AMARILLO, Texas — With all the confusion surrounding CMS' new post-cap oxygen payment rules, it's time for some answers. In a special series for HomeCare Monday, Lisa K. Smith, Esq., an attorney with the Health Care Group at Brown & Fortunato, P.C., a law firm based in Amarillo, Texas, responds to several of home medical equipment providers' most common questions about the new rules.
Corrections and Updates: On Jan. 27, CMS issued additional guidance regarding billing for oxygen contents and replacement oxygen equipment after the expiration of the five-year useful lifetime. The guidance was issued as a listserv message with the Change Request (Transmittal) to follow. This guidance can be found online at http://www.cignagovernmentservices.com/jc/pubs/news/2009/0109/cope9216.html. Based on this information, the following Q&A's previously published have been revised to reflect the new guidance.
Question: Does a portable unit take on the exact start date of the stationary system or can the two be unique? The situation is the physician may initially order a stationary system and a few months later the portable is added. Does the portable unit have a unique oxygen cap start/end date (36-month period), or do I start billing for portable contents once the stationary system caps?
Updated Answer: The 36-month cap period for the portable unit will be different from the 36-month cap period for the stationary system if the portable equipment is added at a later date. The supplier will continue to bill the portable unit as a rental until it reaches the 36-month cap. However, the supplier can start billing for portable contents after the stationary system caps, and need not wait for the portable unit to cap.
This means that the supplier is able to bill for both the portable rental and portable contents for that period after the stationary system caps and before the portable system caps. Once the portable system caps, the supplier can continue to bill for portable contents.
In other words, stationary and/or portable contents can be billed after the stationary system has reached the 36-month cap. Stationary and/or portable contents cannot be billed during the 36-month rental period for the stationary system. This means that when a supplier replaces the stationary oxygen equipment at the end of the five-year useful life and starts a new 36-month rental, it cannot continue to submit claims for portable contents.
Question: When billing for oxygen contents after the 36-month cap period, can the supplier bill for a month's content if it did not make a delivery in that month? In other words, can a supplier deliver oxygen contents for multiple months at one time and then bill for contents for each of those months?
Updated Answer: Yes, the supplier is not required to deliver oxygen contents during the month in order to bill for contents for that month, so long as the supplier delivered oxygen contents for that month at an earlier date. For example, a supplier can deliver a three-month supply of portable tanks on Jan. 15, and then submit monthly claims for portable contents with dates of service of Jan. 15, Feb. 15 and March 15.
The new CMS guidance states that a maximum of three months of oxygen contents can be delivered at one time. It further states that "in order to bill for contents for a specific month, you must have previously delivered quantities of oxygen that are sufficient to last for one month following the date of service on the claim."
Question: What are the logistics for providing replacement equipment after the end of the five-year useful life period? What documentation is required? Will the patient need to see the physician and is a new CMN required?
Updated Answer: The five-year useful life period begins when the oxygen equipment is first delivered to the patient and ends at the point when the equipment has been used by the patient on a continuous basis for five years. It does not restart if there has been a change in oxygen modality, change-out of equipment or change in supplier.
As to CMN and testing requirements, CMS states: A new certificate of medical necessity (CMN) is required in situations where oxygen equipment is replaced because the equipment has been in continuous use by the patient for the equipment's reasonable useful lifetime or is lost, stolen, or irreparably damaged. New testing, however, is not required unless it is necessary in order to meet existing medical review guidelines for oxygen and oxygen equipment. You should continue to follow the existing guidelines requiring recertification CMNs for all situations in which oxygen equipment is being replaced. The most recent qualifying value and testing date should be entered on the CMN.
It is not clear whether the reference to a "new" CMN means a new initial CMN, recertification CMN or revised CMN, and we have sought clarification from CMS.
Regarding additional documentation requirements, CMS states that the supplier must maintain proof-of-delivery documentation showing that replacement oxygen equipment has been provided. CMS states that the supplier must also have proof-of-delivery documentation that demonstrates that the oxygen equipment being replaced has been in use for at least five years. While this may not be a problem for a supplier who has had its equipment with the patient for the full five years, it could easily be a problem if the patient has changed suppliers during the five-year period. We are seeking clarification from CMS concerning alternate forms of documentation that would demonstrate that the equipment has reached its five-year useful life, such as the initial CMN on file with the DME MAC.
Claims for replacement oxygen equipment for the first month of use only must have the RA modifier for dates of service Jan. 1, 2009, or after, or the RP modifier for dates of service prior to Jan. 1, 2009. The supplier must also include on the first month's claim a narrative explanation stating that the five-year useful life of the prior equipment has expired, and include the date that the beneficiary received the original equipment that is being replaced.
CMS states: When submitting claims electronically for replacement of oxygen equipment, you may use, for the narrative explanation, loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ASC X12, version 4010A1 professional electronic claim format. If you are billing using the Form CMS-1500 paper claim, you may report this information in item 19 of the claim form.
Lisa K. Smith, who is Board Certified in Health Law by the Texas Board of Legal Specialization, represents HME companies, pharmacies, hospitals and other health care providers throughout the United States. She can be contacted at lsmith@bf-law.com.
