CMS Updates the Standard Documentation Requirements Policy Article – Effective Jan. 1, 2023

WASHINGTON, D.C. – Earlier this week, CMS published the new Standard Documentation Requirements for All Claims Submitted to DME MACs that goes into effect beginning 1/1/23. The future effective policy article updates the references to the certificate of medical necessity (CMN) & DME information form (DIF), noting that CMN and DIF are only required for certain items prior to 1/1/23, and they will not be accepted beginning 1/1/23.  CMS further clarifies that if suppliers submit claims with a CMN or DIF when it is not needed, the claim will be rejected, effective 1/1/23.

The future effective policy article also states that a recent order/prescription by the treating practitioner will meet continued need requirements for repairs. This is a big win for suppliers that provide PMD and other capped rental items. Current policy requires repairs to be noted in the medical record. AAHomecare is pleased to see the DME MACs listened to members and made this change.

New Oxygen and Oxygen Equipment LCD Highlights

WASHINGTON, D.C. – As AAHomecare shared in its Nov. 18 alert, CMS published the new future effective Oxygen and Oxygen Equipment LCD and related Policy Article that will go into effect on 1/1/23. The DME MACs updated the LCD based on the new Home Use of Oxygen NCD.

Below is an overview of the changes found in the Future Effective Oxygen and Oxygen Equipment LCD and related Policy Article:

• Removed the following:
  • All references to CMNs. (Initial & RECERT)
  • Chronic stable state requirement
  • Severe lung disease criterion which no longer limits oxygen’s coverage to severe lung disease or hypoxemia related condition expected to improve with oxygen therapy
  • Alternative treatment method requirement
• Since the CMN was eliminated, the 30-day requirement for the face-to-face and qualifying test was also eliminated. This was replaced with the statement “the treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need.”  The LCD defines time of need as “during the patient’s illness when the presumption is that the provision of oxygen will improve the patient’s condition in the home setting.” It further clarifies “for an inpatient hospital patient anticipated to require oxygen upon going home, the time of need would be within two days of discharge.”
• Repurposed Group III criteria that allows coverage for patients with the absence of hypoxemia defined in Group I and Group II, but who have a medical condition with distinct physiologic, cognitive, and/or functional symptoms documented in high-quality, peer-reviewed literature to be improved by oxygen therapy, such as cluster headaches (not all inclusive).
• Group IV was added to replace the previous Group III which now list the non-covered conditions for oxygen.
• Formal re-evaluation and testing are not required for Group I patients. However, suppliers are still responsible to ensure oxygen and oxygen equipment remain reasonable and necessary.
• Group II patients should be re-evaluated and retested by the treating practitioner between the 61st and 90th days after initiation of therapy. A new SWO by the treating practitioner is also required.
• Group III patients should be re-evaluated by the treating practitioner between the 61st-90th days after initiation of therapy. A new SWO by the treating practitioner is required.
• For patients leaving a hospital setting that need oxygen upon going home, a blood gas study must be performed two days prior to discharge.

HME Issues in the Spotlight at Medicaid Directors Conference

WASHINGTON, D.C. – The HME community had a strong presence at the National Association of Medicaid Directors (NAMD), 2022 Fall Conference, held earlier this month in Washington, DC. Laura Williard, AAHomecare vice president for payer relations was on hand, along with Jason Morin (Coloplast; AAHomecare Payer Relations Council Clair), Ryan Bullock, (Aeroflow and PRC Vice-Chair), Kathryn Vaughn (Coloplast), Anna Markiewicz (Coloplast), and Kim Cook (Numotion).

The three-day session touched on multiple areas of interest to HME suppliers, including a chance to connect with Kate McEvoy, the incoming Executive Director for NAMD.  In a brief conversation with McEvoy, who we have worked with in her past role as Connecticut Medicaid Director, she expressed interest in meeting to see how AAHomecare and NAMD can collaborate going forward.

AAHomecare attends these meetings to learn about current  Medicaid program priorities and to make new connections and strengthen existing relationships with Medicaid officials from around the country.  See additional highlights and takeaways from the session in this expanded article.

NAMD Calls for Additional Guidance Related to End of PHE
On Nov. 17, NAMD sent a letter to Congress requesting certainty around the timing and fiscal resources available to support the Medicaid eligibility redeterminations when the COVID-19 Public Health Emergency (PHE) comes to an end.  Their requests include maintaining the current 6.2 percentage point FMAP enhancement through the first quarter of redeterminations and phasing the enhancement down over a 12 month period.  The PHE is expected to be renewed in January for an additional 90-day period, lasting through mid-April, at least. See NAMD’s full request here.