Revisions and updates for 2014

US Rehab November article

Peggy Walker, RN

Revisions and updates for 2014

Ø  New HCPCs codes

Clients in Penal institutions 42CFR 411.4Cb          

Definition: under arrest/ incarcerated/imprisoned/escapee/under supervision (parole) /Medical furlough/ required to reside in a mental institution – halfway house/ live under home detention or confined completely or partially in any way under a penal statute or rule 

Ø CERT error requests letters will now allow 60 days for response

Ø  SNF Consolidated Billing for 2014 list can be found on the CMS web site at /SNFConsolidatedBillling/index.html

Ø  Competitive bid modifiers continue to be a real issue with the industry working with NCART and AAH Complex Rehab to attempt to get the issues corrected. It seems that CMS says they did not intend for accessories to ever be paid except the single payment amount even on complex rehab claims—they “Made a mistake” on their education of proper modifier use – UGHHHHH – US Rehab has identified the issues and is working closely with industry experts to have this corrected.

Any examples would be helpful in getting the issue corrected. Please send to with patient information removed. The DCN number can stay so that the claim can be researched and reviewed. This is not to get them corrected but just examples. You will still need to follow redetermination to get corrected.

Ø  OPEN Enrollment is mid November to December 31st – this means that if you wish to change from a participating supplier to a non participating supplier you may do so.

Advantage of being non par is that you can choose to do a non assigned claim and collect money up front for an item of DME if you feel it is not going to be covered and not have to wait till you bill a claim and have it deny before you can collect your money. You can still be a CB provider but when you win the bid you can only do assigned claims for the CB areas.  This is important to assist you in being more flexible with providing equipment to beneficiaries.


Ø  Improper patient solicitation from the ZPICs

Currently, there are only three specific situations where suppliers of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) are allowed to contact beneficiaries by telephone about providing a covered item.

·         The beneficiary has given written permission to the supplier to make contact by telephone;

·         The contact is regarding a covered item that the supplier has already furnished the beneficiary; or

·         The supplier has furnished at least one covered item to the beneficiary during the preceding 15 months.

According to the Health and Human Services Office of Inspector General (HHS/OIG), some DMEPOS suppliers are attempting to bypass these requirements. The following are two examples of such behavior:

·         Suppliers contracting with independent firms to make unsolicited telephone calls to Medicare beneficiaries to market DMEPOS; and/or

·         DMEPOS suppliers contacting beneficiaries by telephone based solely on treating physicians’ preliminary written or verbal orders

These actions are not allowed for the following reasons:

·         A supplier cannot use a marketing firm to indirectly act in such a way they are not allowed to do directly; and/or

There are situations when a physician’s preliminary written or verbal order can be a substitute for the required written permission from a Medicare beneficiary. However, it is important that suppliers understand that a physician’s order does not override the written permission requirement 100% of the time. The determining factor is beneficiary knowledge. If a physician contacts a supplier on behalf of a beneficiary, with the beneficiary’s knowledge, and then the same supplier contacts the beneficiary to confirm or gather information needed to provide that particular covered item, the contact would not be considered “unsolicited”. Conversely, if a physician contacts a supplier, without the beneficiary’s knowledge, and the same supplier contacts the beneficiary to confirm or gather information, the contact would be considered “unsolicited.”

It should also be noted that during an initial contact between supplier and beneficiary, the supplier is prohibited from attempting to solicit the purchase of additional covered items since the supplier only had permission to contact the beneficiary regarding the particular covered item prescribed by the physician. SS A §1834(a)(17)  42 Code of Federal Regulations §424.57(11)

Ø    Stimulation Device Systems (E0762). 12/1/2013 Non covered serviced deemed not a Medical Necessity

Ø    E1161 being provided in nursing facilities. There are suppliers that are putting out multiple manual tilt in spaces in nursing facilities and billing them as place of service 12 (home) or 33 (custodial care) this is not something that is allowed. If the patient is in a 31 or 32 that is the only code you can bill for that facility. Putting the place of service incorrectly on a claim to receive payment could be construed as fraud and will result in referral to people with 3 initials in their names – like OIG – FBI and other little groups—

Ø    F2F implementation was July 1, 2013 and this means it was implemented on that date. The delay is only for active reviewing of claims. It is very important that you make sure your staff is not just by passing this rule. You need to make sure you have the documentation and detailed order BEFORE you put the item out. If you need assistance with referral training call contact myself or Ronda Buhrmester and we can assist you.

Peggy Walker, RN

Director of Reimbursement Services

US Rehab/VGM


It is imperative that suppliers understand that when prohibited solicitation results in claims being submitted for the items, those claims are considered false claims and violators are potentially subject to criminal, civil, and administrative penalties, including exclusion from Federal health care programs.