several months of intensive training, Eric has returned toNorman, Oklahoma, where his office is located. He looks forward toserving Arkansas and Oklahoma suppliers.

Tennessee

As part of our continuing efforts to meet educational needs,Palmetto Government Benefits Administrators, LLC is pleased toannounce two new members of its Professional Relations department: Ronja Fayne and Eric Kast. They are profiled below.A complete directory of Palmetto GBA ombudsmen and their territo-ries can be found on page 68 of this Advisory.

Any changes to the information provided on the HCFA form 855S(1/98), including change of address and telephone number, shouldbe reported to the NSC within 35 days of the occurrence of suchchanges. You may contact the NSC at:

National Supplier ClearinghouseP.O. Box 100142Columbia, SC 29202-3142(803) 754-3951

NSC CHANGE OF ADDRESS

NOTIFICATION


NNeeww PPrroodduucctt CCllaassssiiffiiccaattiioonn

The following are product classification additions for 1999:

Product Name Manufacturer HCPCS Code Effective Date

Enteral Nutrients:Ensure HN (Category I) Ross Labs B4150 9/9/96Jevity RTH (Category I) Ross Labs B4150 2/2/99

Nebulizers:Pulmo Aide Compressor De Vilbiss E0570 3/24/99Pulmo Aide LT Compressor De Vilbiss E0570 3/11/99Pulmo Mate Compressor De Vilbiss E0570 3/11/99PulmoSonic Ultrasonic Nebulizer De Vilbiss K0270 2/16/99Ultra-Neb Ultrasonic Nebulizer De Vilbiss E0575 3/11/99

Power Operated Vehicles:5000 Series Transport Tuffcare E1031 4/12/99Activa POV Hoveround E1230 3/5/99Cabbie Companion Lumex E1031 3/5/99Chauffeur Models 250, 255, 270, 275 Electric Mobility E1230 3/5/99Escort II 3000 Tuffcare E1230 12/10/96Excel Passenger Transport Medline E1031 3/19/99EZ Fold 400 McBon E1031 8/5/98Limo III 3500 and 4000 Tuffcare E1230 12/10/96Maple Leaf MLT 700B Tilt Chair Maple Leaf Wheelchairs E1031 12/18/98Maple Leaf MLT 500 T/R Chair Maple Leaf Wheelchairs E1031 12/18/98Optiway 2001 LXS3 Optiway Technology E1230 12/17/98Optiway 2001 LXS4 Optiway Technology E1230 12/17/98Panda Pediatric Positioning System Otto Bock Rehab E1031 3/19/99P2 Companion Wheelchair Everest & Jennings E1031 4/12/99PM 100 McBon E1031 8/5/98Ralley Scooter Pride Healthcare E1230 9/22/98Rascal Models 250, 255, 270, 275 Electric Mobility E1230 3/5/99RC 200 McBon E1031 8/5/98Shuttle Pride Pride Healthcare E1230 9/22/98Tracer Transport Invacare E1031 3/19/99Transporter Tuffcare E1031 3/5/99Trekker C Lumex E1031 3/5/99Ultra Lightweight Transporter Tuffcare E1031 3/5/99

Pressure Reducing Support Surfaces, Group I:AccuMax Mattress BG Industries E0186 04/08/98AccuMax PC Mattress BG Industries E0186 04/08/98AccuMax Residential Mattress BG Industries E0186 04/08/98Air-O-Pad (AOP1) WITH PUMP Huntleigh Healthcare E1399 02/16/99Bubble Pad (OPB2, OPB2FF) WITH PUMP Huntleigh Healthcare E0180 02/16/99CareGuard APP Invacare E0180 02/16/99



Pressure Reducing Support Surfaces, Group I, cont.:CareGuard 101 HomeCare Mattress Invacare E0184, 02/16/99CareGuard SA Static Air Overlay Invacare E0197 02/16/99Pressure Guard CFT Spann-America E0176 04/08/99Pressure Guard Renew Spann-America E0186 03/23/99Super Life Bubble Pad (OPB3)WITH PUMP Huntleigh Healthcare E0181 02/16/99Tri-Zone Mattress Overlay Atlantis Medical E0199 02/16/99

Pressure Reducing Support Surfaces, Group II:Autoexcel Huntleigh Healthcare E0372 03/26/99Autoexcel with 3 inch foam pad Huntleigh Healthcare E0372 & E0272 03/26/99Cyclone LTS Low Airloss Mattress Tempest International E0277 04/08/99DFS 2 Huntleigh Healthcare E0277 02/16/99Excel 5000 Best Care CorporationE0372 02/16/99Excel 5500 Best Care CorporationE0372 02/16/99Excel 8000 Best Care CorporationE0277 03/19/99Europa Mattress Overlay James Consolidated E0372 03/16/99GenAir 8000 Genadyne Biotechnol. E0277 02/16/99GenAir 8000 Plus Genadyne Biotechnol. E0277 02/16/99Pro 2000 MRS Cardio Systems E0277 03/26/99Supportair I Air Support TherapiesE0277 03/24/99Supportair II Air Support TherapiesE0277 03/24/99Tradewind 1000 Tempest International E0277 04/08/99Tradewind 3000 Tempest International E0277 04/08/99Tradewind ATS Tempest International E0277 04/08/99

Surgical Dressings:One Step Skin Care Lotion 3M A6250Amerigel Topical Ointment Amerx A6250 (A6020 prior to 9-15-98)Carrasmart Foam Carrington A6257-A6258Dale Secondary Wound Dressings/Holders Dale Medical ProductsA4649Genus Bordered Gauze Dressing Genus Biomedical A6219-A6220Genus Hydrocolloid Pad Low Gel Thin Version Genus Biomedical A6234-A6236Genus Hydrocolloid Pad Low Gel Thick Version Genus Biomedical A6234-A6236Genus Hydrocolloid Pad Standard Gel Genus Biomedical A6234-A6236Snugs Tapeless Secondary Dressings Incare Medical A4649Dyna-Flex Cohesive Compression Bandage Johnson & Johnson A4460Fibracol Plus Johnson & Johnson A6020J & J Cohering Bandage Johnson & Johnson A4460Spand-Gel Hydrogel Gauze Dressing Medi-Tech A6222Phytacare Alginate Wound Dressing Phytatec Labs A622Mitraflex Plus SCA Molynlycke A6209-A6214Mitraflex SC SCA Molynlycke A6209-A6214Subdue (Category III) Mead Johnson B4153 4/8/99



Walkers:Avant (E0146 prior to 12/98) ETAC Walkers E0143 & E0156 5/16/97Brooks All-Terrain Walker(E0146 prior to 12/98) Brooks Locomotion E0143 & E0156 12/15/93Buddy Safety Roller White Cap Ent. E0147 12/1/98Freedom Cart Tuffcare E0143 12/10/96Gait Trainer Rifton E0143 & E0156 3/26/99Gilliam Walker SMW, Inc. A9270 4/16/96Merry Walker Merry Walker Co. E0142 12/14/94Merry Walker Ambulation Device Merry Walker Co. E0143 & E0156 8/14/97

(E0146 prior to 12/98)Model K Walker(E0146 prior to 12/98) Wheel Walkers E0143 & E0156 5/29/98Model N Walker(E0146 prior to 12/98) Wheel Walkers E0143 & E0156 5/29/98Nannie Walker Winnie Walker Co. K0459 2/17/98Nova Walker(E0146 prior to 12/98) ETAC Walkers E0143 & E0156 5/16/97Opal 2000 (E0146 prior to 12/98) Medbloc Walkers E0143 & E0156 7/15/97Opal 3000(E0146 prior to 12/98) Medbloc Walkers E0143 & E0156 7/15/97Primo 2000 (E0146 prior to 12/98) Medbloc Walkers E0143 & E0156 7/15/97RisingStar Super Walker, Folding Momentum Medical E0135 6/17/97RisingStar Super Walker, Wheeled Momentum Medical E0143 6/17/97Roll-A-Bout Roll-A-Bout Corp. E1399 10/11/95Roller Aid Stone Heart E1399 3/23/95Roller Walker-Folding Roller Walker, Inc. E0143 2/14/95Roller Walker-Non-folding Roller Walker, Inc. E0141 2/14/95Samhall Plus Rollator SamHall E0143 & E0156 10/19/98Savy Walker (E0146 prior to 12/98) Winnie Walker Co. E0143 & E0156 7/15/97Spartan Rollator Invacare E0143 & E0156 3/9/99Sprint Rollator Invacare E0143 & E0156 3/9/99Stargazer Rollator Invacare E0143 & E0156 3/9/99Stingray Rollator Invacare E0143 & E0156 3/9/99Tuffcare Folding Walker W200 Tuffcare E0135 8/5/98Tuffcare Folding Walker W200BW Tuffcare E0143 8/5/98U-Step Walking Stabilizer, With Seat(E0146 prior to 12/98) In-Step Mobility E0143 & E0156 10/21/97U-Step Walking Stabilizer, Without Seat In-Step Mobility E0143 10/21/97UNO Walker (E0146 prior to 12/98) ETAC Walkers E0143 & E0156 5/16/97WalkAide Neuromotion E1399 3/11/99Wenzelite Walkers CE1000, CE1000XL, CEOBESE Wenzelite K0459 3/9/99

Wheelchairs:Magic VM Hemi Canadian Wheelchair Mfg K0003Magic VM Semihemi Canadian Wheelchair Mfg K0003Magic VM Standard Magic VM Superlow. Canadian Wheelchair Mfg K0003Streamer 888WStreamer 888WS DCC Shoprider K0011



Wheelchairs, cont.Metro LE Everest & Jennings K0003PaceSaver Scout Leisure Lift, Inc. K0011Excel (MDS806100) Medline K0001Excel Narrow (MDS806150N) Medline K0001Excel Hemi (MDS806400) Medline K0002Excel Lightweight (MDS806600) Medline K0003Excel Extra Wide (MDS806700) Medline K0007World Class Wheeled Chair Suiter Medical K0009


Alabama

Fadul, Oscar V. Specialty: Family Physician/1235 Deborah Dr., S E General PracticeHuntsville, Ala. 35801 Period of Exclusion: Indefinite

Effective Date: 1/20/99

Ross-Mathis, Jean Ann Specialty: Family Physician/105 Dumbling Dr. General PracticeMadison, Ala. 35758 Period of Exclusion: Indefinite


Florida

Burney, Dawn W. Specialty: Family Physician/14122 Crystal Cove Dr. General PracticeJacksonville, Fla. 32224 Period of Exclusion: Indefinite


Preferred Medical Equipment Specialty: DME Company2526B Tampa Bay Blvd. Period of Exclusion: 10 yrs.Tampa, Fla. 33607 Effective Date: 1/20/99

Suggs, Ronnie E. Specialty: Podiatrist4555 Hoffner Ave. Period of Exclusion: IndefiniteOrlando, Fla. 32812 Effective Date: 1/20/99

Vacca, Alberto H. Specialty: EmployeeP.O. Box 500, #N024278 (Non-Government)Sanderson, Fla. 32087 Period of Exclusion: 10 yrs.


Georgia

Dixon, Robin Specialty: Employee 2655 Thornbury Way (Non-Government)College Park, GA. 30349 Period of Exclusion: 5 yrs.

Effective Date: 1/20/99Schutz, David Charles Specialty: Family Physician/3214 H Post Woods Dr. General PracticeAtlanta, GA. 30339 Period of Exclusion: Indefinite


Solomon, Robert L. Specialty: Employeec/o 4425 Memorial Dr. (Non-Government)Decatur, GA 30322 Period of Exclusion: 10 yrs.


Stivali, Alfred M.,III Specialty: Podiatrist944 Ashbury Heights Court Period of Exclusion: IndefiniteDecatur, GA 30030 Effective Date: 1/20/99

SUPPLIER SANCTIONS


SUPPLIER SANCTIONS

(continued)

Kentucky

Rangaswamy, Avvari Specialty: Family Physician306 Town Mountain Rd. General PracticePikeville, KY 41501 Period of Exclusion: Indefinite


Mississippi

Ellis-Whiting, Marguearite Specialty: Social WorkerBox 86 Period of Exclusion: 3 yrs.Port Gibson, Miss. 39150 Effective Date: 1/20/99

Joyner, Debbie P. Specialty: Licensed PractitionerP.O. Box 32 Period of Exclusion: IndefiniteCollinsville, Miss. 39325 Effective Date: 1/20/99

Mitchell, Jerry III Specialty: Osteopath498 Lamar St. Period of Exclusion: IndefiniteLucedale, Miss. 39452 Effective Date: 1/20/99

New Mexico

Dwight, Jonathan B. Specialty: Physician Assistant4501 Morris St., NE, #1126 Period of Exclusion: IndefiniteAlburquerque, NM 87111-3795 Effective Date: 1/20/99

North Carolina

Scher, Stephen Barry Specialty: Family Physician/105 Dave Warlick Dr. General PracticeLincolnton, N.C. 28092-4411 Period of Exclusion: Indefinite


South Carolina

Baines, Daisy L. Specialty: Health Care Aide3536 Starling Rd. Period of Exclusion: 5 yrs.Mullins, S.C. 29574 Effective Date: 1/20/99

Barlow, Carlo Pedro Specialty: Health Care Aide300 Tillison Period of Exclusion: 5 yrs.Hartsville, S.C. 29550 Effective Date: 1/20/99

Fulbright, Paul, Jr. Specialty: Family Physician/5403 N Highway 81 General PracticeWilliamston, S.C. 29697 Period of Exclusion: 5 yrs.


Gray, Jeanette C. Specialty: Health Care Aide124 Squirrel Dr. Period of Exclusion: 5 yrs.Kingstree, S.C. 29556 Effective Date: 1/20/99


Preston, Tonya D. Specialty: Health Care Aide817 W. Sumter St. Period of Exclusion: 5 yrs.Florence, S.C. 29501 Effective Date: 1/20/99

Yates, William M. Specialty: Family Physician/P.O. Box 24506 General PracticeColumbia, S.C. 29244-4506 Period of Exclusion: IndefiniteFlorence, S.C. 29501 Effective Date: 1/20/99

Texas

Gittens, Kenneth Alphonso Specialty: Podiatrist1710 Colcord Ave. Period of Exclusion: IndefiniteWaco, TX 76707-2248 Effective Date: 1/20/99

Louisiana

Turner, Craig S. Specialty: Family Physician/304 Azalea Dr. General PracticeMonroe, LA 71203 Sanction Date: 3/16/95

Reinstatement Date: 12/4/98

Texas

Pariani, Harish Kumar Specialty: Family Physician/20114 Atascosita Shores Dr. General PracticeHumble, TX 77346-1637 Sanction Date: 8/20/98

Reinstatement Date: 12/21/98

SUPPLIER SANCTIONS

(continued)

SUPPLIERREINSTATEMENTACTIONS


If you would like to submit a question, please contact your designated ombudsman. For the name, phone numberand address of the Palmetto GBA ombudsman assigned to your area, check “Ombudsman Addresses and Their

Territories” in the back of this DMERC Medicare Advisory.

SUPPLIER STANDARDS:

� Are suppliers held to the current (11) Supplier Standards, and to the Proposed (20) Standards?

Suppliers must adhere to the current published (11) Standards until they receive notice of the implementation of the Proposed (20) Standards, which will include the 11 current standards.

� The Supplier Standards state that a supplier must accept returns of items unsuitable at the time they were fitted, etc. If a wheelchair is suitable for the beneficiary, but not suitable for the residence, (i.e. the wheelchair is too wide to fit through the doorways) would the supplier be expected to accept the return?

Any item that cannot be used in the beneficiary's home is considered unsuitable. The supplier is expected to accept this type of return, or modify the chair to accomodate the beneficiary’s needs.

� What constitutes a complaint? Would a call to repair a flat tire on a beneficiary’s rental wheelchair be a complaint?

A complaint is when the beneficiary is dissatisfied with an item for a specific reason. A beneficiary call regarding a flat tire is not a complaint. It is a request for service. However, if the tire is not repaired, the request could result in a valid complaint.

� Is a complaint in the beneficiary's file appropriate or does the supplier have to have a log?

The proposed standards require the supplier to have a complaint log.

PROOF OF DELIVERY:

� Do all items delivered to the beneficiary have to be listed on the delivery ticket?

Yes. All items delivered to a beneficiary must be noted on the delivery ticket.

Certificate of Medical Necessity:

� Can a supplier key an ICD-9-CM diagnosis code on the electronic CMN if the physician indicated anarrative diagnosis on the hard copy CMN?

No. The CMN completion instructions on the back of the CMN instruct the physician to provide ICD-9-CM codes. If there is a narrative diagnosis, the instructions have not been followed. Suppliers who transmit CMNs electronically cannot provide information that is not on the CMN.


� Another DMERC permits providers to enter a "D" on the EMC CMN if the physician does not indi-cate a “yes” or “no” answer. Does Region C DMERC allow this as well?

No. Suppliers cannot submit responses not indicated on the hardcopy CMN by the prescribing physician. The EMC CMN must reflect the exact information indicated on the hard copy CMN in the supplier's file.

� Will Region C accept EMC CMNs with a request for review?

Yes. We will accept look-alike CMNs if they comply with the EMC CMN regulations that were published in the July '96 DMERC Advisory. CMNs must have the correct wording and OMB num-bers.

� Can a mask and supplies be billed at the initial issue of the CPAP?

Yes, the items listed on page 42.2 of the Region C DMEPOS Supplier Manual may be billed at initial issue whether or not the CPAP is rented or purchased.

APPEALS:

� Can suppliers combine review denials from multiple beneficiaries to meet the $100.00 requirement to request a Hearing?

Yes. The request must make a clear distinction between beneficiaries and give all pertinentinformation regarding the beneficiary. The combined beneficiaries and claims must be for thesame provider. When submitting a multiple listing make sure to use one Hearing request form for each beneficiary claim. Number the request ( e.g., page 1 of 5, page 2 of 5, etc. ).

If you would like to submit a question, please contact your designated ombudsman. For the name, phone numberand address of the Palmetto GBA ombudsman assigned to your area, check “Ombudsman Addresses and Their

Territories” in the back of this DMERC Medicare Advisory.


Team Tips is a section created by your dedicated teams to assistyou with claims filing, appeals and inquiries. These helpful tipswill be provided by each team based on trends identified in theirdaily interaction with you, their customer.

Team A: Do not span dates on oxygen claims. Refer to the Autumn1997 DMERC Medicare Advisory, page 110, for a listing of the onlyitems that require the usage of span dates.

Team B: When calling into the VRU with a Medicare number withmultiple alphas, remember to enter into the VRU this way:WC12345 would be *91*2312345#. Information on how to enteralpha characters is found on page 13.6 of the Region C DMERCDMEPOS Supplier Manual.

Team C: For diabetic beneficiaries, please be sure to use the appro-priate 5 digit diagnosis code along with the KS modifier on claimsfor non-insulin treated beneficiaries and the ZX modifier for insulintreated beneficiaries.

Team D: If you have a ten-digit supplier number, you must fileclaims on behalf of the beneficiary.

When requesting a review, please use the Review Request Formfound in the Spring 1997 DMERC Medicare Advisory. Make surethe form is completely filled out.

Team E: When filing claims with the HCPCS code V2799, pleaseinclude a description for the item.

Please remember to include the cataract surgery date when filingclaims for vision services. This information will be listed in the HAØfield on electronic claims and in Item 21 (next to the diagnosis field) for paper claims.

Team F: When billing wheelchair options and/or accessories as areplacement to an existing part, please include documentation of themedical necessity for the item, make and model number of thewheelchair base they are being added to and the date of the pur-chase of the wheelchair.

Team G: When filing claims for diabetic supplies, be sure to use thecorrect modifier - KS for non-insulin dependent beneficiariesand ZX for insulin-dependent beneficiaries.

Team H: When billing accessories for equipment such as wheelchairs, be sure to note on the claim that the beneficiary ownsthe equipment with which the accessories are used.

T E A M T I P S


Team I: Please remember reviews can not be conducted on returnedor rejected claims or on claims denied as duplicate. If a claim isreturned or rejected, please correct and resubmit the claim. If youare sending a review to make changes to a claim, please referencethe claim control number (CCN) on which the original claimprocessed, not the CCN of a duplicate denial.

Team J: Status on reviews and hearing can be accessed through theVRU. Use Option 3, then Option 5. Remember to have the claimcontrol number of the claim you are checking.

Team K: Remember to file the CMN with the first claim for the itemrequiring the CMN. After the initial CMN has been sent, it is not nec-essary to send it in again unless there is a revision or recertification for the therapy.

Team L: HCPCS code E0146 (folding walker wheeled, with seat) is acapped rental item. HCPCS code E0146 must be filed with theappropriate capped rental modifiers (KH, KI or KJ) (This HCPCScode is not valid for Medicare billing effective 10-1-98).

Team M: When filing K0108, please put the manufacturer and partnumber of the item being billed and the make and model of the mainequipment for which it is being billed.

Team N: Oxygen suppliers, use only the HCFA-484 (5/97) OMB form0938-0534 which can be found in the Autumn 1997 DMERCMediare Advisory and in the Region C DMERC DMEPOS SupplierManual.

Team P: Please have your supplier number ready when you call.

Team S: Never ask for a consideration of review on a duplicatedenial.

If you want additional payment on a particular item or to changeunits, file the review changing the submitted amount or units.

Remember, there are no review rights on returned or rejected claims.

Team T: (1) Miscellaneous options, accessories or replacementparts for wheelchairs that do not have a specific HCPCS code shouldbe coded K0108. (2) HCPCS code L8499 is a miscellaneous code for prosthetic services that do not fall under anestablished HCPCS code. (3) In general, any time a miscellaneous ornot otherwise classified (NOC) code is billed, the claim shouldinclude a narrative description of the item, manufacturer name,product number, make and model name/number and any other per-

T E A M T I P S


tinent information that may be needed for pricing purposes. Include a brief statement defining the medical necessityfor the item or service.

Team U: All blocks on a CMN should be completed. If the question does not apply, then D should be entered by the physician.

Team W: When submitting claims for HCPCS code E0453, therapeutic ventilator, please remember that there must be a state-ment on the claim declaring “This item is being issued for the treat-ment of a condition other than obstructive sleep apnea.” Failure toinclude this will result in the claim denying for lack of medicalnecessity documentation.

Team MSP: Item 29 on the HCFA-1500 (12/90) form is only torecord payment received by the beneficiary, not by another insurance company. If you fill in this block with other categories ofpayments, we will interpret the amount as paid by the beneficiaryand reimbursement will be sent to the beneficiary.

Overpayment Team: Yellow envelopes that are included with anOverpayment Request letter should be used for refunds only. Pleasedo not send anything other than refunds in these envelopes norshould anything but refunds be sent to:

Palmetto GBA PO Box 100183 Columbia, SC 29202-8183

All other correspondence should be sent to your dedicated team’spost office box.

Data Entry Department (for hardcopy claims): When filing claims,you must total each HCFA-1500 (12/90) claim form. You cannothave one total for multiple claim forms.

Fair Hearings & ALJ: When submitting a request for a Hearingbefore a Federal Aministrative Law Judge (ALJ), please include acopy of the Fair Hearing Decision Letter. This will aid research andtimeliness in preparing the file.

T E A M T I P S


OMBUDSMEN ADDRESSES AND THEIR TERRITORIES

Ombudsmen investigate complaints, report findings and facilitate problemsolving through training and education of the supplier community.

AlabamaLia BunchP.O. Box 146Union Grove, Ala. 35175(256) 498-0205

Arkansas/OklahomaEric KastP.O. Box 720313Norman, OK 73070(405) 292-8234

Colorado/New MexicoIN THE INTERIM CONTACT:

Gina ThoreP.O. Box 100141Columbia, S.C. 29202-3141(803) 735-1034, Ext. 35781

Florida (south)(covers the southern portion of Florida toinclude Manatee, Hardee, Highlands,Okeechobee and Indian River counties, andall points south)

Teresita OrtizSuite 3289737 N.W. 41stMiami, Fla. 33178(305) 418-5009

Florida (north)(covers the northern portion of Florida toinclude Pinellas, Hillsborough, Polk, Osceolaand Brevard counties, and all points north)

Keith SmithSuite 13910991-55 San Jose Blvd.Jacksonville, Fla. 32223(904) 886-2887

Puerto Rico/Virgin Islands

Adie FuentesUrb. Muñoz RiveraAve. Esmeralda #53

Call Box 50Guaynabo, P.R. 00969

(787) 782-0544

South CarolinaDana Church

P.O. Box 100141Columbia, S.C. 29202-3141(803) 735-1034, Ext. 35714

TennesseeRonja Fayne

5341 Mt. View Rd., Suite 122Antioch, Tenn. 37013

(615) 717-0840

Texas (south)(covers the southern portion of Texas

to include El Paso, Seminole, Abilene,Austin, San Antonio, Corpus Christi,

and all points south)

Dana CauseyP.O. Box 7891

Horseshoe Bay, Texas 78657(830) 598-4882

Texas (north)(covers the northern portion of Texas to

include La Grange, Houston, Killeen, Dallas,Amarillo, and all points north)

Peggy Miller2601 Cartwright Rd., Suite D392

Missouri City, Texas 77459(281) 416-9688

GeorgiaMary Jo Gochett

P.O. Box 81850Conyers, Ga. 30208-9426

(770) 761-0509

KentuckyTeresa CamfieldPO. Box 436767

Louisville, Ky. 40253-6767(502) 254-5011

Louisiana/MississippiBobby SmithP.O. Box 9225

Jackson, Miss. 39286(601) 856-4368

North CarolinaSharon Briggman

P.O. Box 97424Raleigh, N.C. 27624-7424

(919) 846-3552

Out of Region CIN THE INTERIM CONTACT:

Dana ChurchP.O. Box 100141

Columbia, S.C. 29202-3141(803) 735-1034, Ext. 35714


REGION C DIRECTORYPlease retain this list as your new DMERC telephone directory.

Palmetto GBA contacts

MAILING ADDRESS TELEPHONE NUMBER

Anti-Fraud Unit (803) 788-5414Palmetto GBA, Medicare Region C DMERCP.O. Box 100236Columbia, S.C. 29202-3236

Dedicated Work Teams/ (803) 691-4300DMERC General Information

Electronic Data Interchange (EDI) (803) 788-9751Palmetto GBA, Medicare Region C DMERCP.O. Box 100145Columbia, S.C. 29202-3145

Hearings Department* (803) 691-4300Palmetto GBA, Medicare Region C DMERCP.O. Box 100249Columbia, S.C. 29202

Prior Authorization Department* (803) 691-4300Palmetto GBA, Medicare Region C DMERCP.O. Box 100235Columbia, S.C. 29202-3235

Professional Relations Department (803) 735-1034,Palmetto GBA, Medicare Region C DMERC ext. 35744P.O. Box 100141Columbia, S.C. 29202-3141

*Inquiries regarding hearings or Prior Authorization should be directed to the Dedicated Work Teams.

National numbers

MAILING ADDRESS TELEPHONE NUMBER

National Supplier Clearinghouse (NSC) (803) 754-3951P.O. Box 100142Columbia, S.C. 29202-3142

Region A DMERC (570) 735-9445

Region B DMERC (317) 577-5722

Region D DMERC (615) 251-8182

Statistical Analysis Durable Medical (803) 736-6809Equipment Regional Carrier (SADMERC)Palmetto GBA400 Arbor Lake Drive, Suite A 900Columbia, S.C. 29223


Are you keeping up to date on the latest Medicare publications andinformation? By registering on the Palmetto GBA, LLC Web Site, youcan be notified by e-mail when new or important information isadded to our web site.

You only need to register once to use many extra features. It is quickand easy. You do not have to register to use our web site, butregistering lets you:� Receive weekly e-mail notification of Medicare news and updates

� Fully participate in our Discussion Forums (more information inlater advisory articles)

� Update your e-mail profile at any time

Follow these steps to register on our web site.1. When you have connected to the Internet, access our site at

www.pgba.com.2. Select Providers, then DMERC.3. Click on the Register/Profile button from the menu on the

left of the screen. The first registration screen displays withWelcome to Palmetto GBA site information.

4. Click on "Register if you are a new visitor to this site" link. The registration form displays.

5. Complete the Registration form. Make note of your user nameand Password, as these items are case sensitive.

6. Click on the Submit Registration button.7. Click on the Login link. Enter your user name and password.

Click OK.8. Complete your profile information to receive weekly e-mail

notification. Check the topics of your interest and check theEvery Week notification frequency box. Otherwise you will notreceive notification, although your profile will be noted in thesystem.

9. Click on the Save and Close button.

Subsequent Logins

After you register the first time, you only need to login when youwant to use the features for registered users: participating indiscussion forums, changing passwords, or updating profiles. We arein the process of implementing the discussion forum feature on ourweb site. Look for more information in future advisory articles.

To Login to our web site as a registered user:

1. Once you have accessed the area of your interest, such asProviders / DMERC, click on the Register/Profile optionfrom the menu on the left of the screen.

2. Click on the Login link.3. Enter your username and password. Click on the OK button.

AN OVERVIEW OF PALMETTOGBA’S WEB SITE

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