Ask-the-Contractor Teleconferences (ACT)

Transcription

1 Ask-the-Contractor Teleconferences (ACT) Moderator: Scott White Date: Time: 2:00 pm CT Operator: Good day and welcome to the CGS Administrators Ask-the-Contractor Teleconference. Today s conference is being recorded. At this time, I d like to turn the call over to Scott White. Please go ahead, sir. Scott White: Good afternoon everyone. My name is Scott White and welcome to the CGS Administrators first Ask-the-Contractor teleconference call for Moving forward, in today s call, we will be referring to CGS Administrators, LLC as simply CGS. We would like to begin by extending thanks to those suppliers who are attending today s call. Your participation in these calls is an important way for us to better meet the needs of our supplier community, in Jurisdiction C, and we appreciate the opportunity to partner with you to accomplish this goal. We are joined on the call today by representatives from several departments within CGS who will be available to answer your questions pertaining to their respective areas of expertise. Now, I m going to go over some recent Jurisdiction C updates. These impact our supplier community. At the conclusion of this brief updates, we will open the lines up for your questions. On February 17, 2012, Health and Human Services or HHS announced that a process will be initiated to postpone the date by which certain health care entities has to comply with international classification of diseases 10th edition diagnoses and procedure code for ICD-10. The final rule adopting ICD-10 as a standard was published in January 2009 and set a compliance date of October 1, 2013, a delay of two years from the compliance date initially specified in the 2008 proposed rule. HHS will announce a new compliance date moving forward. So just be sure to check the ListServs and stay up-to-date when that new compliance date is published for ICD-10. On November 15, 2011 CMS announced the prior authorization of Power Mobility Devices demonstration project to reduce improper payments for Power Mobility Devices. There are three states in Jurisdiction C affected by this demonstration project, Florida, North Carolina and Texas. CMS has removed the 100% pre-payment review phase, formerly phase 1 of the project and CMS will allow suppliers to perform the administrative function of submitting the prior authorization request on behalf of the physician or treating practitioner. CMS anticipates the start of this demonstration will be on or after June 12, In addition to the information available at go.cms. gov/pademo, CMS is also hosting several open-door forum calls to offer updates and answer questions regarding the PMD demonstration project. These calls are scheduled for April 26, May 21, June 28 and July 27. Suppliers should continue to monitor the CGS ListServ for updated information including educational events related to the PMD demo. On April 2, 2012, a new documentation case identification number is being added to all DME MAC Jurisdiction C documentation request letters. This information is part of a new process which allows suppliers to submit requested medical records and documentation electronically. This new process is called Electronic Submission of Medical Documentation or ESMD. The documentation case ID number will provide a unique number for each request in order to facilitate the submission of documents through ESMD. If you receive a request for additional documentation from Jurisdiction C and you wish to respond electronically, you can submit your documentation as a PDF file through the CMS ESMD gateway. The DME MAC will receive your file and process your claim accordingly. For more information about how to connect to the ESMD gateway as well as additional information about ESMD, visit the CMS ESMD webpage at Additional information about ESMD can also be found in MLN Matters article SE1110. In addition, CGS has just received notice that the implementation of PWK, a new process that gives Medicare suppliers the option to mail or fax hard copy documentation to accompany their electronic claim submissions has been delayed from its original start date of April 2, We do not have a new implementation date at this time. Page 1

2 Switching gears here a little bit, the CGS Provided Outreach and Education team or POE team is conducting several face-to-face workshops this spring, the first being on April 25 in Charlotte, North Carolina. Now, during the Charlotte workshop, Melanie Combs-Dyer, the deputy director of CMS Provider Compliance Group, will be leading a PMD prior authorization demonstration project session. If your company sells Power Mobility Devices, you definitely want to attend this session. Ms. Combs-Dyer will discuss the background for the program, outline the process of the PMD project, provide resource information and answer any questions you may have about how the project will affect you as a Medicare supplier. The POE team is also conducting workshops in Dallas, Texas on May 15 and in Nashville, Tennessee on June 12. These workshops will provide a wide range of topical education opportunities and will offer attendees a chance to ask questions about Medicare policy to members of the POE team. In addition, the POE team will also be conducting a Spanish language workshop in Coral Gables, Florida on April 25. You can register for these exciting educational opportunities on the CGS website which is click on education and then click on workshops and seminars. I also want to mention our online resources that are available to you at your convenience. We invite all of you to enroll in the CGS ListServ so that you may stay abreast of updates news and Medicare program information. To sign up for our LIstServ, please visit our website at click on Jurisdiction C, click on the join the ListServe quick link in the lower right hand side of the page and follow the prompt. While on our website, please also take a few moments to review the other resources available such as the medical review resource pages through the coverage and pricing button or learning opportunities from provider outreach through the education button. There is also a link to the CGS Facebook page on the website which is another great way to receive Jurisdiction C announcements and updates. This concludes our brief or not so brief update session however you want to look at it. Before we open the phone lines for questions, I want to touch on a few housekeeping issues. Please be aware that we are not able to answer questions about individual claims. Be sure to remove any mention of a beneficiary s name or Medicare number in your question as we want to assure confidentiality and protect the member s PHI. If you have a question regarding a specific claim or beneficiary, our customer service specialists are available from 7 am to 5 pm central time Monday through Friday at Additionally, we are not the correct resource to answer questions regarding round two of competitive bidding. If you do have questions about competitive bidding, please contact the Competitive Bidding implementation contractor at or find them on the web at dmecompetitive bid.com. A transcript of today s call will be added on our website. When this transcript becomes available, it will be posted in the education section. Again, we d like to thank you for your participation today and we will now begin the question and answer portion of the call. Operator: If you d like to ask a question, please press star 1 on your telephone keypad. A voice prompt will come on the line and indicate when your line is open. You may provide your name or remain anonymous as you choose. Once again, that s star 1 to ask a question. And we do have our first question. And (Nicole), your line is open. (Nicole): Can you hear me? Scott White: Yes, I can. (Nicole): Okay. My question is with regards to sterile kits. If the coverage criteria for the A4353, the sterile catheter kit hasn t been met, will that claim be down-coded to an A4351? Scott White: Actually, as of February of last year, we are no longer resorting to least costly alternative information. So we re no longer down-coding claims anymore as of February of last year. (Nicole): So, you re just flat-out denying them? Scott White: If the qualifications for payment were not met, it would be denied or if it was audited and the documentation shows that the qualifications were met it could be recouped. (Nicole): If it hasn t been met, can we resubmit that claim as an A4351? Scott White: So you ve submitted a claim previously and this might be one of those very kind of specific one that customer service would need to look at. If you just resubmitted something, you might get the same or similar denial on that claim. (Nicole): Okay. Female: Even if it s a different HCPC code? Scott White: It all again, if it s ((inaudible)) specific, I have to take a look at the claims in question to really to really be sure on that. I mean if they have been paid, you know, if you ve been paid for a certain HCPC code and then you just fill another one it might go through initially but it might be caught by something Page 2

3 that might come up in an audit later or something to look at or something like that. It s just hard to say without seeing the claim. Female: Alright. Female: All right, now for our next question, Female: Yes, my question is concerning diabetic supplies. Female: We just recently got some pre-pay, I guess, audits on our diabetic supplies and first they were just over-utilization patients, now they are just regular diabetic patients that are checking, you know, within Medicare s norm. So my question is on the download of the meters, how often are we expected to have that? Scott White: Actually I m going to (Carol) from the medical review standpoint might be able to shed some light on that part from a diabetic supply point of view? (Carol): If you re billing for normal utilization supplies like for example if they re not being treated with insulin you re billing for 100 units every three months you don t have to have a test log. The only thing that you would need is a medical record basically to verify that they are a diabetic and they are being treated by a physician for that condition. The only time that you need a test log for a medical record within six months of the date of service that we re looking at that tells us how often they are testing, if it s an over-utilization claim. Well, you know, on these pre-pay audit things we have gotten on the normal utilization patients it s asking for the logbook (Carol): Well, you know, it s a standard letter, and so, you know, we really can t change the verbiage based on the number of units but, you know, a lot of our edits and the number that we look for is based on workload issues and things like that and I think you ll probably be seeing less of those in the future. Scott White: And if you ve got the logbook, I mean, if it s there, you know, it doesn t hurt (Carol): We ve spent all week going over with everyone what the expectations are so the people that will be reviewing those claims are well aware that if you re just billing for normal units you don t have to have that log. But when were you going to let the suppliers know that? (Carol): Well, it s in the LCD. Female: Well, I mean, yes, it says in the LCD you have to have it every six months (Carol): No, only for over-utilization. Female: But then, you know, when you all ask for it in a letter, you know, we re pretty much used to jumping through the hoop, so, you know, we re making the patient free in their logbook for just a normal, non-over-utilization patient. But we don t have to have that. (Carol): We will not be looking for that if you re billing for the normal utilization listed in the LCD. Female: But you are going to continue to audit those patients as well over? (Carol): Well, like I say, you know, our edit parameters are based on what we see, you know, in errors and work with considerations and things like that. So, you know, they change. All right, and in relation to that, if we do have an over-utilization patient and say the doctor has ordered it for a non-insulin dependent patient to be checking three times a day, and when we do get the download on the monitor and it s showing they re only checking once a day, but we have given them the strips for the order for three times a day then are we you know, then we the next time they come in are we supposed to only get the strips for one time a day or are we supposed to be getting the order from I guess we would notify the doctor. (Carol): We re publishing an FAQ about that that should be online; if it s not online, it should be on there later today or tomorrow. Basically, you know, I mean, you can t give somebody, you know, you are bound by the doctor s order. Now certainly if the beneficiary is not testing at the frequency that you re dispensing supplies you might want to check with the doctor and see if something is changed. Because, you know, it just could be that they forgot to update your order, that if they say, well, no, I really want them to test three times a day they re just not doing it, then, you know, the better thing to do instead of deciding on your own, well, I m not going to give them that many is to bill it as an upgrade, you know, it s to get the beneficiary to sign an ABN, to say, you know, I m not, you know, testing like I m supposed to, the doctor s order three times a day so the supplier is bound to give three times a day, but Medicare is only going to pay like for once a day maybe if that s all the test shows. So like I say, go out to our website later today and tomorrow and that answer will be out there with some links to how you should bill in that situation. It s under medical review FAQs. It will the spring of 2012 medical review FAQs. Female: All right. Okay. I think that covers the question, thank you. Page 3

4 Scott White: Thank you. Thank you, (Carol). Female: Okay, I ve spoken to them. Operator: And now for our next question. Female: Hello? Scott White: Hello? Female: Hi, I have two questions. One of my questions is if a patient had surgery and they went from a hospital to ((inaudible)) and we gave them durable medical equipment while they were in the hospital and we didn t know they were going to a skilled nursing home. Can we still if the claim was denied can we actually do a re-determination on it? Scott White: Give me just a sec. You can do you always have appeal rights with a claim that s denied. If they are truly in-patient though there s not going to be much that s going to change on that denial from re-determination but you do have appeal right, you don t have to go to appeals. Female: So just because you appeal it doesn t mean that they ll pay, even if you because I went on in the LPD and I saw something that if may be paid if they met certain requirements? Scott White: If their Part A, say, was expired or something like that but in this situation it sounds like that that s not going to be paid in appeal but you re always welcome to, to send that in with, you know, make or state your case and send in a redetermination. My last question is (RACs). We ve got a lot of claims that were put in (RACs) and it was saying that it was the wrong place of service but it was actually the right place of service. So how do you stop that because actual surgeries were done at the hospital and they were saying they were done in the office with a place of service code? Scott White: So that the (RACs) in these cases were misinterpreting the place of service codes? Female: Exactly so I have go in and print out the hospital records and our CMS 1500 and send it into them, well, they retracted a couple of the claims. There was one that they haven t done yet but I m quite sure they re going to do it, and so, my question is how do you stop them from doing the (RAC) saying this is the wrong place of service and it s the correct place of service? Scott White: I mean the (RACs) do have a customer service number, try that and I can let our (RAC) coordinators know if there s something they do. That, you know, that, again, is a separate contractor, it s not with us at CGS but we do have a coordinator and everybody is taking notes here so I ll get with her and let her know that s going on but try to call the (RAC) customer service and let them know that that s happening as well. Scott White: Okay, well, then I ll tell the coordinator so she can speak to them as well. Scott White: Yes, thank you, ma am. Female: Okay, thank you. And now for our next question. Female: Hi, can you hear me? Scott White: Yes, I can. My question is we are from a really small town and there s only three DME companies in our town. One is about to close so we re kind of wondering if the 36 month for oxygen will start over if they come to us or will it still continue to pay the difference if we do take them? Scott White: The rules there are somewhat bound pretty strictly by the statute that s in place and we really only have recourse to start over before the scheduled end of the 60 month reasonable useful lifetime. In the case where the company that is treating the patient or the beneficiary actually declares bankruptcy and we have all that paperwork, if they simply just kind of disappear which we see some happen here, unfortunately we don t have any recourse to start the cap (trial) over prior to the end of the reasonable useful lifetime. So you pick them up, get what s left of the rental cap if any or maintenance and service and contents filled until we get the month 60 from the original CMMD. Female: Okay, and then I also I just want to make sure, I did read this in the LCD but if we cannot get any CMNs, initial CMNs from the company our revised will work alright, is that correct? Scott White: A lot of that has to depend on how old that initial CMN is, obviously if it s, you know, past the record timekeeping period we can t request it. If it is within that time that they want to take a look at that initial CMN they ll need to work through those specific situations and not being able to obtain it and the reasons why, probably or most likely in the appeals process. But, you know, it is something that we can request it is not past the records retention guideline of seven years. But you certainly do want to get a good revised CMN to move forward with from the moment you take the patient on. Female: Yes, correct, and then we ll still have to get the ((inaudible)) off from their initial, the other company s initial, right? Scott White: And like on the Group 1 patient and if we re in Page 4

5 within the first year of that kind of thing is the ((inaudible)) they won t change. (Carol): What recourse do their old customers have if they close their doors and they need tanks or service? Scott White: That s a tough one because, again, the statute kind of guiding that oxygen payment is very tight. You know the patient can take their normal sort of recourse directly with Medicare through the Medicare and that, we ve had situations where patients will use their elected officials in those situations, but unfortunately if they just disappear and aren t there to provide service anymore, all we can really do with the new supplier is to continue that cap rental or continue that reasonable useful lifetime. Female: Okay, thank you. (Carol): Okay, thank you. Female: And now for our next question. Female: My question hello? Scott White: Hello? My question is we ve been, had a lot of patients deny use of, you know, diabetic shoes and inserts and when we call to verify the benefits, you know, that s one of the questions that might verify ask, you know, has the patient received a pair for the year? Of course, you know, Medicare approve a pair of diabetic shoes and inserts a pair of shoes and three pair of inserts a year. Scott White: ((Inaudible)). Female: Well, we ve been getting a lot of denials back stating that the patient had already received the item. And, you know, what can we do because we don t get paid and you don t give me a PR 96 where I can bill the patient. Hello? I m here. Just give me just a second. You know, the best resource and what ve seen happen is the best resource is actually calling a (CSR). Now, sometimes what we ll see happen is the provider calls and they ll check and see and then they haven t had that shoe within a year but then it ll be two months later before that claim actually gets billed and they get another shoe. You know, the best thing you can do is just call the (CSR), so that s the best recourse that you have for that and right when you call be ready to have everything together and bill that claim because we had do have a lot of instances where we call, say it s clear but then the claim doesn t come through until three months later or something and another company is billed ((inaudible)) going to be ((inaudible)). Female: Well, and I agree, because when the patient comes in for the (initial eval), you know, we have to evaluate the patient to make sure and then we order the item. Female: You know, we have to wait until the item comes back. But my problem is, you know, we called to get clarification to make sure that the patient has not received it. And I ve had cases where the patient s shoes was back within four weeks and they go somewhere else and get it get another pair of shoes and inserts. Female: And our claim is denied because the other party claimed it before mine. Scott White: Sure, sure and that s then how it s going to be, to just be as thorough as you can, talk to that beneficiary. Let them know, this will be this amount of time, we ll get your shoes. If you go anywhere else, you know, please let me know. Unfortunately, that s about that s about just being as thorough and double checking and that s going to happen sometimes, but there s nothing that we can do to fix it from a system perspective or anything like that. Female: So you can t make the patient response, whether they ve gotten two pair shoes and six pairs of inserts. Scott White: Well, that s why, again, check and make sure if they ve got something else and you know they ve had it within that calendar year and they want your shoes too, that would be an (ABN) situation. I understand that. Female: I m just ((inaudible)) clear. Scott White: But, yes, that s not there s no foolproof on it. There is no foolproof plan. Okay. Thanks. Scott White: Yes, ma am. Operator: Now for your next question. Female: Hi. Can you hear me? Scott White: I sure can. The (LCDs) for urological supplies says that the quantity limitation occurred A as in apple, 4357 which is bedside drainage bags and then also for A as in apple, 4358 which is ((inaudible)). It s 2 units each per month and so my question is does that mean that the beneficiaries can get a total of 4 drainage bags per month? It s not clear if it s a combined Page 5

6 quantity of (2) per month or if they can actually get up to 4 per month based on medical necessity. Scott White: Sure, give me just a second. (Carol), do you have any insight on that? I m trying to look up the LCD here. (Carol): I don t because it s not a policy I look at very much. I think that they I think because we don t expect them to wear the bedside bags while they re sleeping. Scott White: ((Inaudible)). (Carol): That they can get it, but I think that maybe a question that we have to research with, look at the LCD. Let me get your address, caller, and we ll get back to you on that one. (Carol): (Mia) says that it s (2) per month. Scott White: Two per month? Female: So a combined quantity of 2, whether that means like either one of the (A4257) and one of the (A435) excuse me, 4357 and 58, not 4 total? Scott White: That s what we re saying, but you know what? I m going to I want to follow up with you still on that because I don t want to we re not sure so I want to check and make sure. What s your address and I ll get back with you? Female: It s hperez And we ll get back to you. I ll do some quick research here off the call and get back to you. Thank you. Operator: Once again, that is star, one, if you d like to ask a question. And we do have another question. Female: Hello? Scott White: Hello? Female: Yes, I have a question in regards to enteral supplies. Female: When billing prospectively for an enteral patient, when how would you include, you know, say, you bill for (3/1 through 3/31) and then the patient goes to the hospital in the middle of the month or either the calories change, what is the best way to include those hospital days you ve already billed for the month? Scott White: Sure. And that s one of the things with the prospective billing. You know, you want to be in contact, this is how to meet those refill requirements, situations like that are going to happen. I would make sure it s documented just for an audit perspective, but you want to call that beneficiary or the nursing facility and you really adjust it on the next month s claim, so if they didn t use they have 10 (cans) left and they usually have none at this point, you would just adjust the next month. So you just make sure it s documented well, what happened and your call for your refill requirements. So that s kind of how the things go but again, it does happen, the calories change. So you just kind of adjust it on the next month. So that would be okay. So you would ((inaudible)). Scott White: That s okay. And just document it again in an audit situation. It s third party person looking at your claim and if you don t document it well, and there is discrepancies like that, they re not going to understand what s going on and it could cause you, you just have to go through, you know, appeals or something like. So document it well. Have your refill request documented well. We re going to make up for it here next month because they have some left over because they went in the hospital the previous month. All right. Female: And then what if, well, say, what if the patient expires within that span date with its are you required to Scott White: You know, from a Medicare standpoint that nutrition now belongs to the beneficiary s family. You are welcome to refund Medicare, if you feel that s necessary, although, it s going to be paid. It would just again be documented if the beneficiary died, as long as they Female: ((Inaudible)) you would not. Scott White: If they died in the middle of the month, or something like that, and you already billed for 3/1, from Medicare standpoint that nutrition now belongs to the beneficiary s family. And you re required to refund the difference. Scott White: No. And the refill request for enteral feeding, when they re in the nursing home, at what exactly are they and it does have to be a written document, is that correct? Scott White: (Carol), do you want to shine some light on that one? (Carol): It does have to written and basically it s the same as for anything and you know, you have to show that the beneficiary Page 6

7 or someone on behalf of the beneficiary, I mean in the case of a (snip) it could be one of the nurses, someone in central supply, a dietician, but someone has to request the refill. You have to document I m sorry, excuse me. You know, I mean each individual beneficiary, if you had, like, 10 people, you d have to have documentation for each person. You can have it on one sheet of paper but, I mean, it has to be individualized because as far we re concerned we are doing business with for the individual beneficiary, so you have to show that, make sure that you ve got to if the beneficiary which in case of ((inaudible)) they probably aren t the one that s going to replace the refill, so make sure you documented who you talk to and, of course, it s very important to put the quantity down and you can either do that in terms of the number of cans left or the number of days left. Thank you. Okay. (Carol): But I mean, you know, basically, just the routine refill requirements. And I do have one more question. This is in regards I guess until medical review of the enteral feeding. If a patient is on a category four and then switches to another category for, for a different, say, for a renal problem, they were on a diabetic formula and then they switch to another formula for say, renal problems, would they want to see the documentation as to, for the first enteral, you know, the first category four as well as the when they change to the second or does that make sense? (Carol): I think I know what you re saying, is that they re on one specialty nutrient and they go to another and that we want to see well, I mean, you know, that sort of hard to just talk about a hypothetical for that. (Carol): I mean, I guess the best answer I can give you without looking at a specific case is that specialty nutrients have to be individually justified. We don t pay for them based on a diagnosis. So I don t think that we would necessarily, I mean, like I say they re on Glucerne and you change them to Nephro, you would have to justify the Nephro. But they wouldn t want to see well, why were they, why did they start off on a category, the other category four, they would just basically be looking ((inaudible)). (Carol): Well, I mean, if they started if they, you know, if they started off on a category four, I mean, we re no longer trying to justify that. (Carol): You know, we re trying to justify the Nephro so, you know, we might want to know, I mean, the reason they changed would be part of the overall explanation, but you re still going to have to justify the specialty nutrient. (Carol): But not that they went from one specialty nutrient to another one, but why they need that one right then. Scott White: Thank you. Operator: Thank you very much and now for our next question. Female: Yes. Hello? Scott White: Hello? Female: My question is I hope it s simple, I guess, is there another site that maybe we can verify the doctors to assure that they are authorized to prescribe DME? The reason I ask is because we currently use, I guess the verification on your PECOS, the listing on there and, you know, that s the first thing we do is we verify the patient s doctors against that list, and then, I guess one of our claims just recently got denied, and that doctor is still on that list and he insists that he is authorized. But we are down now to an appeal because they re claiming or Medicare is claiming that they re not authorized. Scott White: Yes, give me just a second. Let s see if there s another site. You know, and just to be clear as well, this isn t a PECOS issue because we re not denying for PECOS yet to see if the physician s enrolled in PECOS. This is it sounds like something, you know, somewhere along the line that physician has done something and it says, I don t prescribe DME. By now I know they re telling you that they haven t done that, but that s where a denial like this would come from. It s not a PECOS issue because we re not denying for PECOS yet. And we still don t have an implementation date for when those denials will start for PECOS. So it sounds something I mean, take it to appeal, you know, if you ve got information from the physician, but somewhere along the line it sounds like they have sent something into Medicare which is I do not prescribe DME. Then I will get with the doctor and see if maybe we can get something from him so we can appeal this. Yes and again, not a PECOS issue so continue to check the PECOS site, but the denial s not going to be PECOS-related yet. Female: I appreciate your help. Thank you. Scott White: No problem. Operator: And now for our next question. Page 7

8 Female: Hello. Scott White: Hello. Female: My question is in regard also to enteral feeding. Are you able to hear me? Scott White: Yes, I am. When we go back to the specialty formulas again, really having a difficult time with those doctors documenting why they are placing that patient on that formula. Would it be acceptable since you have medical review there would it be acceptable to have the dietician document why he s placing that patient on that formula and then have the doctor sign off on it? Or wouldn t that be, does the doctor himself have to justify? Scott White: (Carol), you take that ((inaudible)). (Carol): It is perfectly acceptable, I mean, the doctor doesn t even have to sign off, you know. We recognize the dietician as being a health professional, you know, who can write their own note. The problem is that, again, it has to be individually justified so it can t be something like, you know, I recommended that Dr. X order Glucerna for this patient they re diabetic. It has to be more individualized and that is why that particular individual needs the specialty nutrient. But a lot of times in terms of getting good information about enteral nutrition and the medical necessity for it, we get a lot of good information from dietician and speech therapy records. So I encourage you to get those because a lot of times they give us more information than maybe a progress not would. Female: Yes. We see excellent documentation coming from dieticians, but we were understanding it had to be the doctor to justify it. (Carol): Unless a policy specifically says that something can only come from a doctor. (Carol): Now, we accept documentation from other health professionals and, you know, and this is one policy, like I say, where a lot of times the better information comes from other health professionals. You know, certainly, the order and the ultimate plan of care has to come from the physician. (Carol): But, you know, if you ve got dietician records, that s great. And they do not have to be co-signed by the doctor as long, you know, as we got the order from the doctor in everything. Female: Thank you very much. Operator: Okay. Now, for our next question. Female: Hi. I have actually two questions. Female: One is, when we send in our out notes for durable medical equipment and it says that it s authenticated by the doctor, does he still have to sign the out note or that s sufficient enough? Scott White: So he s electronically signed those notes? Female: Yes, from the hospital and their system, yes. Scott White: If they re electronically signed, electronic signature is a valid form of signature. And we do look for something like authenticated by or, you know, certified by or something. Female: It doesn t have to be he does with that line, he doesn t have to sign the out notes? Scott White: If only it says Authenticated by, let s say, Scott White, you know, at May 15, 2012 at 10:54 pm. That s what we usually see. That s got to have their name on it. It just can t say authenticated by. And it can t be a nurse signing for the doctor or something like that. Scott White: We see sometimes like electronically signed on behalf of doctor by Female: So it actually does he goes into the portal and does it himself ((inaudible)). Scott White: That s a valid electronic signature. Female: Oh, yes! Scott White: ((inaudible)) thing, right? Awesome. And then my last question is are there going to be any changes with durable medical as far as the documentation or anything like that in 2012? Scott White: That s pretty broad. Do you mean LCD specific or Female: Exactly. Scott White: I mean, there s new standards, so we had a ListServ come out last month, February 17 I believe, about the new LCD boilerplate language. Female: And where can you find that? Scott White: Oh, you can find it on our website, cgsmedicare. com. Click on News and go to News archive for 2012 and it s February 17. It talks about LCD language that s getting updated. Page 8

9 Scott White: But again, as much documentation as possible, those audits are not going anywhere so getting as much upfront is the key. Female: Exactly. Female: All right, thank you. (Carol): Scott? Scott White: Yes, (Carol)? (Carol): I ve got an answer to the drainage bag question. Scott White: Oh, okay. (Carol): In addition to two bedside drainage bags, we ll pay for two vinyl leg bags or one latex leg bag a month. So it would be two bedside drainage bags plus two vinyl bags for a total of four or two bedside drainage bags and one latex leg bag for a total of three. Thank you. Operator: Okay. Once again, that s star 1 if you have a question. If you find that your question has been answered, star 2 will remove you from the queue. And our next question is up. Operator: (Nicole), your line is open. You may be muted. (Nicole): Okay. ((inaudible)) right now? Operator: Yes, we can hear you now. (Nicole): Okay. Great. On the ((inaudible)) also, we have when we ((inaudible)) the monitor and supplies, we do an orientation sheet on the patient showing that they we demonstrated to them, they ve returned demonstration to us and that s our training, I guess you would say, of the patient. (Nicole): All right. But in the glucose monitor s documentation checklist, it states that the treating physician states that the patient of caregiver has successfully completed training and is or is scheduled to begin training in the use of the monitor and supplies and that the treating physician states the patient or caregiver is capable of using the test results to assure appropriate blood sugar control. I don t know that the physician is saving that in his medical record Scott White: Sure. Give me just one second. (Carol): Scott, can I? Scott White: Oh, sure, (Carol), yes. (Carol): Okay. The training requirement is actually in the National Coverage Determinations and it specifies that the physician has to be the one to provide the information. The physician doesn t necessarily have to be the one to train them, but the physician has to basically certify that the training took place and the patient is able to do that. Now, you know, most of the time, we require that anything that verifies something in a coverage determination has to come from the physician in the form of a progress note or something like that. But we do recognize that a lot of doctors do not keep training records of any kind. So we will take other formats. You know, if it s in the progress note that s fine and good, we would take a letter from the doctor. Some suppliers choose to have a statement on their order form where the doctor, in addition to signing, you know, the order, specifies that the training requirement has been met. So we will take all of those formats, but the training certification or verification has to come from the doctor. (Nicole): Okay. Okay. So if we do have audits now and we don t have that, we need to get something from the doctor before we send those in. (Carol): I would recommend that you do that, yes. (Nicole): Okay. Thank you. Operator: Now, for our next question. (Janet): Hi, I m (Janet) from ((inaudible)). And I just got a of notice today saying that the ABN for upgrade for mastectomy products has changed. Where can I find some more information on this? Scott White: Give me just a second. I believe some information is going to be forthcoming. We actually have a webinar on April 20 for the mastectomy bra. It s free. You can sign up on our website at cgsmedicare.com and go to the Education page and you can sign up for the webinar. That information has come out and we re actually awaiting some clarification as well on that from the medical director. So that webinar will be the best place to get that information and ask that question. That s April 20. (Janet): Okay. They say that the ABN will not be accepted as valid upgrade. So are we not going to be able to use an ABN at all? Scott White: Now, you can always use an ABN if, you know, medical necessity is not met. But there was some issues that came up with the upgrade and that was the understanding that we had received that, you know, the upgraded bra, like with lace or with something else, was not going to be an ABN issueable thing. So again, more to come on that. That webinar is Page 9

10 going to be the best place, you ll have some more clarification at that point. (Janet): Okay. I just registered for that so I ll be listening to that. There s something Yes, ma am, and that is my understanding. You re correct that the ABN is not going to be valid in that situation any longer, but again, more information to come. (Janet): Okay. ((inaudible)) you re just talking about, is that 9:30? Is that central time or eastern time? Scott White: Yes, ma am. It is central time. (Janet): Central time? (Janet): Okay. Thank you. Operator: And now for our next question. Female: Hi. Good afternoon. I m calling about a question for the O2 medical records request. Female: We have been getting denials. We sent everything we ve had ((inaudible)). Scott White: I lost I lost you there. Sorry. Female: I m sorry. Is that better? We sent everything including the hospital notes and records, what was ordered by the physician, the records of the O2 testing. Female: And we re actually getting back denials stating that the records do not show any other treatment attempted when I have asked someone at Medicare in the review department what in the world would they try other than O2. They actually said to me I don t know. So the doctors think I m a little bit crazy when I asked them what else they did. So, I mean, how do we deal with that one? Scott White: From a medical review perspective, (Carol)? (Carol): That s something that we re really trying to talk about right now. Part of it maybe I can help you understand. Another part, we may have to wait about. Female: I keep losing you guys. (Carol): Can you hear me now? Female: Yes, you keep going in and out. (Carol): Okay. You know, basically, part of that goes back to the chronic-stable state... (Carol):... in terms of, for example, if someone has an acute exacerbation of COPD and they don t go into the hospital before ((inaudible)) Medicare would pay for oxygen, there would have to be, you know, maybe antibiotics and medications to clear secretions and things like that. (Carol): And that s part of what we re looking for. Female: You re talking about the chronic stage. (Carol): Is it that is that that there was a treatment plan in place? You know, because oxygen is very rarely the first thing that somebody gives. There s usually, you know, been some disease process going on and there s been treatment, but despite the treatment thing progressed to the point that now they now they need oxygen. So, you know, basically, we re just looking for a treatment plan that was in place that addresses the situation, which is usually going to be a chronic illness, and, despite that, they continue to deteriorate and now they need oxygen. Now, that was another FAQ that I intended to publish this time. And, you know, some of the medical directors, you know, they went back and looked at what the (NCD) says. And the (NCD), which I don t remember, I think it s like 280 point something, and it really sort of gives an example where it talks about, you know, clearing secretions and all that. So you may want to go back to the (NCD) and actually look at it. But I think that the medical directors are going to talk among themselves a little bit about, you know, exactly what the reviewers need to look for. And I think at some point we will may be publish some more information to help clarify that a little bit more for your sake... Female: You ll address those again. (Carol):... and for the reviewers sake also. I you dropped off there again. So you re saying that they re just going to talk about with the reviewers what it is they need to look for. (Carol): No. No. I said I think I think that the medical directors want to be clear... (Carol):... you know, that they are following the (NCD) requirements. So they re going to talk about exactly what that Page 10

11 is and then at some point the intent is to publish an answer either an article, an online article or an FAQ for the suppliers. I mean, you know, certainly, we will do an internal education with the reviewers, but we will also do external education with suppliers to help them understand that requirement better. What would you recommend for us to even find out these records if it s a patient who is chronic and is in the hospital and then released with this conditions, but had not been on oxygen before? Are you saying we need to go to their (PCP) and get copies of their records as well? (Carol): Well, I think, you know, the thing of it is, you know, there s not the chronic-stable state issue if they if they are coming out of the hospital. So I think, you know, as long as you know, if you ve got records prior to the hospital admission that s good, but if you ve got you know, a lot of times in the hospitals, you know, they ll have a really good history on physical or discharge summary that really sort of, you know, shows you what s going on and and discusses the other treatments and everything. But most of the time, they don t. They d say a patient came in with this condition. They have this in the past, past history shows this discharge with oxygen, but there is no proof that they have tried something else. (Carol): Well, you know, I just I can t you know, that s another situation where, you know, you can t really speak to, you know, every case. I mean, everybody is different. But, you know, you just have to I mean, like I say, you just have to show that they didn t go in and get tested and the doctor said, Oh, they ve got hypoxia, and put them on oxygen. (Carol): That s the under whatever the underlying condition is that that was treated, you know, first. Like, for example, if they ve got OSA, you know, the first line of treatment for that is sleep (patch). (Carol): So, you know, you just whatever the condition is, the first, you know, logical line of therapy, you know, you need to show that those were tried and despite that, you know, the hypoxia persisted. Okay. Thank you. Operator: And now for our next question. (Kim Cole), your line is open. (Kim Cole): Can you hear me? (Kim Cole): Okay. So my question is if skin (wipes), which are included under (A5120), are covered to press the skin before applying an external male catheter which is coded as (A43 and 49). Scott White: Give me just a second. We re just doing a little bit of research here just a second. Actually, let me just take your because some of these ((inaudible)) looking at (LCDs) for things, it will be easier just to do off the call and I ll just you? (Kim Cole): Sure. And I actually have another question that might be specific to the (LCD) research as well. My question is ((inaudible)) cleaner is covered for your logical drainage bag, the (A4357 and A4358)? They maybe considered disposable, but they re used for up to a month, so patients often require cleaning of the drainage bags throughout the month. Yes, we ll we ll get together. I ll send you an and then, you know, you will get these questions answered. That s probably the best way because it s going to take a little bit of (LCD) research. So what s your address? (Kim Cole): It s (hpress@liberatormedical.com). Scott White: All right. ((Inaudible)) you were on. You heard the answer to the drainage bags question previously ((inaudible)). (Kim Cole): Yes. Just to repeat, I think what I heard was that two vinyl bags and two bedside drainage bags for a total of four drainage bags per month was acceptable. These are medical necessities. Four (tube) bedside drainage bags and one latex bag were three per month. Scott White: That s correct. Yes. (Kim Cole): Okay, great. Thank you. Scott White: And we ll get together and ((inaudible)) urological supplies webinar so. (Kim Cole): Great. Thank you. Operator: And now for our next question? Female: Yes. I m with a prosthetic company, and we send in our paper claims. And during our re-accreditation, we had a sign up for electronic funds so that the payments go directly into our checking account. Will we receive a paper (EOB) like we used to do? Hello? Scott White: Yes, I m here. Give me just a second. Scott White: If you want a paper copy of that, you have to call customer service and request it for individual claims. So each claim, once it s cleared I just call in and ask for paper claim? Page 11

12 All right, that s what I need to know. Thank you very much. Operator: And now for our next question. Female: Hello. I have a couple of questions about it s about (Inerol) and (Milrinone). My first question would be for the (Inerol). We had we have a patient that who went through with (direct audit) and it was due to hospitalization dates. Well, according to the guidelines, you know, we have to contact the patient prior to delivery. So, you know, say, we contacted the patient Monday and and we re set to deliver tomorrow, but the patient just happened to go into the hospital, you know, the day before our delivery. What can we do as far as appealing appealing that? Or do we have any grounds to appeal it? Scott White: Give me just a second. ((Inaudible)). Now, your ship date on that is going to be your date of service. Scott White: So that would that could possibly be before, you know. Unfortunately, there s not you always appeal rights. You know, you could always, you know, make your case, but there s not when things like that happen, there s not a clear cut way to you know, again, it s just a bad situation. I definitely empathize that. I mean, your ship date usually would be before the hospitalization date if in the situation that you described, at least. Female: No. I mean, you know, according to the (guidelines content) the patient 5 days before before you ship it out to find out the quantity on hand and what s needed and whatever whenever. Scott White: Sure. Female: So, you know, we contact when we contacted the patient Monday, we were not shipping out until tomorrow. Female: So our actual date or actual date would be tomorrow s date. But if that patient it s happening is hospitalized today... Female:... then, you know, fortunately, we shipped out because we did not contact the patient the day of delivery. We had already made our contact that we needed to make. There s not a lot of I mean, it s not just an issue of changing dates of service because that s not going to be going to be a valid issue. Female: Yes. Scott White: You know, that s if to do an appeal process, try to document what happened. The best way to do that is going to be through appeal, but I can t guarantee that it s going to get get paid at the first two levels of appeal though just because we have strict guidelines for date of shipment and (in patient) responsibility. And then we had a we had another one. It s pretty much the same circumstance. The patient is he was on (Milrinone) and we had made our prior our prior contact with the patient the actually the day before. And the date that we shipped it to him, they called him from the hospital and told them that they a (heart) for him to get to the hospital immediately for, you know, for ((inaudible)). So even though our shipment was that morning and the patient was not contacted until the afternoon, it s still, you know, the (rep) is still we still had to go to the (rep) audit process and decided what, you know, ((inaudible)) with them. Scott White: Yes, what they did from admission and date of discharge, so I would definitely take that appeals. Female: Yes. I mean, because we showed them a copy of the delivery the proof of delivery showing the time of the that it was delivered to patient s house and then he actually signed for it. Send it to appeals. We should (pay) date of admission and date of discharge. And then I had I need a ((inaudible)) supporting documentation for the (Inirol) supplies. We have a couple of patients that were recently diagnosed with dysphagia or whatever it was and they re also diabetic. So, of course, the physician, you know, wrote the order for the higher formula, the (B4154). So what kind of documentation do we need, because basically we just have what the documentation from the hospital just stating the dysphagia or whatever but nothing as far as the (B4154) formula versus the (B4154). I mean, there s got to be something that shows why that regular formula is not going to work that patient more than just the diagnosis. You want to see what, why that special nutrient is necessary. I mean, they want specifics. I know from a medical review standpoint. I always have discussion about the specialty formula. It s got to it s got to show why the the regular formula will not meet the need that necessitates that specialty formula. And, (Carol), if you want to add something to that, but that s just, you know, from a policy standpoint, but we ve been Page 12