Monday, January 24, 2011

BALTIMORE — On an Open Door Forum call Jan. 19, CMS officials made a string of announcements and answered a range of caller questions, some going over old territory and some completely unexpected.

For starters, the agency's Lori Anderson told listeners that despite the announced Jan. 1 implementation date for verification of face-to-face encounters now necessary for both home health and hospice benefits, CMS would not expect full compliance with the new requirements until the second quarter of 2011. Anderson said the agency had concerns that "some providers may need additional time to establish operational protocols necessary to comply with these requirements."

DME providers, however, didn't exactly get the same relief.

"Have you issued any guidance on whether or not you have started implementing the face-to-face requirement for DME suppliers as well?" asked a caller.

"No, that is a different statutory requirement," Anderson replied, adding that "the implementation regulation associated with that is still in process."


"Any idea when that might come out?" the caller inquired.

"No, I don't know that," Anderson replied, "but at the next Open Door Forum we can try to get someone in here to give us an update."

Providers did get something of a reprieve on enforcement of the expanded direct solicitation ban, included in CMS' August 2010 final rule on supplier standards.

"Among other things, the final rule included expansion of the provision regulating the direct solicitation of Medicare beneficiaries by DMEPOS suppliers," explained the agency's John Spiegel.

"The new rule enlarged the scope of the provision beyond telephone contacts to include in-person contacts, email and instant messaging. Since then, unanticipated issues have arisen regarding implementation of the newly expanded portions of the provision. CMS feels further investigation is necessary to determine the best way to apply these changes.


"In the interim," Spiegel said, "CMS does not intend to instruct Medicare contractors to implement the expanded provision."

In other announcements/Q&As during the Open Door call:

  • "We've noticed that sometimes physicians will fall off of the current PECOS list," a caller said. Why is that, she asked?

    One CMS official responded, "I don't have a good explanation." But Spiegel said there could be a number of reasons, such as physician applications that haven't been processed, problems in completing the enrollment review or information that physicians didn't send in time, "things like that. And when it exceeds time limits for processing … sometimes things recycle and end up starting over again," he said.

    Those are reasons physicians might not appear on the PECOS "pending" list, the caller pointed out, but that doesn't explain why physicians might appear on the actual "approved" list only to disappear from that list later.


    Spiegel responded that if providers are having problems figuring out whether physicians are PECOS-registered, they can call 410/786-5704 "and we'll find an answer to your questions."

  • "Several of our doctors have complained they have tried to register for PECOS but it's not showing up as even pending, and they're telling us that CMS is backlogged. Is that true?" another caller wanted to know.

    Said Spiegel, "There is a backlog at the moment our contractors are working to resolve, so, yes, that's true, there is a backlog."

  • CMS' Susan Webster said Cigna, the Jurisdiction C DME MAC, is individually contacting any provider that had more than 200 claims denied as a result of an internal claims edit error on Jan. 3. That process "should be completed this week," Webster said. (Read a notice on the Cigna website.)

  • Webster also reminded non-contract grandfathered suppliers to use the KY modifier on claims for beneficiaries residing in a competitive bidding area "for purchased, covered accessories or supplies furnished for use with rented grandfathered equipment. There are 24 codes that fall into that category" in the CPAP, hospital beds and walker categories, Webster said. "Suppliers must use the KY modifier to receive payment, and they are reminded to please submit the single payment amounts as their submitted charge so their claims will process correctly." (Additional information is included in a revised issue of MLN SE1035.)


  • Do contract suppliers need to use a special modifier on their claims to identify themselves as contract suppliers, a caller wanted to know? No, said a CMS official. "For competitive bidding in general, the claims are identified in the system based on the beneficiary's address, the zip code in the address, and the item is identified based on the HCPCS code and the supplier is identified based on a file we have with all the contract supplier numbers. So that's how the competitive bidding claim is identified and a competitive bidding supplier is identified, and there's no modifier that's used."

For a replay of Wednesday's Open Door Forum, call 800/642-1687 and use Conference ID 29116124 (available for 10 business days after the call).

The next Home Health, Hospice & DME Open Door Forum is scheduled for Wednesday, March 2, from 2 to 3 p.m. ET. To listen in, call 800/837-1935 and use Conference ID 39057815.