Effective Jan. 1, 2023, the Centers for Medicare & Medicaid Services (CMS) updated the Medically Unlikely Edit (MUE) for HCPCS code E2394 (Power wheelchair accessory, drive wheel, excludes tire, any size, replacement only, each), from two (2) units per date of service to one (1) unit per date of service.
Most of our clients, and perhaps most suppliers in the industry, replace both drive wheels at the same time. On March 6, ACU-Serve reached out to CMS via e-mail to request that the quantity be updated from the one (1) unit per date of service to two (2) units per date of service.
CMS responded the same day to acknowledge our inquiry and agreed with ACU-Serve that the MUE should be two units per date of service. The e-mail response from CMS stated, “CMS decided to increase the MUE from one to two. CMS implements changes to edits as soon as technically possible; although we cannot guarantee edit implementation dates, we expect that this change will be implemented in the July 1, 2023, edit files. Providers may choose to delay submission of claims for this code until after the July 1 implementation date, or appeal claims denied to the appropriate Medicare Administrative Contractor (MAC) including supporting documentation.”
The DME MACs published additional guidance advising that claims submitted for more than one unit for dates of service on or after Jan. 1 through June 30, 2023, will be held and processed once the July 1, 2023, MUE quarterly file is in production. The MACs also advise no further action is required by suppliers on MUE denied claims, as they will automatically reprocess claims for dates of service on or after Jan. 01, 2023.
We applaud the quick response of CMS and the DME MACs. We are particularly happy the submitted claims will no longer be denied and the previously denied claims will automatically adjust for payment without further actions of the supplier. Instead of filing appeals on the denied claims, we suggest suppliers mark these claims for follow up in late August or early September 2023. Alternatively, suppliers can run reports in late August or early September on MUE denial (CO151) for the E2394. If denials remain, they can reach out to their respective DME MACs for the appropriate next step.
Errors for CRT PMD Accessory Claims
CGS and Noridian have acknowledged a claims processing error for Complex Rehab Technology (CRT) power mobility device (PMD) and accessories claims. Suppliers received CO284 denials on accessories like E1007 (Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction) and E2313 (Power wheelchair accessory, harness for upgrade to expandable controller), and a CO16 remark code MA66 on the remaining items on the claims.
The DME MACs began accepting voluntary prior authorization requests for some PMD accessories on March 20, 2023, for claims with dates of service on or after April 6, 2023. The common working file (CWF) was updated by the system maintainer to accommodate the claim processing changes for the select PMD accessories. However, the update resulted in erroneous claim denials on the PMD and accessories if the Unique Tracking Number (UTN) was submitted on the claim lines that were not submitted for a Prior Authorization (PA). The DME MACs are working with the system maintainers on a resolution. In the meantime, the DME MACs instructed suppliers to submit the UTN only on claim lines for Voluntary PA items for which a PA was requested. The UTN should be submitted in loop 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = “G1” qualifier and REF02 = UTN. The DME MACs began reprocessing the claims that were denied in error.
Suppliers should closely monitor their DME MAC’s claims alert Web page. Once updated, the page will notify suppliers if additional actions are required.
Is Prior Authorization Helpful?
I was recently asked about voluntary prior authorization. I believe the PA for PMD accessories is a positive thing.
When some PMDs were under Advanced Determination of Medicare Coverage, suppliers appreciated the benefits of the accessories being reviewed for medical necessity. This went away when the remaining PMDs transitioned to PA.
This is helpful for providers who often get denials on electronics and other accessories for Medicare Advantage Plans (MAP). Obtaining approval on PMD and accessories from Medicare sets standards for the MAP, which cannot be more restrictive in coverage than Medicare Fee for Service (FFS).
We encourage our clients to submit simultaneously to Medicare FFS and the MAP. If the MAP denies the PMD or accessories but Medicare approves them, the supplier can use Medicare’s approval with appropriate citations in the regulations to appeal the MAP’s denial.
Point to remember: Monitor — internally/on your own or vicariously through a third-party billing service — denials frequently to look for unexpected new denials. And tap into HME state associations to stay abreast of funding/policy trends and news.
This story was originally published in the HME Handbook edition of HME Business. To subscribe to future digital eBook editions, click here.