A new Centers for Medicare & Medicaid Services (CMS) FAQ page for Medicare coverage of noninvasive positive pressure ventilation (NIPPV) is addressing common questions from suppliers and providers of the equipment and related services.
Here are three takeaways from the FAQ sheet, last modified on April 30.
Clinicians can provide utilization information
CMS reminded stakeholders that its national policy “does not state that information supporting the service must be data from the machine.”
The national coverage determination (NCD) 240.9 notes that the patient “must be determined by a clinician to use the device at least four hours per 24-hour period, on at least 70% of days in a 30-day period.”
The clinician “could refer to documentation a clinician enters into the medical record that would provide support to pay the claim,” the FAQ said. “This could be achieved by the clinician recording in the medical record the amount of time the beneficiary states using the machine and that amount being no less than the NCD requirements.”
Records provided by suppliers or healthcare professionals with financial ties to the claim “are not considered sufficient by themselves for determining that an item is reasonable and necessary,” the FAQ added.
Rental timing confirmed
In answer to the question “Can [the] supplier use the previous month’s compliance to allow for continued prospective billing” — since the date of service in rental situations is the “from” date — CMS confirmed that the NCD “does not change current billing practices.”
“CMS understands billing on a rental is prospective and occurs before the NCD usage requirements are known to be met for that month,” the FAQ added.
The NCD and noninvasive equipment
The FAQ sheet said ventilators “fall under “frequent and substantial servicing” of the DMEPOS benefit.” Therefore, CMS reviews claims “using the policy that is in place at the time the item was initially provided. CMS will direct the MACs [contractors] to focus claim reviews on claims where the initial claim for the item falls under the effective date of the new NCD.”
In keeping with CMS’s current antifraud initiatives, the information above “does not restrict/limit applicable contractors from performing medical review where there is concern about potential fraud,” the NCD noted.
