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From The Desk Of Ronda Buhrmester: More Details On Breaking Down The PHE Rules As It Relates To Billing

You have taken care of your patients, now it's time to get the claims paid! As more information is being released on the COVID-19 public health emergency (PHE), we are getting a better understanding with regards to getting claims reimbursed especially in the respiratory area.  

Let's break down the latest release as it relates to in-person encounters (F2F), clinical indications for coverage, the standard written order requirements, claim instructions, and diagnosis coding. 

Starting with the diagnosis codingonly apply one of the following ICD-10 codes if the patient has this diagnosis. Do not use either diagnosis code below if it’s a standard patient that was not or is not affected by this virus. For example, if it’s a patient with COPD and no Coronavirus, then only append the J44.9 diagnosis code, no coronavirus code is needed. 

  • For claims with dates of service before April 1, 2020, suppliers and providers should enter two ICD-10 codes on the claim.The first code entered should be used to describe the clinical diagnosis (pneumonia, bronchitis etc.). The second code entered should be B97.29 (OTHER CORONAVIRUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE). 

  • For claims with dates of service on or after April 1, 2020, suppliers and providers should enter ICD-10 code U07.1 (COVID-19) on the claim. 

Claim instructions have finally been released for submitting the oxygen claims that require a CMN (CMS-484). Up until May 7th, suppliers have not been able to submit oxygen claims (due to relaxation of the medical policy) which also meant no reimbursement for oxygen equipment and services.  The new direction is that the CMS-484 CMN will not be enforced at this time. According to the DMACs, their system has been set up to accept oxygen claims without a CMN or even with the CMN 

What does this mean? If a supplier has a completed CMN or can get the CMN completed, the claim can still be submitted with a CMN (RRKX). If an oxygen order is all that you have from the practitioner, then submit the claim without the CMN. (RRKXCR). Best practice is to try for coverage criteria being met and obtaining a completed CMN. The same instruction applies to the DIF for enteral infusion pumps requiring the DIF 10125 form. 

The CR modifier only applies to claims that do not have the coverage criteria met as outlined within the medical policy. The easy way to remember this logic is if all the coverage criteria is met (like a normal environment) then no CR.  If the coverage criteria is not met as outlined within the medical policy, but the medical record does show a need for the item being ordered, then a CR is appended.  In either situation, use the standard modifiers as well on the claims including the including KX, if applicable 

The CR modifier also requires a narrative in the NTE segment (2300/2400) with "COVID-19". 

If you are using the CMS-1500 claim form, please follow the same claim instructions. 

  • Coverage criteria met = NO CR 

  • Coverage criteria not met = CR Required (with narrative COVID-19)

Throughout the PHE, we all have been trying to wrap our heads around the guidelines surrounding the coverage guidelines outlined within the medical policies (NCD & LCD). According to the most recent information released, for claims with a date of service March 1, 2020 through the duration of the PHE, the following NCDs and LCDs that are not being enforced: 

  • Home Oxygen (NCD 240.2) 

  • Infusion Pumps (NCD 280.14) 

  • Continuous Positive Airway Pressure for Obstructive Sleep Apnea (NCD 240.4) 

  • Intrapulmonary Percussive Ventilator (NCD 240.5) 

  • Oxygen and Oxygen Equipment (L33797); 

  • Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea (L33718); 

  • Oral Appliances for the Treatment of Obstructive Sleep Apnea (L33611) 

  • Respiratory Assist Devices (L33800); 

  • Mechanical In-exsufflation Devices (L33795) 

  • High Frequency Chest Wall Oscillation (L33785) 

  • Nebulizers (L33370) 

  • Glucose Monitors (L33822) – Only clinical indications for Therapeutic Continuous Glucose Monitors (CGM) are not enforced 

  • External Infusion Pumps (L33794) 

  • NCD 190.11 Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management 

What does this mean?  If an item is needed under the waived enforcement, that item still needs to be reasonable and necessary.  The medical record still needs to have information to show the medical need, it’s the enforcement of the specific details that do not need to be met.   

All other medical policies not listed above, the coverage criteria does need to be met as outlined within the specific medical policy. However, the medical need can be determined by a clinician (i.e. nurse, RT, PT, OT) where they would indicate the necessary coverage within the patients' medical record. With that, a treating practitioner must still order the DMEPOS item/equipment. This also means a standard written order (SWO) is required for all items for claim submission.  (Please note PMDs still have specific policy requirements to be met.) 

In the end, proving medical necessity is important, we need to continue to be good stewards of our industry.  I highly encourage our members to follow the medical policies as close as possible taking each referral case by case.  There may be situations where only minimal information is available. In these cases, document with the patients file exactly what has occurred and track the patient for future reference. 

This is all temporary as we are working through the COVID-19 PHE.  At the end of this emergency, the enforcement of the clinical indications for coverage apply.  

This is our time to SHINE!  Thank you for all you are doing. 

Ronda Buhrmester 
[email protected]