ALEXANDRIA, Va.--In an April 20 letter addressed to Herb Kuhn, director of CMS' Center for Medicare Management, the American Association for Homecare has asked for clarification on the oxygen and DME rental cap provisions in the Deficit Reduction Act.

The association is concerned about a number of issues involving implementation of the DRA--signed into law on Feb. 8--which will cap Medicare rental of home oxygen equipment at 36 months and transfer the title to the beneficiary, as well as eliminate the cap rental option for DME (see HomeCare Monday, Jan. 9).

"AAHomecare understands that these new payment methodologies do not take effect immediately. However, their impact on our members' operations is immediate because they must begin to structure their operations to respond to the changes," the letter said. "Moreover, providers must plan now for their implementation in order to ensure a smooth transition for Medicare beneficiaries."

The letter included the following 33 questions addressing medical necessity and documentation, reimbursement, service and maintenance and other issues:

1. Will current regulations defining "continuous use" for capped rental DME remain unchanged?
2. How will CMS define "continuous use" for oxygen equipment? What will constitute a break in service so that a new period of continuous use commences for beneficiaries on oxygen?
3. When a beneficiary owns his or her oxygen equipment, will Medicare pay for new equipment on the basis of a change in condition? Does the change in equipment begin a new period of continuous use?
4. Will CMS issue regulations to address the issues raised in questions 1 and 2 above? If so, what is the projected timeline for a proposed rule?
5. If new technology becomes available that is medically appropriate and has the potential to improve health outcomes, will the beneficiary be responsible for paying for the new equipment (assuming there has been no change in condition)?
6. How will CMS define "oxygen" after the 36-month period of continuous use ends? How will the medical necessity documentation for oxygen change? Will lifetime CMNs be valid for beneficiaries who own their own equipment?
7. Will beneficiaries who have both a concentrator and stationary liquid or a concentrator and a portable concentrator be responsible for purchasing one of the two systems after 36 months?
8. How will CMS pay for refills on an oxygen cylinder? Will the payment amount differ between patients who require more refills because they have a greater need for mobility or a higher prescribed liter flow?
9. How will CMS take into consideration those patients who have a concentrator and a liquid system, where the liquid system is being primarily used for ambulatory/portable requirements? Will the Medicare program pay for additional portable cylinders after the 36-month rental period, or will it be the beneficiary's responsibility to purchase these items?
10. Will the beneficiary be responsible for purchasing supplies such as cannulas and tubing for their oxygen equipment or other items such as humidifiers?
11. May providers charge beneficiaries a rental or purchase for a back-up emergency cylinder that is not used to meet the patient's portable oxygen needs? These units would be used solely in the event of an emergency such as a power outage, a natural disaster, or a malfunction of the beneficiary's primary equipment. Will Medicare pay for the contents once these cylinders are used?
12. Will the payment amount differ based on different oxygen technologies that may be more or less costly for the provider to furnish?
13. Providers may be unable to service a patient-owned portable oxygen cylinder that they did not furnish. Will the beneficiary be responsible for purchasing a new oxygen cylinder under these circumstances?
14. Will rental months at a beneficiary's second residence apply towards the 36 months of continuous use? If so, which provider is responsible for transferring title to the beneficiary (i.e., the primary provider, or the provider at the second residence)? Similarly, if a beneficiary moves during the period of continuous use, which provider is responsible for transferring title (the new provider or the original provider)?
15. For short-term travel, the beneficiary pays for the oxygen out-of-pocket and the primary provider may reimburse all or a part of those costs. AAHomecare anticipates that this rule will not change for beneficiaries who own their oxygen equipment. That is, the beneficiary will continue to be responsible for arranging and paying for travel oxygen. With respect to the period of continuous use, please confirm that our understanding is correct. After title to the equipment transfers, will Medicare pay the beneficiary directly for short-term travel oxygen?
16. Will the beneficiary be responsible to pay charges for pick up and delivery of oxygen refills after title to oxygen equipment transfers to the beneficiary? If not, what data does CMS propose to use to arrive at an appropriate payment amount for pick up and delivery charges?
17. For beneficiary-owned equipment that requires servicing, will Medicare pay pick up and delivery charges? If so, what data will CMS use to arrive at an appropriate payment amount for pick up and delivery charges?
18. Does CMS intend to apply any of the billing rules that applied to capped rental equipment to rent-to-purchase DME? A purchase option letter is unnecessary inasmuch as the beneficiary no longer has the "option" to purchase the equipment. Consequently, we see no need to use the BP, BR, or BU modifiers in the 11th, 12th and 13th rental months.
19. How will CMS define the useful of life of oxygen equipment?
20. If oxygen equipment is "irreparably damaged" after title has transferred to the beneficiary, but before the end of the equipment's "useful life," will Medicare pay for new equipment? If so, will this commence a new period of "continuous use," or will CMS pay a lump sum amount for the new equipment?
21. Does CMS have a timeline for issuing regulations that address questions 17 and 18 above?
22. Oxygen cylinders must undergo hydrostatic testing and other checks periodically. Though technically these tests are not "repairs," will they be reimbursed as repairs to account for the more extensive service they involve?
23. Will the Medicare program pay for emergency service calls for beneficiary-owned equipment that is still under warranty? If not, can providers contract with beneficiaries to provide on-call services for patient owned equipment?
24. If the manufacturer of equipment that is under warranty is no longer in business, will the beneficiary be responsible for paying for replacement parts? If the provider who furnished the equipment to the beneficiary is no longer in business, who is responsible for the repairs?
25. How will providers document that the maintenance and service they performed on oxygen equipment were reasonable and necessary? Will CMS require different documentation depending on whether the provider repairs the equipment it furnished or equipment furnished by another provider?
26. Will CMS issue temporary HCPCS codes to identify the service, maintenance and repairs for oxygen equipment, or will providers have to apply for the codes?
27. How will providers be reimbursed for service or maintenance to non-covered oxygen equipment such as conserving devices or oxygen titrating devices? Will providers bill the beneficiary for these services?
28. Will CMS issue temporary HCPCS codes to identify service and maintenance repairs and parts for equipment in the capped rental category, such as motor and hand controls for a bed, or will providers have to apply for the codes?
29. Will the requirements of the DRA apply retroactively to January 1, 2006, regardless of whether the need for systems changes result in administrative delays in implementation?
30. Will CMS require providers to transfer title to beneficiaries who have unpaid deductible and coinsurance balances?
31. After title to the oxygen equipment transfers to the beneficiary, will beneficiaries be responsible for paying for clinical assessments required under state law? Will the beneficiary be responsible for paying for respiratory assessment ordered by the physician?
32. Please confirm that parenteral and enteral pumps are not subject to the rent-to-purchase methodology established under the DRA.
33. How will providers be reimbursed if beneficiaries begin to use oxygen or capped rental equipment under a Medicare Advantage plan? Will CMS begin a new period of continuous use each time the beneficiary has a payer change in or out of traditional Medicare?