1 Centers for Medicare & Medicaid Services DME MAC - CGS

This document has been edited for spelling and grammatical errors.

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Centers for Medicare & Medicaid Services

DME MAC National CERT Education Task Force Oxygen Ask-the-Contractor Teleconference

Moderator: Leah Nguyen February 3, 2011

2:00 p.m. ET

Welcome and Presentations

Operator: Welcome to the DME MAC National CERT Education Task Force Oxygen Ask-the-Contractor teleconference. All lines will remain in the listen-only mode until the question and answer session. Today's conference call is being recorded and transcribed. If anyone has any objections, you may disconnect at this time. Thank you for participating in today's call. I will now turn the conference over to Ms. Leah Nguyen. Ma'am, you may begin.

Leah Nguyen: Thank you, Simon. Hello. I'm Leah Nguyen, from the Provider

Communications Group here at CMS. I would like to welcome you to the Oxygen Ask-the-Contractor teleconference presented by the DME MAC National CERT Education Task Force. The call is scheduled for 90 minutes.

Today's call is being recorded and transcribed and will be posted to the CMS

CERT web page at www.cms.gov/cert, under the Provider tab in approximately two weeks. It will also be offered as an encore presentation available on all DME MAC websites. You'll receive a listserv message from your contractor letting you know when the encore recording, written transcript, FAQs and written responses to your questions are available.

In a unique approach to reducing common Comprehensive Error Rate Testing

or CERT errors, DME MAC Jurisdictions A, B, C and D have collaborated to form the DME MAC CERT Education Task Force. The Task Force has identified common national errors and has developed consistent educational messages which are used by all four DME MAC jurisdictions in support of reducing errors.

Today, the task force will conduct a national Ask-the-Contractor teleconference specific to oxygen policies. Members of the DME MAC CERT


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Education Task Force and knowledgeable CMS policy experts will be available to answer your questions on oxygen and oxygen equipment for the following categories:

- Coverage criteria, - Testing requirements, - Certificate of Medical Necessity, - Documentation and others. At this time, I would like to introduce Jody Whitten, from Jurisdiction D,

Denise Winsock, from Jurisdiction A, Nina Gregory, from Jurisdiction B and Mark Loney, from Jurisdiction C.

And now, it is my pleasure to turn the call over to our first speaker, Jody

Whitten, from Jurisdiction D. Jody Whitten: Thank you, Leah. And again, my name is Jody Whitten and I am an Education

Consultant with Noridian, the Jurisdiction D DME MAC. Again, we just want to thank everyone for joining us today. Before we open up the lines for questions, each jurisdiction would like to go over some common questions and concerns that we received prior to this ACT.

And just to let you know, many of the pre-submitted questions were answered

directly from the LCD or policy article and all jurisdictions encourage suppliers to look and review both of those documents.

Now, documentation is – to support the medical necessity – is a requirement

for suppliers. Many suppliers have incorporated thorough intake business practices to verify that coverage criteria are met and medical records are available upon request, including testing results.

I now would like to go over just a few of the common questions that we

received, the first one being, most physicians do finger pulse testing which does not print out a report, would documenting this result in the patient's medical record chart notes be acceptable? The answer is yes. Finger pulse


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testing reports in the patient's medical record is acceptable. Making sure that's available upon request.

Question two, when oxygen testing is obtained during exercise, must there be

documentation of additional testing? And the answer to that is also yes. In order for a beneficiary to qualify for oxygen based on exercise, there must be documentation in the patient's medical record of three tests taken during one session. These tests would be the test at rest without oxygen, the second test would be the testing during exercise without oxygen, and the third test is during exercise with oxygen applied.

This is going to demonstrate certain improvement of the patient's hypoxemia.

But also note that only the qualifying test is the test that's reported on the Certificate of Medical Necessity.

And my third question is, is something from the patient's medical record at the

physician's office showing qualifying saturation levels sufficient to document medical necessity for oxygen, or is more required?

The answer to this is yes. First of all, there is multiple requirements that must

be documented in order to justify reimbursement. While many are listed in the LCD, others come from the NCD or CMS manual or regulations and statutes. Suppliers are expected to be knowledgeable about all of these requirements and convey this relevant information to their referral sources.

And now I'd like to turn the line over to Denise Winsock from Jurisdiction A.

Denise. Denise Winsock: Thank you, Jody. Good afternoon, everyone. My name is Denise Winsock and

I'm an Outreach Specialist from NHIC Jurisdiction A. I'm going to review some questions again regarding coverage concerns. But first, I want to remind everyone that not all requirements are outlined in the LCD. As Jody just stated, multiple statute, regulations and CMS manuals have additional requirements that must be followed.


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We do encourage suppliers to discuss this with their referring physicians and/or referral sources to dispel this inaccurate perception that coverage is only based on what's in the LCD.

Now, the first question is, is there a form provided that we can print out for

the doctors to fill in that specifically address all the requirements? If so, where can we find it? And no, there is no single form that can be used to meet all the Medicare documentation requirements for an item. There is an oxygen and oxygen equipment Certificate of Medical Necessity attached to the LCD. However, the Certificate of Medical Necessity does not address all documentation. And the same CMN answers must be backed up by a comprehensive medical record that supports the need for the item.

The second question, when will the six-month contemporaneous notes be part

of the LCD and required to have on file? There is no specific time frame to support continuous need or use. Reviewers will assess each patient separately to determine medical necessity based on the records that are available. Realistically, oxygen is a serious drug that should be monitored by the physician periodically.

The third question, if the patient is seen in the emergency room for one condition and they address a respiratory problem at the same time, can the ER doctor order oxygen if necessary? And for the LCD criteria four, the qualifying blood gas study was obtained under the following conditions:

One, if the qualifying blood gas study is performed during an inpatient

hospital stay, the reported test must be one obtained closest to but no earlier than two days prior to the hospital discharge date.

Or if the qualifying blood gas study is not performed during an inpatient

hospital stay, the reported test must be performed while the patient is in a chronic stable state such as not during a period of acute illness or an exasperation of their underlying disease. Testing obtained during an acute event usually would not meet the standard.


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And the second part of that question is, if not, should the patient then be referred to the ER doctor or by their ER doctor to their primary physician to be qualified. And yes, if the patient was not in a chronic stable state, to be tested while they were at the hospital.

And now I would like to turn the line over to Nina Gregory from Jurisdiction

B. Nina Gregory: Thank you, Denise. My name is Nina Gregory and I am a Provider Outreach

and Education Consultant with the National Government Services, the Jurisdiction B DME MAC.

Suppliers must be able to provide documentation upon request if the

beneficiary has met the specified testing requirements per the medical policy. So, whether qualifying under Group I or Group II, the reported blood gas values must meet the requirements.

Now, I'd like to go over some more common documentation questions that we

received. Question number one, what defines exercise when a patient is being tested in

the doctor's office? Per the LCD, when oxygen is covered based on an oxygen study obtained

during exercise, there must be documentation of three oxygen studies in the patient's medical record – testing at rest without oxygen, testing during exercise without oxygen, and testing during exercise with oxygen applied, to demonstrate the improvement of hypoxemia.

All three tests must be performed within the same testing session. Only the

qualifying test value, for testing during exercise without oxygen, is reported on the CMN. The other test results – the other results do not have to be routinely submitted but must be available upon request. Suppliers are encouraged to refer to the published clinical literature for information about oximetry testing and exercise testing protocols.


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The second question. Does an overnight oximetry test need to be any certain length of time? No, there's no specified minimum sleep test – sleep time. The testing requirement requires a minimum of five minutes of qualifying values in order to meet the standard for coverage.

Question number three. Can a home health agency with an order for oxygen

from the doctor complete their oxygen saturations to qualify patients for oxygen? No, home health agencies are not considered a qualified provider or a qualified laboratory for purposes of oxygen and oxygen equipment LCD. Testing must be done by a Medicare-qualified provider, for example a Part A provider, a laboratory or independent diagnostic testing facility.

And now I'd like to turn the line over to Mark Loney from Jurisdiction C. Mark Loney: Thank you, Nina. My name is Mark Loney and I'm a member of the Provider

Outreach Education team here at CIGNA Government Services, the DME MAC for Jurisdiction C.

Today, I'm going to be talking about the Certificate of Medical Necessity, or

CMN, which is an important component of the documentation requirements of the oxygen policy. A CMN which has been signed and dated by the treating physician is required for all oxygen claims billed to Medicare.

It is important to note that both an initial and a recertification CMN are

required to justify the continued need of oxygen therapy. In addition, the CMN may act as a substitute for a written order if it is sufficiently detailed.

Now, I'm going to go over three common questions regarding CMNs. Question number one, if the required physician reevaluation is not performed

within 90 days prior to recertification but it is performed at a later date, what should be entered as the recertification date on the oxygen CMN? And the answer there is, in that situation, the date of the late physician visit should be entered as the recertification date on the CMN.

Question number two, if a beneficiary has stationary oxygen equipment and

portable oxygen equipment is added, do I need a new initial CMN? The


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answer there is no. A revised CMN is required in this situation and not a new initial. In addition, I want to point out that the chapter four of the supplier manual contains a list of common scenarios for initial, revised, and recertification CMNs.

Lastly, question number three is how long is a CMN good for? Most

beneficiaries who require home oxygen therapy beyond the few months are going to require it lifelong. Therefore, for that CMN which is specifically Form CMS-484, recertification establishes that the medical necessity continues, subsequent recertifications are not routinely required.

Leah Nguyen: Thank you, Mark.

Questions and Answers

Leah Nguyen: We have now completed the presentation portion of this call and we will move on to the question and answer session.

Before we begin, I would like to remind everyone that this call is being

recorded and transcribed. Before asking your question, please state your name and the name of your organization. In an effort to get to as many of your questions as possible, we ask that you limit your question to just one.

All right. Simon, you may open the line for questions. Operator: We will now open the lines for our question and answer session. To ask a

question, press star followed by the number one on your touchtone phone. To remove yourself from the queue, please press the pound key. Please state your name and organization prior to asking a question and pick up your handset before asking your question to ensure clarity. Please note your line will remain open during the time you're asking your question, so anything you say or any background noise will be heard in the conference.

One moment please for your first question. Your first question comes from the

line of Sheila Streddy. Your line is open.


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Sheila Streddy: The question is, on a lot of documentation that's required, it's really a physician's standard of practice and not ours, how do we deal with that?

Jody Whitten: Sheila, this is Jody from Jurisdiction D. What jurisdiction are you calling

from? Sheila Streddy: B. Jody Whitten: B as in "boy"? Sheila Streddy: Yes Jody Whitten: Nina. Nina Gregory: Hi. This is Nina. So – I'm sorry. Can you repeat your question one more time? Sheila Streddy: The question, a lot of documentation that's required, that we have to find,

really applies to a physician's standard of care practice, and at what point and how do we get that information? How do we deal with that because it's their standard of practice that they are doing or not doing? How would you recommend that we get the documentation that you're requiring, that physicians are not aware of all of that, no matter how much education. We're shut out of their offices for educating and they're obviously not giving us from their sources.

Nina Gregory: Right. I definitely do understand the problem with that. What we recommend

is definitely that suppliers educate the physicians and work hand in hand with their physicians. We have Dear physician letters out there that we definitely do recommend that you supply to your physician’s offices and try to walk them through what Medicare policy guidelines are.

And then, you know, definitely try to obtain the documentation that supports

the coverage criteria up front as much possible so that, you know, you know ahead of time whether your beneficiary meets coverage or does not. And in that way, you can make a business decision at that time.


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We are trying to educate the physician side as much as possible, but we do – we are limited in that area.

Sheila Streddy: Thank you all. Nina Gregory: You're welcome. Sorry. Operator: Your next question comes from the line of Jackie Montdale. Your line is open. Judy Burns: Thank you very much. Actually, this is Judy Burns. One clarification on

question 11. The answer states that the existing coverage and documentation requirements must be met except that the original test done while the patient was at a hospice may be used, and I would assume that that needs to be within 30 days of the start date of the service. Would that be correct?

Jody Whitten: Judy, and this is Jody from Jurisdiction D. What jurisdiction do you bill to? Judy Burns: I'm sorry, Region B. Jody Whitten: B, as in "boy"? Judy Burns: Yes. Jody Whitten: Hello, Nina. Nina Gregory: Hi, Judy. Are you talking about a pre-submitted questions? Judy Burns: Yes, I'm sorry. A patient who's currently on oxygen is moving into my area or

is disenrolled from a home hospice that required oxygen during that hospice stay. In those situations, is the patient required to see a physician within 30 days prior to the initial setup? The answer is, yes, all of the existing coverage and documentation requirements must be met except that the original testing done while the patient was in the hospice, may be used as the qualifying test.

I would assume that that test needs to be within 30 days of the initial date? Nina Gregory: Correct.


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Judy Burns: OK. My real question is in regards to number 21, though. The question, when oxygen is being bled into a continuous – into a CPAP or a bypass, what are the testing documentation requirements? Do the sleep study sat qualify the patient?

The answer was pretty interesting, basically saying that if the patient has got

OSA and has hypoxia, they're not in a chronic stable state. Maybe I'm misinterpreting the answer, but in that case, any patient who has

got hypoxia wouldn't be in a chronic stable state. This answer, I'm not understanding. It's not making a lot of sense. Could you guys please clarify?

Nina Gregory: Well, Judy, that we had assistance with our medical director, so maybe we

would have to take that back in and have that on the – after the call Q&A document to clarify. Would that be OK?

Judy Burns: Absolutely. Nina Gregory: Thank you. Judy Burns: Thank you. Denise Winsock: Excuse me, this is Denise Winsock. Dr. Hughes would like to address that

question as well. Is that OK? Judy Burns: Absolutely, please. Thank you. Dr. Paul Hughes: Can you guys hear me? I don't even know how this conference system works.

So… Denise Winsock: Yes, we could hear you. Dr. Paul Hughes: Judy, the idea of chronic stable state – and this was asked in actually one of

the earlier questions – this is the central re-testing requirement for oxygen. You guys all know that. And what that means is not that the patient may not be sick, but that everything else that can be done to treat the conditions that


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are causing the hypoxia has been done to the best that you're able to get them done.

And then if there is hypoxia left, at that point, then it is presumed that that

hypoxia can be treated by the administration of oxygen. So, we'll use COPD for an example. If I've got COPD and I've got an exacerbation or pneumonia on top of it and I'm sick with – with that and you do a saturation, I'm going to be probably hypoxic.

Certainly you can get a qualifying number but that's not my real baseline level

when I'm in the chronic stable state. So, you've got to treat my bronchitis, cure my pneumonia, make sure I'm on my regular COPD medicines and that everything else is as stable as can be. And then you check my – my saturations and if I have a qualifying value, then I'm in the chronic stable state and the qualifying value qualifies me for oxygen.

That same thing is true with obstructive sleep apnea. Obstructive sleep apnea

by itself makes people hypoxic and they're hypoxic because of the blockage in their throats that – that interferes with their breathing. Oxygen is not the treatment for obstructive sleep apnea. CPAP or oral devices or weight loss or surgery are all the treatments for obstructive sleep apnea.

So, if I go to the sleep lab and I'm getting a sleep study done and they say,

"Oh, gee, you have obstructive sleep apnea," and your O2 saturation is 68 percent, you can't qualify for oxygen with that sleep test because you have not treated the obstructive sleep apnea. And you have to do that and get – and get a monitor feedback at an adequate level, get them treated, get their oral device in, whichever the treatment modalities you use.

And once that obstructive sleep apnea is under control and reasonably treated,

then you test them again. And then if they remain hypoxic, then you can add oxygen in. But you can't do it during the diagnostic portion of the – of the sleep study because you haven't treated their – their obstructive sleep apnea.

It's a long – it's kind of a long answer, but a real important concept. I hope that

helps.


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Judy Burns: Thank you. Operator: Your next question comes from the line of Cindy Sendra. Your line is open. Cindy Sendra: Good afternoon. Jody Whitten: Good afternoon, Cindy. Cindy Sendra: Hi. How are you? Jody Whitten: Good. What jurisdiction are you calling from? Cindy Sendra: I'm Jurisdiction A. Jody Whitten: Great. Cindy Sendra: My question is, I would like to know from you, all you folks; exactly what

documentation needs to be written on the prescription prior to dispensing the oxygen? There seems to be some confusion within my organization.

Liz Daniels: Hi. Actually, right at the moment, we don't have the written part but you can

get documentation dealing with a particular question about one particular item, but what item were you questioning.

Cindy Sendra: Do the oxygen saturation levels have to be on the prescription or they may be

included in the patient medical record available if need be. Liz Daniels: No, that does not have to be on the prescription. It would be in your records.

That would be on the Certificate of Medical Necessity, but it does not have to be on the actual order itself.

Cindy Sendra: Thank you very much for clarifying that for me. Liz Daniels: Thank you. Operator: Your next question comes from the line of Jennifer Delaney. The line is open. Jennifer Delaney: Hi.


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Jody Whitten: Hi, Jennifer. What jurisdiction are you calling from? Jennifer Delaney: I'm calling from Jurisdiction C. Jody Whitten: Alrighty. Jennifer Delaney: And my question is, when the patient starts a new 36 months rental period

after their initial five years of the oxygen service, the policies state that the qualifying test can be the same test from the most recent CMN. And we're getting COPD denials for the test date being older than 30 days prior to the date of service on the CMN when the test issued is the test from the last CMN on file.

We are under the impression they are not supposed to deny for that. So, I was

wondering if anybody could tell me why they are? Mark Loney: Yes, this is Mark, with Jurisdiction C. I know the policy is worded to say that

I believe it's the most recent qualifying test on file, which could be from your recert CMN in your situation about four years old.

Keep in mind, though, the other things that the national coverage

determinations and statutes that come into play that talk about contemporaneous data and contemporaneous notes to support that.

So, if you start over after a 60 months cap is reached and, you know, a

reviewer looked at documentation they are going to look for something more recent, more contemporaneous than that four year old data.

Jennifer Delaney: They will look for it. OK, thank you. Mark Loney: Thank you. Operator: Your next question comes from the line of Jennifer Heft. Your line is open. Jody Whitten: Hi, Jennifer. What jurisdiction are you calling from? Jennifer, is your phone

on mute? Operator: Jennifer Heft, your line is open.


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Stephanie Coleman: I'm sorry. This is Stephanie Coleman from Jurisdiction D. I have a question on a CMN. Can you hear me? Jody Whitten: Yes. And you said Jurisdiction D, as in "dog"? Stephanie Coleman: Yes. Jody Whitten: Alrighty, go ahead. Stephanie Coleman: On a CMN, if I have initial and a recert and now I have a revised CMN

because the patient transferred services from another provider to us. Is it OK to have the initial date, the recert date and the revised date all on one CMN? Even – I mean, we would have all three CMNs or at least initial and the recert, but then we got the revised, we had all three dates on there. Is that allowed?

Jody Whitten: So, you're going to have the initial date, the same initial date that we have in

our system, the recertification date and the revision date as well? That is absolutely OK.

Stephanie Coleman: OK. And only one question at a time. Is that correct? Jody Whitten: That is correct. We have quite a few on the phone today. Stephanie Coleman: OK. Thank you. Operator: Your next question comes from the line of Geri Mickland. Your line is open. Geri Mickland: Yes, I'm calling from Region C and I have a question. Earlier, one of your

presenters talked about exercise for qualifying. And we understand that you have to have three tests being the exercise test, but what defines that exercise? Is that a patient getting up to move from the exam table to the chair? Is that them walking 50 feet down the hall to the doctor's office? Or do they have to do a six-minute exercise test?

Mark Loney: Again, this is Mark with Jurisdiction C. I don't know that the LCD actually

defines a specific type of length of exercise at all. Again, we're going to –


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we're going to follow those – the published clinical literature there about exercise testing protocols. We have to keep in mind our demographics, the beneficiaries and their – and their capabilities. Each one would have a different set of circumstances or criteria that would qualify them for exercise based on their activity levels and all of that.

So, there's not a – there's not a specific piece of data or time frame that we're

looking for. Stephanie Coleman: Because the doctor's office could – it's whoever is performing the test on

the patient, the determination on whether that's exercise or not. So, if a nurse is saying that the patient is at rest but he's actually standing up, you know, how is that documented?

Mark Loney: Well, I don't know where – where a note about just standing up would be

considered exercise. But it would be up, you know, to the case in each physician's office.

Stephanie Coleman: Well, walking if it’s put down that the patient has walked, you all consider

that exercise? Mark Loney: For some patients, walking would – would certainly create more hypoxia than

– than sitting down certainly if – even in the kind of the routine of their activities of daily living, if walking is the most strenuous thing they do and that's creates events for them, then we can look at that as exercise.

Dr. Paul Hughes: Mark, this is Dr. Hughes. Would you mind if I interrupt you just once? Mark Loney: Not at all. Go ahead. Dr. Paul Hughes: Certainly on what Mark is saying with regards to the – about the exertion that

– and the amount of energy that any individual has to expend, that's going to be very variable. So, you know, I have one guy who worked in the mines for a million years and was a big smoker on top of it. And getting out of bed and changing his chairs is just exhausted him and used every molecule of oxygen in his body.


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And so I think the point Mark is making is that, that how – how much activity is needed to get a patient to desaturate will vary depending on the patient. But that's not really what exercise testing is all about. Exercise testing is a real lab test, OK? It's not just, oh, do whatever you want and get a measurement. It's a real lab test and there are rules that are about how it's supposed to be done, how much exertion the person being tested is supposed to put out and so on and so forth.

And so you know the national policy, our policy talks about tests in those

contexts, we're talking about real lab tests. We're not talking about homemade, do-it-yourself kind of mechanisms.

So the answer to your question is, what do you have to do to do an exercise

test? You should be talking to the respiratory therapy department at your local hospital saying if I send a patient in to do exercise testing, what do they have to do? You should be talking to the pulmonary doctors in town who have a lab in their offices. There are a number of techniques and protocols—you can walk on treadmills, you can walk up and down stairs, you can ride a bike and there's a walk test, but they're all controlled. They're all done by supervised and trained people. They're all designed to get a standardized, reliable, repeatable, accurate measurement.

And so I know there are lots of physicians who informally walk patients

around the halls and do this and that and the other and they may desaturate, but that's not an official real exercise test. So you just – again, the way testing is done varies around the country, so you got to talk to your local doctors and hospitals to see the methods that are popular in your area. But just be aware, it’s a real test, it's not something you just – every individual doctor gets to make up on their own. So I hope that helped.

Stephanie Coleman: Well, one question, now that you've clarified that because that's – you

know, we were hearing from our RTs that you know you had to do a certain standardized testing for this. But my question now to you is that so if you have a patient that is in the doctor's office and he is – has been a smoker all his life and he has chronic obstructive, or a chronic bronchitis and he's COPD and he's emphysema, but he's not been on oxygen. If he is sitting on the exam


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table and his test is 89, which qualifies for three months, but then he stands up and walks to the door while the pulse ox is still on and then he, you know, desaturates to 85.

Would that be an at rest test or is that… Dr. Paul Hughes: No, because he's moving at rest. I mean, all of these words are defined. I

mean, if you're in a hospital and I need an at rest test, you've got to be laying around for like 30 minutes. They are all, all these are technical terms that mean something in the context of official testing.

And we, in our DME world, tend to be a little informal about this because

we're dealing out of the hospital and so on – but the reality is even for at rest saturation, overnight testing—all of the different things that can be done, these are real lab tests and there are rules about how you do them. And the words describing the condition under which the test is done, they're all standardized.

And the reason for that is so that when I say, "Gee, I did an at rest test on my

patient here in Pennsylvania" and when I send that person to Tennessee to see Dr. Hoover, he knows exactly what was done with that test because it's all standardized. And so, you know, when the NCD, the LCDs talk about these tests. All these concepts come from the world of medicine. These are not informal make it up as you go along kind of concepts.

Stephanie Coleman: I understand and I agree and I appreciate your help with it. And is there

any time that these standards of test and the way it's supposed to be performed, they're going to be added to the LCD for…

Dr. Paul Hughes: No, absolutely not. This is just the everyday practice of medicine when using

these – when you work in a medical field this is stuff you've got to know. These are not Medicare rules. Medicare says you need to have a test. And that is – the entity that does the test has to be a qualified provider of laboratory tests. Well, now, maybe you begin to see the reason why it says that. These are real tests and have to be done according to the standards for doing tests—the people that run labs, the people that do IDTFs, those sorts of things. It's their business to know how to do that.


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I'm a family doctor. If I want to know about exercise testing, I can go talk to

the American Academy of Respiratory Medicine. I can look on guidelines.gov. I can search the literature. I can learn about it. But these are not Medicare rules about what at rest means. This is not a Medicare rule about what you need to do for an exercise, how an exercise test is done. These are the medical rules. When you do an exercise test, this is what it means. And so you know that stuff is never going to be involved.

Stephanie Coleman: OK. But it’s our responsibility as suppliers to let these facilities know that

when they are doing the exercise test that they are qualified to do them and they understand the guidelines to do them, that we have to have these three testing results.

Dr. Paul Hughes: Yes. One thing that Medicare specifies about exercise testing is the three

numbers that Medicare wants reported. Stephanie Coleman: Right. Dr. Paul Hughes: Medicare doesn't care whether you walk on a treadmill, whether you go up

and down steps, whether you do a six-minute walk, whether you ride a bicycle. You know, which of the techniques that are done to do the test, Medicare doesn't care. All Medicare cares about is that it was a properly done test whichever way they chose to do it and that you got the three results reported.

Stephanie Coleman: Correct. Thank you very much. Dr. Paul Hughes: All right. I'm sorry we beat that to death, but that's also a question folks have

asked a lot over the years. Stephanie Coleman: Yes, sir. And thank you very much. Dr. Paul Hughes: Mark, sorry to intrude on you there. Mark Loney: No problem.


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Operator: Your next question comes from the line of Sheila Van Dyke. Your line is open.

Sheila Van Dyke: Hi. I'm calling from Region B. We have several clients that are on oxygen

concentrators greater than four liters per minute. They have not reached the 36-month cap. And when we're trying to bill for oxygen content, Medicare is denying stating that we'd never billed for a portable.

We want to know how we can get this fixed to be able to bill for the portable

content after the 36 months, when they're greater than four liters. Charity Bright: Hi. This is Charity Bright from Jurisdiction B. I think I understood your

question, but I just want to make sure. You're saying that you have patients who have not reached the 36th month?

Sheila Van Dyke: They have already exceeded the 36 months. Charity Bright: They have exceeded. Sheila Van Dyke: They're on like 5 – 6 liters and now, we're trying to bill for oxygen portable

tank content because they've met that 36-month cap. We are getting denials due to the fact that we never billed for a portable unit.

Charity Bright: OK. Are you indicating in a narrative of your claim line in the NTE segment

that the patient was on four liters or greater during the 36-month cap ? Sheila Van Dyke: And we have – in fact, we submitted one person three times doing different

narratives per Medicare's direction of what to put in it. And we still keep getting denials on this one client.

Charity Bright: OK. Well, what we would have to do – I don't have access to the claim

payment system to look to see what's causing that error to occur. We would have to look at some claim examples to determine what's causing that to happen. Have you contacted customer care and provided any examples to them to elevate…


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Sheila Van Dyke: Yes. They've gone to level two and they've given me a different way to put it in my NTE note and we've changed the NTE note and we submitted it and they still deny, stating that we never billed for the portable.

Charity Bright: OK. Nina, are you there? Nina Gregory: Yes. Charity Bright: Can I send the example or can she send her contact information through the

Clinical Education mailbox? Sheila Van Dyke: That would be perfect. Charity Bright: OK. Can you give her that address so I'll make sure she gets it correctly. Sheila Van Dyke: Oh, yes. Nina, we have it. Nina Gregory: OK. Sheil Van Dyke: We e-mail you frequently. Charity Bright: OK. Yes. If you'll send us your contact information, we will definitely get in

touch with you and see what's going on with this claim. Sheil Van Dyke: Thank you. Charity Bright: You're welcome. Operator: Your next question comes from the line of Heronida Jefferson. Your line is

open. Heronida Jefferson: Yes. Hi. My question is in regards to complete documentation. I'm

wanting to know if the doctor or the ordering physician puts the… all the information on the actual order. Would that justify the sufficient documentation or would the information related to the testing and how it was done or performed also need to be documented in the patient's chart?


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Jody Whitten: This is Jody from Jurisdiction D. Are you calling – what jurisdiction are calling from?

Heronida Jefferson: B. Jody Whitten: All right. Nina? Nina Gregory: Hi. This is Nina. No, the clinical information or the medical necessity

information needs to come from the patient's comprehensive medical records. So just because you have the diagnosis on the order or many suppliers put medical necessity information on the order and it's completed, that does not cover you in an audit situation.

So you must have your detailed written order, the CMN, or they could be the

same. And then you must have medical record documentation from the physician, from the respiratory therapist, from whoever to get the holistic picture of the patient and the proof of delivery and everything else to go with for an audit.

Heronida Jefferson: OK. That's understandable to me. Now if I can get the doctor to know.

OK. That's it. Nina Gregory: Thank you. Heronida Jefferson: Thank you. Operator: Your next question comes from the line of Megan Juraki. Your line is open. Megan Juraki: Hi. I'm calling from Jurisdiction B. We also do billing for a Jurisdiction D,

too, but I was just wondering, does this clinical documentation need to be submitted when we submit our claims?

Jody Whitten: This is Jody from Jurisdiction D. Since I haven't had the chance to talk, I'll go

ahead and answer that question. No, you don't need to have it submitted with your claim, your clinical documentation. You just need to make sure that it exists and is available upon request.


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Megan Juraki: OK. Thank you very much. Jody Whitten: You're welcome. Operator: Your next question comes from the line of Jennan Silver. Your line is open. Jennan Silver: Hi. Yes. I'm in Region C – as in cat. And I have a question about this

contemporaneous medical record. It's something new that we've been noticing on the CERT letters we've been receiving. I can’t find anywhere on the Jurisdiction C website or on the LCD where it states that it's a requirement to have this type of record. And also, I was wanting to know, if it is a new requirement, what sort of documentation you're looking for.

Jody Whitten: This is Jody. Mark, are you going to answer that one? Mark Loney: I am. Sorry, I couldn't find my mute button. The language that you're talking about, the contemporaneous that you are

seeing that in some of the CERT response letters and other audit response letters, it is general language and that covers the entire program, so you won't find it in any specific LCDs. But the need to have medical documentation that supports any claim that's being billed still exists and is, that language is there, in the documents that govern the entire program, Program Integrity Manuals and things like that.

So the LCD is going to be specific and it's going to be specific when

necessary. But I guess, we also need to keep in mind that and not forget that we're always going to have documentation from within a reasonably recent timeframe to support any claim that's being billed.

Jennan Silver: OK. But based off of the way that it reads on these letters and stating within

six months of the date of service on claim, that's very like random because you're not necessarily auditing all at the same timeframe. So, in other words, you could be hitting me with this on a second month claim or you could be hitting me with this on an 11th month claim and yet I'm required to have medical records within the last six months of any of those dates and services.


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So every month, am I needing to get, you know, medical records for these patients or what sort of documentation are you wanting and is it literally within six months of the claim date or how does this work?

Mark Loney: I don't know that there's a specific timeframe. It's certainly the type of item

that's being billed and we'll stick to oxygen because that's the topic of today's call. Oxygen is something where you're going to want to have fairly recent documentation. It is a drug that's being used and it's to treat and manage an ongoing disease. So the documentation about that should be generated fairly frequently.

There's not a specific timeline set. I would agree with you that I hear the

timeframe of six months, that's a good rule of thumb to follow. Jennan Silver: That's what is says on the – I’m reading from one of the CERT letters. It says

contemporaneous within six months of the date of service on claim, medical records confirming that the beneficiary continues to use oxygen in the home.

Mark Loney: Right. Jennan Silver: My problem with that being that depending when the date of service is that I

filed, the patient may not – for whatever reason – have been to the doctor within the last six months. And I have seen where they've actually denied my claim based off of that.

The problem with that being is I can't expect my patients to constantly be

going to the doctor worried that you're going to audit one of my claims and I'm not going to have a record within the last six months, you know? It might have been outside. It might have been seven months ago they were at the doctor and I've had a denial.

Mark Loney: Right. Jennan Silver: So what you're wanting in your records and is this for sure, a six-month limit

here or…


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Mark Loney: No. I think –pardon me, I’m not sure what letter you're speaking of. During the CERT process, you'll get a remit, but I'm not sure what letter it is you're reading.

But, again, I can't point you to a specific timeframe. Certainly, speaking

directly about oxygen, we’re going to want to have recent contemporaneous data of the chronic condition. If you get a denial from whatever appeal or – excuse me, whatever audit process that you don't agree with, there is the appeals process and you can use that if you feel that your data supports the need for the item.

But I can't tell you with any certainty that's there's a specific timeframe that

you have to adhere to. It is contemporaneous data, keeping in mind the type of equipment that you're billing.

Jennan Silver: OK. And I am speaking of oxygen because that's the only thing I've received

these letters on is oxygen. What sort of information are they looking for in the medical record? Do they – does it need to specifically state that the patient has at that visit – I mean, the patient is using oxygen or could it be a visit just regarding their overall respiratory care?

Mark Loney: I would expect – when we're looking at documentation, specifically for an

oxygen patient, that if they are seeing their treating physician, that there is a discussion, at least, some however quick it may be, but there is some discussion about the use of the oxygen. Again, we're managing this chronic condition with that therapy.

So if there is a discussion about their overall respiratory situation and they're

on oxygen, we would expect that the documentation would reflect that—that that's showing that they're on oxygen.

Jennan Silver: Unfortunately, I think, my problem that I'm running into is I have

pulmonologists who are treating patients with COPD and they're going in, you know, for a follow-up and or for treatment for a bronchitis or something like that, and the pulmonologist is aware that they’re on oxygen, but they're notating it in that office visit. What do I do in those circumstances?


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Mark Loney: Each interaction – and I realize we're talking about very specific

circumstances that you face on a daily basis. So we're trying to answer in general terms.

Jennan Silver: Right. Mark Loney: But each circumstance is I guess going to stand on its own in a lot of cases.

You're going to need the documentation to support your claim. Yes, you're going to rely on the doctor or other medical professionals to generate that documentation, but you have to be the expert, if you will, and know that the documentation that you have on hand supports your claim or the documentation that you can access if that's the way you choose to do it.

So I can't give you a specific direction other than ongoing be a partner with

that referral source, ongoing education about the kind of documentation that you need. You know, the physicians’ notes in their billing to Medicare can undergo the same kind of auditing. So if they're treating and managing an ongoing condition and not making any notes about it, that would be something that would be, you know, in their own practice as well, something to focus on.

So I can't give you a – you know one fail-proof situation to handle everything,

but just make sure since you're the one billing the claim with your NPI attached to it that you have the documentation or can access it to support it.

Jennan Silver: OK. Thank you. Mark Loney: Thank you. Operator: Your next question comes from the line of Lou Anne Getty. Your line is open. Lou Anne Getty: Hello? Jody Whitten: Hi, Lou Anne. How can we help you? What jurisdiction do you bill to? Lou Anne Getty: Region A. Jody Whitten: All right. Go ahead.


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Lou Anne Getty: OK. We have a respiratory therapist on staff and we want to know how soon

after we deliver the oxygen, do we send them out to examine the patient? Denise Winsock: Yes. That's not a requirement of Medicare for the therapist to go out and

examine the patient. That's nothing that we would require for them to be – for you to be paid for oxygen with.

Lou Anne Getty: OK. Thank you so much. Denise Winsock: You're welcome. Liz Daniels: I just want to add that you definitely want to make sure that somebody is

going out to make sure that the equipment is in working condition over time, but it doesn't necessarily have to be the respiratory therapist, but you would periodically want to check on the equipment to be sure it's in working condition.

Lou Anne Getty: OK, that we do. Liz Daniels: OK. Thank you. Lou Anne Getty: And how do I hang up from this? Jody Whitten: You could just click mute on your phone. Lou Anne Getty: OK. Thank you. Jody Whitten: And, operator, this is Jody from Jurisdiction D and I would like to also just

recommend that everybody be aware that there's a prior standard – not a prior standard, there's quality standard under the CMS website that needs to be followed as well that you have obtained through your accrediting organizations.

Was somebody else going to speak? Operator: We're actually going to move on to our next question here.


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Jody Whitten: All right. Operator: Your next question comes from the line of Laurie Brown. Your line is open. Laurie Brown: OK. Thank you. We actually bill all four jurisdictions and I'm looking for

some information on the question that Mark had previously answered. Common scenarios eight and nine independently address the late physician visit and the retesting outside the 30-day window. But can you direct us on the re-cert date when the patient has both a late physician reevaluation and a late retest when a qualified retesting is required at time of the recertification and specifically when the retest is after the physician reevaluation date.

Jody Whitten: This is Jody. So this is more of a testing question, right, as far as if they

receive late testing as well as a late office visit. Laurie Brown: Yes. And the testing has followed the office visit. It's not in your common

scenarios. They're addressed independently and they both tell you to use the physician date – visit date. But if a test is after the physician date, I think that’s creating conflict.

Jody Whitten: Correct. You want to make sure you're following – this is Jody again from

Jurisdiction D. You want to make sure that you're following the rules and regulations regarding requiring a new test. There's a few times when we actually require a new test from the original. I believe, Group II patients need to have a new test prior to their recertification, but I don't believe the other ones require the new test.

So – and Nina, you are doing the testing requirements. If you have anything

you wanted to add to that. Nina Gregory: And it would be specifically in your Group I patients with a length of need of

less than lifetime and would be required to be retested within the last 30 days of your initial cert period.

Laurie Brown: So you're talking about testing for the recertification? Nina Gregory: Yes. And that needs to be done 12 months after their initial certification.


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Laurie Brown: Correct. But that doesn't always happen. When you know patients get sick,

they cancel their appointment. So if that doesn't occur, and we have conflict with both of these occurring after they were due. And we've asked the question on various times and we're getting various answers as well.

It's not documented in any way. I think it needs to be addressed for the

providers. Nina Gregory: OK. Well, can we put that in the follow-up Q&A then? Laurie Brown: Perfect. Nina Gregory: All right. Thank you. Laurie Brown: Thank you. Operator: Your next question comes from the line of Debbie Dunlap. Your line is open. Debbie Dunlap: Yes. I have a question regarding RUL scenarios. We've received two different

answers. Does it go by the initial date that’s on file or the number of months that have been paid?

Jody Whitten: The RUL is based on when the beneficiary first received the equipment

because if they have their equipment, they need to have had their equipment for five years.

Debbie Dunlap: OK. So we submitted two different questions. One patient was Medicare then

went to a Medicare HMO and back to Fee-For-Service Medicare and the answer given to us was that we have to pick up, like I'll say, 24 months, we're paid under Medicare Fee-For-Service, then they enrolled in the HMO and then back to Fee-For-Service. The answer was given that when they went back to Fee-For-Service, it would represent the 25th month even though it's been more than five years.

Jody Whitten: So they're basically telling you that you need to carve out the time they go to

the Medicare HMO?


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Debbie Dunlap: Yes. But then in question number eight – I mean, it's a hospital. It's not the HMO, but that's saying that you would be able to start new RUL. So, I guess, what's the difference between if they're Medicare HMO or if they're in a SNF or a hospital.

Jody Whitten: To me, that's a very good question and we can certainly bring that back unless

anybody else would like to respond. Dr. Paul Hughes: Hi. It's Dr. Hughes. Jody Whitten: Welcome, Dr. Hughes. Dr. Paul Hughes: Yes. Actually, Medicare HMOs are a special case. And so the problem comes

when you change scenarios then the answer changes, OK? Debbie Dunlap: OK. Dr. Paul Hughes: And that’s why you're getting different answers. If you go into a hospital or

some other facility and you have a break in service that you know – that doesn't affect your useful lifetime, at least, as I understand the rule. But when you go into the Medicare HMO, if you were on the items in Fee-For-Service in the first place, it doesn't have to be oxygen. It could be hospital beds or whatever. The rules are the same. And then you go into the managed care plan and you continue to use that thing, whether it's oxygen or a hospital bed or for whatever.

All the while you're in the HMO and then you come out of the HMO and you

come to Medicare Fee-For-Service, then you want to continue the oxygen, your hospital bed, whatever the rental thing is. You pick up where you left off. It's as if for our counting purposes, our Fee-For-Service counting purposes, the Medicare HMO didn't exist, OK?

Debbie Dunlap: OK. Dr. Paul Hughes: But if it's not a Medicare HMO, then the time continues to pass. It's not like a

time warp. So that's – I don't mean to be showy, but that's really – it boiled down to that simple concept. The HMO as a special circumstance, you get to


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go in and as long as you continue the item while you're in the HMO, when you come out of the HMO and come back to Medicare Fee-For-Service, you pick up where you left off.

Debbie Dunlap: OK. Dr. Paul Hughes: But that's not true for – any other situations as far as I know. So, again, I'll

defer to the (inaudible) people if I’ve got that wrong. Debbie Dunlap: OK. And can I ask another question? Dr. Paul Hughes: Well, not if it's too hard. Debbie Dunlap: We had an initial CMN that was good for a lifetime and then we sent the, the

recert to the doctor to fill out and he only put (inaudible) because from the time the recert was effective four months later, the oxygen equipment was returned and we got it back stating that the length of need is not valid on the recert CMN

Dr. Paul Hughes: Well, I don't have a comment on that. All I would tell you is it doesn't matter

what they put on the first initial CMN, if it's a Group I patient. As long as they put 12 or more, it's 12 because the recert is required. So it doesn't matter if they've put 12, 15, 99, 4,000. At 12, it expires and you have to get your recert.

Now, if they put something less than 12 on the initial one, then it expires

when that time is up. When you get to – and then you got to go get another one. For the recert CMN, any number should be acceptable by the system and it will expire. If you put – if any other number is in there that's less than 99, it will expire when you get to that number, OK?

Debbie Dunlap: OK. Dr. Paul Hughes: In the old days when oxygen was paid forever, that was important, you know?

If they – at the recert, they put 24 in, then two years after the recert, it would stop paying because the recert expired and you would have to go out and get another one.


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So – but as far as I know, there is no system reason that they couldn't put four or a six or a 10 or 22 in there. It's just, if they put it in on the recert, when it gets to that number, if it's less than 36, it's going to stop paying.

Debbie Dunlap: OK. So we got these three determinations, so we just can appeal it then? Dr. Paul Hughes: You're not really asking the best person for that, but I think the answer to that

is yes. Jody Whitten: Let me pipe in. This is Jody from Jurisdiction D. Dr. Paul Hughes: Thank you. Jody Whitten: You're welcome. Also, when you are getting an extension to your initial

CMN, it's important to note, you said that originally he had 99 and then he changed it to four. It's important to note that you need to add to the initial. So if you had 12 length of need on your initial and he only wants four more months, you would add the four to the 12, so it goes to our claim system properly so he would need to add it up so it will be 16, if he's adding four more months to the original 12.

Debbie Dunlap: So I need them – my re-cert changed then? Jody Whitten: Right. Debbie Dunlap: If that is four more months from the date of the re-cert. Jody Whitten: Right, exactly. You would need to have it 16 days – 16 months. Debbie Dunlap: OK. Jody Whitten: In that way, it goes to the claim system properly and you don't have any

denials or any problems getting your claim into the system. Debbie Dunlap: OK. Thank you so much. Jody Whitten: You're welcome.


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Dr. Dick Whitten: Jody? Jody Whitten: Yes, sir. Dr. Dick Whitten: This is Dr. Whitten. I couldn't – I had to fight with my mute button to get in. I

appreciated the frustration of the questioner who was talking about the CERT requests for the records going back six months. And we're certainly aware of some of the concern.

I do want to add, however, that it may be helpful to remember that the CERT

contractor is looking for evidence that the item is being – is needed and is being used and each of the comments related to the physician's record. It may be helpful in that physician's record, the total record, there is a note on the pharmacy refill sheet or a note by one of the med techs or one of the nurses that evidences, for instance, that the items being used which, combined with the physician's exam, could provide both pieces of information.

So it's – there are may be other sources from within the physician's record

other than just the clinical notes from the physician itself that would help satisfy some of what these CERT contractors are looking for. I thought that might help.

Jody Whitten: Thank you, Dr. Whitten. Also, I would just like to point out on the

recertification question, for patients as it’s written in the LCD, for patients who fall into Group I, the LCD actually says the patients initially meeting Group I criteria, the most recent qualifying blood gas prior to the 13th month needs to be reported on the recertification CMN, so I hope that helps with the recertification question we had earlier. So, we can go ahead with the next question.

Operator: Your next question comes from the line of Tammy Felt. Your line is open. Jody Whitten: Hi Tammy. Tammy Felt: Are you there? Jody Whitten: Yes, we are. What jurisdiction do you bill to?


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Tammy Felt: All of them. Jody Whitten: All of them? Great, what's your question? Tammy Felt: I just have a question about the three test results for exercise and portability.

I'm trying to remember what year that took effect. Dr. Paul Hughes: I've been doing this since '95 and it's been in place since then. It's Dr. Hughes. Jody Whitten: Tammy, did you hear that from Dr. Hughes? Tammy Felt: Yes, I did. Thank you. Jody Whitten: Great. Thanks Tammy. Thanks Dr. Hughes. Operator: Your next question comes from the line of Anna Maria Martinez. Your line is

open. Jody Whitten: Hi Anna Maria. Anna Maria Martinez: Hi. We actually bill both region B and D and I'm calling with Orbit

Medical. And I'm calling – I'm sitting in on the call today and we’ve got a problem with some of our patients where we don't know – we can't determine if it's a true break in service claim or not.

The previous suppliers are out of business, we can't contact them and the

patient cannot remember the name of the last physician that prescribed or ordered O2. How would we determine if this is a new medical necessity and if a new 36-month rental period should begin or if it's a break in need situation?

Jody Whitten: Anna Maria, if the patient has been continuously using the oxygen and they're

just coming to you because their previous supplier is no longer in business. Anna Maria Martinez: No. And this is not the case, this is the case where the patient hasn’t been

on oxygen for a couple years now. Jody Whitten: OK.


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Anna Maria Martinez: It's been a year and a half or two years since they've last had oxygen in the

home. Jody Whitten: OK. You do need to make sure you have a thorough intake process in asking

the questions. Obviously, it's been two years, you're going to want to make sure you have a physician's order to provide and you want to make sure that when you get that order, that you check with that physician, you know, when was the need originally identified for this patient and finding out, you know, if there was a break, you know, asking these questions upfront, you know, if there was a break, why was there a break?

Ask that from – to the beneficiary and to their caregiver to figure out exactly

why there's been two years where they didn't require oxygen. Anna Maria Martinez: Right. And that's what we – we are currently doing that. But, again, like I

mentioned, a lot of our patients, they have a hard time remembering a couple years back and they're seeing a different doctor now.

So, according to this doctor, this is the first time that the patient is requiring

oxygen; for whatever reason, they're unaware that the patient was on oxygen two years ago or why they were on oxygen two years ago. And the patient can't remember who the doctor was that last prescribed O2 for them. So, I just – I'm not sure, you know what we need to do in these situations.

Jody Whitten: So, you need to have a thorough intake process and obviously asking, you

know, if the beneficiary can't answer these questions, their caregiver, finding – and I would definitely recommend starting fresh if there's no indication that the medical need existed prior to the date that they came to you. So, I would definitely recommend starting fresh.

Anna Maria Martinez: OK. And then as far as the narrative goes, would we just indicate that the

information is not available and if it denies us on the redetermination explaining this information?

Jody Whitten: So, you're saying that you've already have one of these situations denied?


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Anna Maria Martinez: Well, I'm asking if this is what we would do. And if, you know, if we submit, you know, when you're submitting a break in service you have the BIS narrative, to the BIS, the pick up date, the delivery date, the previous diagnosis code and the new diagnosis code. So would we just – the narrative where we would just do BIS and then add previous information is not available? And then, how this claim is processed?

Jody Whitten: This actually sounds like an uncommon situation so yes; I would just do

whatever you could to find out when it was originally billed. It sounds like you're saying you have a pick up slip so there must be somebody involved. I would just make sure that you get as much information as you can and if you can provide information that they did not need the equipment for those two years, that would be something you'd want to include in the narrative, yes Ma'am.

Dr. Paul Hughes: This is Dr. Hughes. There's one element I think that’s real important that you

didn't touch on and that's what justifies the starting of a new payment versus a continuation of the old. And that has nothing to do with the passage of time.

There's only one factor that determines whether you start a new payment cycle

or not. And that's, is there a change in the medical need that justified providing the item the first time, is there a change in that medical condition to the second time? And if the answer to that question is no, it's the same condition, then the answer is no, you don't get to start over.

And if the answer is yes, whatever I had way back when I got better from, I'm

cured, I did not need it anymore, life was good and now we're two years down the line and I'm sick again, either with another episode of the same thing or something new, then that's a change in medical necessity and that justifies a new payment. So, the break in service, break in need questions are, you know, people often focus on the passage of time and how they document the passage of time and why has the time passed. But the heart of the question is, what were you sick with in the first place that qualified you for the oxygen, the hospital bed, you know, whatever rental thing we're talking about.


36

And why did you stop using it? And now, why do we need it again? And if the answer is, I need it today for the same reason I needed it before, then you pick up where you left off. If the answer is, I got better, I did not need it anymore, and now I'm sick again, and I need it, then you start over.

Anna Maria Martinez: Right. Dr. Paul Hughes: So, that's what you need to look for in the record. Anna Maria Martinez: Yes. And we are fully aware of all those rules and that's what we do,

verify and look for. But, again, it just goes, you know, we've got a particular situation where the patient doesn't remember the doctor.

Dr. Paul Hughes: I understand how it can be hard to track that down but, you know, Medicare

doesn't have any suggestions about how to do that beyond all the normal common sense things that everybody already knows how to do. You know, I've talked to doctor, talked to the patient, talked to the family members, if you got access to prior supplier records, you know, wherever you can go to chase that down, you know, there's no something special for Medicare about that. We do empathize with how difficult that is to do though.

Anna Maria Martinez: Well, thank you very much. Jody Whitten: Thank you Anna Maria. Thank you Dr. Hughes. Next question?

Questions and Answers concluded

Operator: Your next question comes from the line of Jessica Diaz. Your line is open. Jessica Diaz: Hi. I am asking a question well, I'm billing region D. My question is, we have

a concentrator and portable that has capped and the patient went five months without receiving any contents.

So, then recently, the patient receives contents and we bill them and they were

denied and then I sent them to redetermination and they're still denying stating that we need a new initial and I do not understand why they would be requesting a new initial. The equipment is capped, the patient’s had the


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equipment the whole time and just hadn't gotten tanks for five months so why would that be denied?

Jody Whitten: So, both the concentrator and the portable, is it gas? Jessica Diaz: Yes. Jody Whitten: Portable gas both capped out at the same time, correct? Jessica Diaz: Correct. Jody Whitten: Well, you're entitled to start billing for the content the month after the 36-

month cap but you're telling us that you didn't bill for the content until five months later?

Jessica Diaz: Well, we only bill for the contents when the patient receives them which is

also confusing as to I don't understand why the contents are tied into the concentrator because you don't use the contents with the concentrator, you use the contents with the portable and so …

Jody Whitten: That's because the portable is an add-on to the concentrator and so content is

always going to be based on the stationary system. Jessica Diaz: So – but why – I mean, if a patient – and we didn't provide the patient with

tanks for five months so then you're technically saying we are OK to go ahead and bill for them even though we're not providing them?

Jody Whitten: Well, if you have portable gas system, you need to be providing that

beneficiary with all the contents they need for one month. And if you're doing that, you can certainly even bill up to a three – you can give them up to a three month supply of content but you can actually bill on the anniversary date for that content. If they had a portable system and they weren't using it, is that what you were saying to me?

Jessica Diaz: Well, maybe he wasn't using it because he wasn't ordering tanks. As the way

we do it is if they're ordering them then we are billing for them.


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Jody Whitten: OK. You can't bill for individual tanks. It's a monthly charge or a monthly reimbursement.

Jessica Diaz: Right. Jody Whitten: Or a monthly reimbursement you get, right. Jessica Diaz: But I understand. Jody Whitten: OK. But, you do need to just bill one unit every single month following the

36-month cap. Jessica Diaz: But, OK, so then that goes along with saying – we need the delivery ticket to

show that we provided the tanks. Jody Whitten: That's correct. Jessica Diaz: So, if a patient doesn't call in to request any tanks and we don't provide them,

then how can we bill it every month? Dr. Paul Hughes: So, you're right. You don't bill for what you don't deliver. I think that's some

miscommunication. I believe Dr. Hughes received clarification from Joel Kaiser that they can.

First of all, the reason you don't – the reason that the contents are paid with

the stationary is because that's the way it was priced. That's just the decision that was made years ago that when they're paying for a concentrator, the payments for the concentrator includes a couple of extra bucks to pay for whatever contents they needed for a stationary system while the concentrator is being paid for.

That's just payment policy, it is what it is. Once the concentrator is done being

paid for, you get to – you have to provide contents, obviously, and you get to bill for it. You get paid one price a month for all the contents you need to bill.

Your example is you go a couple months and you don't deliver something,

well, if you don't deliver something because they don't need and you are


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consciencious then you don't – it's not an automatic payment that you get even if you don't deliver something.

Jessica Diaz: Correct. Dr. Paul Hughes: So, that's the bottom line. So, if you gave them three months worth of tanks

and instead of billing for all three months, at once you could say I'm going to bill in thirds, you could do that but then the fourth one comes and they don't call you and I say I need more tanks, well then you shouldn't bill for the fourth month because you didn't deliver anything.

Jessica Diaz: Right which goes to my saying is, for five months, we didn't provide anything

because maybe he was sick, or who knows what the case was, but he's using his concentrator, not using any tanks, we didn't deliver any tanks for five months so we didn't bill any. Now, he called and requested some, we billed one month and they're denying and they're asking for a new initial.

Dr. Paul Hughes: Well, I don't know why. You have to talk to the claims people at your firm. Jody Whitten: That's correct, Jessica. You'd want to contact the supplier contact center on

that. Jessica Diaz: Well, actually I have but – I mean, I'm not getting any answer. So – I mean,

what is my next level going to redeterminations and I don't have any more documentation to provide them other than what I already provided.

Jody Whitten: Well, if you'd like us to look at that, we would be more than happy to look at

that for you. And I can actually give you – if you could fax an example – that particular example to us at NAS, I'll give you a fax number.

OK. It is area code 701-277-6532. And we'll look into that for you to find out

why. Jessica Diaz: Thank you so much. Jody Whitten: You're welcome.


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Operator: Your next question comes from the line of Elizabeth Skenk. Your line is open. Elizabeth Skenk: Hi there. This is Liz from Jurisdiction D. Jody Whitten: Hi Liz. Elizabeth Skenk: And my question that I submitted wasn't actually addressed and the original

thing so I'm going to address it again. We're trying to go paperless and we're wondering what typical documentation we have to have on site? Like, we scanned all of our paperwork into the system and attach it to individual patient files so it's available on request.

However, do we have to have an actual physical piece of paper on site – in the

file? Jody Whitten: Again, this is Jody with Jurisdiction D, as far as having, you know, there are a

lot of records that are maintained electronically which is acceptable although you do have to make sure that you're able to support the authenticity of that documentation.

Elizabeth Skenk: Meaning what? I mean, a lot of our, you know, CMNs Jody Whitten: Where it came from, from a physician’s office, that kind of stuff. Elizabeth Skenk: So, like, fax transmittal across the top of the sheet or what? I mean, how else

would you do that with any of your documentation that you have on file, if you get them by fax?

Jody Whitten: If you're getting documentation by fax, you know, it would be the same as

getting… Elizabeth Skenk: Which is considered acceptable. Jody Whitten: I'm sorry. Elizabeth Skenk: I said, which on the – it's considered acceptable documentation by fax through

the policies.


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Jody Whitten: Correct. Elizabeth Skenk: So, I guess I'm not sure what – I guess I'm confused by that. How did that –

yeah, I don't know. How could you authenticate that any further than … Jody Whitten: Again, you're getting the medical records, is this what you're asking that

you're getting medical records from the physician’s office electronically? Elizabeth Skenk: No, over the fax. We get it over the fax machine, we get all of our, you know,

our scripts and most of our documentation comes in by fax. However, we also have delivery tickets that patients signed, do we have to have the original of those in a file, like a physical file or like, you know, it's scanned into the patient's electronic file and shredded, OK?

Dr. Paul Hughes: Medicare has not issued detailed instructions to any of us about any of these

kinds of topics. So, as far as I know anyway, there's not a set of official Medicare rules except around the issues of fax, signatures being OK, electronic signatures, if you use like an electronic CMN system and so on. All that's out there in the manual, it is of statements that tell us as contractors, particularly the fraud contractors that in the events of an audit, we have the authority to look into your electronic record keeping system to determine that the documents that are in there electronically are authentic, that you didn't alter them, that they're true copies and so on.

Now, how are you supposed to do that? We don't really have any official

Medicare instructions to give you. What I will tell you based on my practice experience with medical records is that your vendors for your software, particularly if you're into – if you buy a commercial electronic record system, they will have security and measures that will let an auditor come in and you'll be able to show that person. Here's how we put the stuff in and here's how it's secured so it can't be altered, so on and so forth.

My best advice to you and what we usually tell people in Jurisdiction A when

they ask these kinds of questions, you really need to be talking to your attorney about what are generally accepted legal ways to produce an electronic copy of a record that if you're challenged about it, you're going to


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be able to think you're on fairly reasonable grounds and say – I did it this way and this why you should accept it. But, at this point, Medicare, as far as I knowdoesn’t have any detailed instruction to tell you what to do of how to do that.

Elizabeth Skenk: So, it's not a requirement that we keep an original signature on files? Like, if

we were just to scan it directly into our systems … Dr. Paul Hughes: All the regulation says is that you got to keep the records for seven years and

it tells us that if you keep electronic records, we have the right to authenticate that. That's all that it says.

Elizabeth Skenk: Great. OK. Jody Whitten: And I just like to add on a little bit. There's a special edition MLN Matters

article that kind of addresses some of this information you're talking about and I would recommend reviewing that. It's special edition 1022.

Dr. Paul Hughes: Thank you. Elizabeth Skenk: Thanks. Operator: Your next question comes from the line of Heidi Momen. Your line is open. Darla: Hi. This Darla calling from Jurisdiction B. And we have a question about –

one of the questions that we had, is it Nina, went over about the overnight oximetry and it said – you said first that there was no time limit as far as the testing but then she said, it needed to be greater than five minutes. So, we were confused on that.

Nina Gregory: OK. Hi. This is Nina. Yes, the question that was given was, does an overnight

oximetry test – the actual whole test to have to be a certain length of time and there's no specific minimum sleep time requirement. It's just that the testing requirement requires a minimum of five minutes of qualifying values.

So, what they were asking is for the entire test is there's certain length of time

and there isn't specified minimum sleep time. Does that help?


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Darla: Not so much. So, there's no minimum sleep time but the qualifying time is –

has to be at least five minutes? Nina Gregory: Yes, so I guess they do have to be asleep for a total of five minutes at some

point. Darla: OK. That's kind of what I'm getting at because we – I actually had a patient

that we – this came up on and we had trouble with that that's why I – that's kind of caught my attention. So, it has to be at least five minutes?

That's the problem we had. So, I think we did run into where it had to be at

least five minutes for an overnight oximetry. Nina Gregory: Right. If it doesn't need the qualifying value, they have to have five minutes –

a minimum of five minutes but I think we were thinking in general, you know, do they need to be asleep for four hours versus eight hours or is there, you know, a certain length of time …

Darla: OK. So, the five minutes. That does clarify it. OK, thank you. Leah Nguyen: OK Simon, that is all the time we have for questions today. We would like to

thank everyone for participating in the Oxygen Ask-the-Contractor teleconference presented by the DME MAC National CERT Education Taskforce. An audio recording and a written transcript of today's call will be posted to the CMS Comprehensive Error Rate Testing Page at www.cms.gov/cert under the provider's tab in approximately two weeks.

Each jurisdiction will also be posting the transcript and audio file to their

website along with all pre-submitted questions. I would like to thank our speakers, Jody Whitten, Denise Winsock, Nina Gregory, and Mark Loney for their participation. Have a great day everyone.

Operator: Ladies and gentlemen, this concludes today's conference call. You may now

disconnect.

END

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