Funding in 2021: Are You Ready?

In this podcast, billing and reimbursement experts Ronda Buhrmester and Dan Fedor discuss the funding landscape in 2021 and cover ongoing COVID-19 waivers, the payment rates (fee schedule, SPA, etc.), and what we are seeing as the most common denials and how to avoid them.

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Transcript

[00:00:00] This is Industry Matters, powered by VGM, a post-acute healthcare podcast about community, connections, and belonging. VGM is a member service organization serving durable and home medical equipment providers and manufacturers. VGM also has communities for respiratory, complex rehab, women's health/mastectomy, home accessibility, and orthotics and prosthetics industries. 

[00:00:27] Host: [00:00:27] Welcome to Industry Matters. Today we have Ronda Buhrmester and Dan Fedor, our billing and reimbursement experts, on the line. And we are talking about Funding in 2021: Are You Ready? In this episode, Ronda and Dan will discuss the funding landscape in 2021 and cover ongoing COVID waivers, payment rates, and what we are seeing as the most common denials and how to avoid them. 

[00:00:53] So, I guess we will start with Ronda because Dan says that she always has to be first. Ronda, we know the COVID [00:01:00] waivers have been extended again. Could you talk about for how long and what has been extended?  

[00:01:05] Ronda Buhrmester: [00:01:05] Sure. And yes, thank you. I like to go first as always, and I would actually prefer it just be me and Dan just sit in the background on this podcast and nod his head. I'm kidding.  

[00:01:16] Dan Fedor: [00:01:16] Like usual. 

[00:01:17] Ronda Buhrmester: [00:01:17] Yeah. You all know that we like this banter as we even present when you see us in person.  

[00:01:23] So yes. With the waiver and the public health emergency, as you all know, we've been under this public health emergency since last year, early last year. And it does extend on. The secretary of HHS of human health and services has to renew the public health emergency every 90 days. 

[00:01:41] That's just common practice for any, any public health emergency. And it has been extended. Secretary Azar did extend it through the end of April. I would predict that it would get extended a few more times yet this year, if not throughout the remainder of the year. It all depends on where we're at with this [00:02:00] pandemic. 

[00:02:00] So we'll, we should see that discussion happen again with a renewal later on in April when they determine if they're going to renew it or not. But within that public health emergency, the waivers that are underneath that obviously relate to policy. Or some reimbursement increases with it that came with the CARES Act, you know, even the extension of the sequester. 

[00:02:22]The 2% that is even being paused even yet through the end of March now, instead at the end of 2020 , and even some additional funding for businesses. So there's a lot underneath the public health emergency that is applicable to a lot of companies, but even more so our industry in the DME space. 

[00:02:42]And some of those waivers that I deal with on a regular basis are more specifically even to respiratory policies. So like your oxygen, CPAP, nebs, sometimes even the CGMs - continuous glucose monitors - because they're in that non-enforcement part of the waiver. And what that [00:03:00] means is for those of you that haven't been dealing with the hotspots, like they were earlier in the year in New York, Chicago, LA, that you're dealing with it now. 

[00:03:10] And that's what we're hearing in the more rural communities. So you didn't really pay attention to what the waivers meant before, but you do need to now because the hospital beds are getting full or the doctors are trying to avoid putting patients in the hospital that can be treated at home. You can take those oxygen patients on, you can take those CPAP, neb, you know, there's vents, there's the high-frequency chest wall device. 

[00:03:32] There's other products in there too, but you can take those patients on. What you need to remember is, is if you can follow policy, obviously that's ideal to follow the policy a hundred percent, but if you cannot, it's okay. You would need to get an order from the doctor, the doctor, or the nurse practitioner still needs to write the order, but they also have to document something in the medical record. 

[00:03:54]Basically the basic, you know , need. Some kind of what they call reasonable and necessary need for [00:04:00] the equipment that they're ordering under the non-enforcement waiver. So the respiratory, the CGMs. So if you have a patient that's being discharged from the hospital that needs oxygen and you don't have the coverage criteria met, all you have is maybe they have coronavirus or maybe they have pneumonia. 

[00:04:17] Take that patient on, get the office note, or I'm sorry, the hospital note. And then when you submit that claim, you're going to be using a waiver. So you don't need a CMN. You're going to be putting on the claim with your regular modifiers that CR modifier with the COVID-19 claim narrative. And we'll talk a little bit more about that later on. 

[00:04:34] The other part I see with the waivers are those that you still have to have coverage criteria met. But it can be done by another clinician. So maybe it's a support surface or negative pressure wound therapy or urologicals. Maybe some of the assessments that you normally would need to get for the, like a wound measurements, patients aren't able to get back into the doctor's office to do those measurements. 

[00:04:56] So there's telehealth visits being done. That can [00:05:00] still happen. The doctors, the nurse practitioner, can still do a telehealth, or a clinician that it's within their scope of practice, can document, you know, the need's still there for that product without taking measurements and then you can proceed on with the billing. Again, a CR modifier, the COVID-19 claim narrative, because you're using the telehealth and you're not meeting policy. 

[00:05:22] So those are the things that I'm seeing that are common. And I know there's a lot out there, so it is hard to keep up with. And we try to gather all those resources to have them all available to our members. But those are the most common ones is to not be afraid to take those patients on. Just making sure you're using the CR modifier and the COVID-19 in the claim narrative. 

[00:05:43] Host: [00:05:43] Great. Dan, if you can get a word in, what's your take on this?  

[00:05:47] Dan Fedor: [00:05:47] Thanks, Lindy. I appreciate that. So I agree with Ronda, you know, everything she said. I'm just going to give you a little background on what I'm seeing relative to mobility products [00:06:00] since that's my focus. So, you know, as Ronda said, the waivers are still in place and regarding mobility products, they didn't waive the clinical indications as they did with respiratory. So what that means is that all the clinical coverage criteria still must be met. They are giving the waiver to forego the in-person encounter though, to eliminate the contact. So for example, power mobility devices require a face-to-face, an in-person face-to-face. That can be waived to do virtual, to do telehealth, during the public health emergency. 

[00:06:35] The same with the licensed certified medical professional, otherwise known as the PT or OT wheelchair eval. That can also be done virtual during the public health emergency. The ATP assessment does not have to be in-person. The home assessment does not have to be in person. 

[00:06:52] So those are, those waivers are still in place. The key thing, the key takeaway for those of you listening that deal with mobility - and this [00:07:00] applies to manual chairs as well in scooters - is all the coverage criteria still must be documented. So if it can be done virtually, then that's great. If it can't be, if you can't obtain something that's necessary to justify the medical necessity virtually, then an in-person would be required. So just want to make sure that point's out there for everyone. I get a lot of questions about those waivers relative to mobility products.  

[00:07:27] Ronda Buhrmester: [00:07:27] And I'm going to actually jump back in, Lindy. I'm going to ask Dan a question then. So if I'm a mobility supplier and I'm doing a power wheelchair and the telehealth visit's done by the doctor for that wheelchair instead of an in-person visit, even a PT or OT eval's done telehealth. As a supplier when I submit the claim, do I need the CR modifier with COVID-19 as the claim narrative?  

[00:07:53] Dan Fedor: [00:07:53] Yeah, that's a great question, Ronda. And that is a very good point. Yes. Anytime you're, I don't want to say [00:08:00] taking advantage of, but using a waiver outside of normal policy prior to the public health emergency, which would be foregoing an in-person encounter in those areas that I just mentioned, then you do have to disclose that with the CR modifier and then COVID-19 in the extra narrative field, because you're still using the KX to make the claim go through and pay. But 100% of the policy's not met because of the waiver. So yes, the CR, to answer the question, the CR is applicable there.  

[00:08:30] Ronda Buhrmester: [00:08:30] Yeah. And that's what I, how I educate our members too is, and trying to keep it straight in my mind. So I try to help them understand my logic, how I remember it is anytime you're using something that's not normally outlined in the policy like the in-person visit whether it's through a power wheelchair or through oxygen, cause that's an in-person visit. That's the waiver and that's a CR modifier with COVID-19 as the claim narrative. So that's kind of how I try to remember it.  

[00:08:56] Dan Fedor: [00:08:56] Right. Yeah. And it doesn't have to be all of them. Just one, for [00:09:00] example, if for mobility, the face-to-face is in person, the therapist, wheelchair eval, and an ATP is all in person, but the home assessment is virtual, then the CR would be applicable. So any, any time 100% is not met, you do have to use the CR and disclose that.  

[00:09:18] Ronda Buhrmester: [00:09:18] Yep. Just as even the proof of delivery. So if you have the coverage criteria met, like I'll use a respiratory policy. Let's say you got all the oxygen coverage criteria met and you have a CMN completed. Section B has all the answers that you need, but the patient says I'm not signing that delivery ticket. So you put COVID-19. That's a CR modifier with the COVID claim narrative. So just making sure, like Dan said, it has to be 100% met for no CR or if you do anything outside of the normal, you want to make sure you append a CR modifier. 

[00:09:54] Host: [00:09:54] Very helpful. Thank you both for that information. Let's switch gears a little bit. I've heard that since [00:10:00] competitive bidding hasn't been implemented for a lot of the products that the competitive bid areas are no longer applicable. Is this accurate? Dan, could you talk a little bit about this?  

[00:10:11] Dan Fedor: [00:10:11] Yes, absolutely Lindy. So competitive bidding, as we all expected, was going to go forward with multiple products in 2021. And toward the end of last year, it was identified that there only going to be two products part of the 2021 competitive bidding. So with that, the remaining products that are not part of it, what it was before any willing supplier can provide. There are no contracts for mobility products, for example. Anybody can provide, but you do have to keep in mind that those former competitive bid areas are still in place. Meaning you can provide an item, but if you do, it will pay at the former, well at the competitive bid rate, which is called the SPA, the single payment amount, and it will not be paid at [00:11:00] what you see on a fee schedule if you go out to the MACs fee schedule or the PDAC where you see rural and non-rural . If the beneficiary resides in what was a former competitive bid area, and you provide a former competitive bid item, it will pay at the single payment amount. That will be the allowed amount.  

[00:11:18] Very important to know that. I get a lot of questions about that and the rates are different. Single payment amounts are normally lower than the non rural and the rural, and sometimes substantially. So please make sure you're aware of that before you decide to provide, or if you can accept the amount that they're going to pay you. 

[00:11:37] Host: [00:11:37] Okay. Ronda, your take on, you know, other than those few items that are part of competitive bid, does this mean any supplier can provide those benefits that reside in former competitive bid areas or to beneficiaries?  

[00:11:52] Ronda Buhrmester: [00:11:52] Yeah. So as Dan had said, there are 13, and we all know this, there are 13 product categories that were not part of this [00:12:00] next round of 2021. So your vent metal, you know, the respiratory products, you know, you've got wound care products, like the negative pressure. They didn't put those 13 categories in this next round. So that means it's still any willing supplier just as it has been these past two years. So you can continue your business as you are today, or have been these past two years. 

[00:12:25]It's the two product categories of off the shelf knee and back braces that are a part of competitive bid. So if you are in those territories of competitive ed, you have to have a contract for those HCPC codes under knee and back bracing in order to provide those products to a Medicare beneficiary and get reimbursed by Medicare. 

[00:12:47] If a patient wants to pay out of pocket, that's a whole other situation. But with Round 2021, there are contracted suppliers for knee and back brace, which that's new. These are new product categories [00:13:00] for Round 2021. And I'm sure we all know why, because we read the news last year. So those suppliers that haven't done competitive bid before, this is even new to them and what that means. 

[00:13:12]So there's been a lot of education surrounding it. There have been even suppliers that have done competitive bid, but maybe not the knee and back bracing, and they did get the contract. So it's very important you read those policies and know what's in those policies so you can help those patients out. 

[00:13:28] I would like to add one other thing to it is that, you know, the next round of competitive bid, which would be for around 2024, we'll wait and see what product categories they'll include with that, because we don't know at this time, but I can tell you I read on an OIG work plan that urological supplies are being considered for that. They are doing a study on, they the OIG, is doing a study on urological supplies in 2021 to determine what to do. So they're going to do [00:14:00] something with the rates, whether they cut the rates or add it to competitive bid, but something will happen with that. And who knows what else is out there, but just make sure you're paying attention to the news throughout the course of this time for any of that information.  

[00:14:14] Host: [00:14:14] What are you seeing as the most common denials with the products you work with and what can members do to avoid those? 

[00:14:21] Ronda Buhrmester: [00:14:21] Yeah. So I'll start with that. What I see a lot of the denials related to right now are around modifiers. Our suppliers aren't using the right modifiers or adding the right modifiers that they need to. 

[00:14:34] So it's always important to know what product category you're dealing with as far as what payment category it belongs into. So is it a capped rental? Is it under the oxygen payment or, you know inexpensive and routinely purchased items? So you have to know what payment category you're dealing with. 

[00:14:51] And then that kind of leads you into modifiers. So capped rental is your RR. Then you have pricing modifiers of, you know, with the K's. So that's a [00:15:00] common denial. And then obviously the diagnosis code. So using a good ICD 10 code that applies to that product. There are policies out there that have specific ICD 10 codes that can only be used. And there are some that do not have specific.  

[00:15:17] So making sure you know which policies you're dealing with and which ICD 10 codes are appropriate to use, and that must be supported in the doctor's medical record for that patient. So that's a common denial. In addition to the one most recently in the pandemic is when you use the CR modifier, there are suppliers that for some reason haven't included the COVID-19 as a claim narrative, and you have to do that. Some of you have already gotten denials on this and asked me why you were getting a denial, which we found out why, because the claim narrative was missed.  

[00:15:53] So the CR modifier applies to any time there is a disaster, you know, people that live on the [00:16:00] coast deal with hurricanes or, you know, out west, they deal with fires. You'll see those considered natural disasters and the CR modifier will come into play then, and they'll have to put then, you know, if it's a hurricane, they put CR and then the hurricane name, so hurricane Maria or Katrina in the claim narrative. So then when it's processed, then they know what, why the CR is being used and what it applies to.  

[00:16:25] Same thing with this pandemic, you have to put the CR on if you're using a waiver, and you have to include COVID-19, and the contractors have been specific in saying making sure you use COVID-19. So you have to include it and you have to include those words, not your own words, coronavirus or whatever abbreviations we've developed ourselves, as we communicate with each other. Follow their instructions if you want to get paid by them timely.  

[00:16:53] So that's the common ones I've been seeing. I'm not sure what, Dan, you have. I'm sure you've got some denials.  

[00:17:00] [00:17:00] Dan Fedor: [00:17:00] Yeah, I do, and similar to what Ronda said , modifiers are always the common deni a l. Getting the modifier correct based on the payment category. So, you know, as Ronda mentioned, make sure you know the payment category, whether it's capital rental or an expense of a routinely purchase, because that dictates the modifier flow. 

[00:17:18] So that's really important. And also I wanted you to be aware the advanced modifier engine that's out there on the MAC site. Some of it is accurate, some of it isn't, and we've been bringing that to their attention. So if it doesn't seem right, you know, ask myself or Ronda before you submit so we make sure you get the modifiers correct. 

[00:17:37] The other common denial that I'm seeing has to do with the standard written order. This is a very prevalent denial in the mobility area. And the reason is, you know, many times the patient will go see their physician or even telehealth now during the public health emergency. But at that point, the physician writes an order for a [00:18:00] power wheelchair, let's say, or a manual wheelchair. 

[00:18:04] And then they send them to a therapist for the wheelchair assessment to determine what they need. That original order that the physician wrote during the actual face-to-face but before the therapist evaluation, the wheelchair evaluation was completed, is not valid. It means nothing.  

[00:18:24] The reason being is the physician can't write the order before the completion of all the documents to determine the need for the product. So keep that in mind, if you're doing, if you're providing these products, is the actual face-to-face must occur, then the therapist eval. Or vice versa, the therapist eval can occur first, the wheelchair assessment, but both of those have to be completed, signed, dated, co-signed you know, as far as the physician has to co-sign the wheelchair evaluation, before the standard written order for the base can be written. 

[00:18:59] And that's really [00:19:00] important to know. I see a lot of denials with that, where it's being written prior to the physician reviewing and co-signing the wheelchair assessment. The other part to that, I'll add one last thing, I know we're getting close on time, but is the timing of that. That order for the base item has to be written within six months from the actual date of the face-to-face exam. 

[00:19:25] So I'll give you an example of January 1st, a patient sees the physician and then refers the patient to a therapist for the wheelchair assessment. And the therapist does not do this until March 1st and the physician co-signs it on March 2nd, concurring with it. The standard written order has to be written within six months from January 1st, not March. It doesn't get delayed because of the therapist eval. So that means that the therapist eval has to be done within six months as well from the face-to-face.  

[00:19:57] I know it's a lot of content for a podcast, but this is [00:20:00] something that I'm seeing very often and it's causing prior authorization denials, and of course delay in delivery of product. So I want to make sure everyone's aware of that. Any questions,  please don't hesitate asking us. We'll make sure you get on the right track with that.  

[00:20:15] Host: [00:20:15] Perfect. Thank you so much. I know that is a lot of information. I know my head's spinning every time I talked to you guys, I'm like, how would, how would I remember all of this stuff? But please know that we have resources in our membership portal that help with a lot of this information and you can always reach out to Ronda and Dan as well. Anything else before we conclude this episode today?  

[00:20:37] Ronda Buhrmester: [00:20:37] You know, I, I would like to, and I know I even would like Dan to speak on it. I know we don't like to keep podcasts too long, but this won't take long. It's a related to the KE modifier for those in the non rural zip codes. And the reason I want to bring it up is I don't want you all that this applies to is to leave, what we call, don't leave money on the table. This is money that is owed to you and you deserve it. [00:21:00] So we want to make sure you're getting those claims reopened and processed for those HCPCS codes that apply.  

[00:21:06]I know we, between Dan and I, we put out a lot of information on it. We just don't hear a lot about it now. So we don't know what that means. We don't know if that means you're doing it, or if you're not, if you haven't done it yet. So please make sure if, if it's a mobility product and that's usually what applies to is a mobility product, there is a list of HCPCS codes that you are submitting for the reopening with that KE modifier to get that adjustment that is owed to you. So Noridian and CGS both have steps to follow, so make sure you're following that. I know you'll have stuff to add on to that, Dan.  

[00:21:39] Dan Fedor: [00:21:39] Yeah. That's, you know, as Ronda said, you don't want to leave any money that you're entitled to on the table. And you are entitled to this. So, you know, any questions on that, it is pretty detailed, but we do want to make sure you obtain that. If you have any questions about the KE, the reopening, or any type of modifier payment rate, we can help you with [00:22:00] that and send you some information. So please reach out to us. 

[00:22:03] Host: [00:22:03] Great. We will include some links in the show notes for, for resources. And again, thank you both for your expertise and all of the wonderful resources and knowledge that you bring to our members.  

[00:22:16] Ronda Buhrmester: [00:22:16] All right. Thank you. I appreciate it.  

[00:22:17] Dan Fedor: [00:22:17] Thank you, Lindy.  

[00:22:18] Host: [00:22:18] Thanks.  

[00:22:19] Thank you for listening to industry matters. Make sure you never miss an episode by visiting vgm.com/industrymatterspodcast.