Medicare Part B Requires a Claim Modifier If You Are Not Collecting Patient Signatures!

On March 13, 2020, the Secretary of the Department of Health & Human Services (HHS) authorized waivers under Section 1135 of the Social Security Act to relax certain administrative rules to ease burdens on Medicare providers and suppliers to more easily provide care during the COVID-19 pandemic. The “1135 blanket waivers” include, among other things, waiving the enrollment fee for Medicare B Providers for those pharmacies that want to provide COVID-19 testing and the requirement to obtain patient signatures for proof of delivery for DME Supplies such as diabetic test strips. These waivers are retroactive to March 1, 2020 and are effective until the end of the emergency declaration.

On April 6, 2020, CMS issued Interim Final Rules with Comment (CMS-1744-IFC & CMS-5531-IFC) and the DME Medicare Administrative Contractors (MACs) issued bulletins in late May explaining that suppliers must include a “CR” modifier and include a narrative of “COVID-19” for claims where patient signatures were not obtained as proof of delivery. Claims that do not include the modifier and narrative may be subject to denial.

Here is an excerpt from the DME MAC joint bulletin:

‘Suppliers should continue to use the appropriate modifiers, including the KX modifier where applicable, for all HCPCS codes included in the NCDs and LCDs listed above. In addition, the CR modifier (CATASTROPHE/DISASTER RELATED) should be added to the HCPCS code(s) billed. Finally, suppliers are instructed to enter “COVID-19” in the NTE 2400 (line note) or NTE 2300 (claim note) segments of the American National Standard Institute (ANSI X12) format or field 390-BM of the National Council for Prescription Drug Program (NCPDP) format. These abbreviations may also be used in Item 19 of the CMS-1500 claim form.’

If your pharmacy dispensed DMEPOS items and did not obtain a patient signature as proof of delivery on or after March 1, 2020, then you must include

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  • Access Services
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    • An online form to submit safe filling and billing questions
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    • Audit flags – list of various claim attributes the PBMs use to select claims for audit
    • Billing insulin vials – flowchart to assist whether you should bill Medicare Part B vs Part D
    • DAW Codes Explained – use to understand when to effectively use DAW codes, their definitions and why claims may be flagged for audit if a DAW code is used incorrectly
    • Basic DMEPOS documentation guidance
    • Onsite Credentialing Checklist and expanded definitions of policies and procedures
    • Proof of refill request and affirmative response form for DMEPOS items
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    • And more!
  • Days’ Supply Charts
    • Utilize the days’ supply charts for inhalers, insulins, nasal sprays, eye drops and topicals to aid you in calculating the correct days’ supply
    • Guidance on overbilled quantities and incorrect days’ supply account for a sizable portion of audit chargebacks
    • Additional miscellaneous charts, which include: Dispense in Original Container and Return to Stock
  • Forms
    • Signature Logbook for print
    • Signature Trifold Mailer
    • Fax and Email Coversheet
    • Patient Attestation for over-the-counter COVID-19 test kits
  • On-Demand Webinars
    • Short webinars on hot topics in the PBM industry. Here are a few examples:
      • USP 800 Compliance
      • Cultural Competency Training
      • Dispensing Prescriptions Off-Label
      • Biologic Medications and Interchangeability
      • Continuous Glucose Monitor Requirements for Medicare Part B

PAAS Tips:

  • MORE AUDITS, MORE INSIGHT – PAAS National® is the industry-leading defender of community pharmacy dealings with Prescription Benefit Programs, including Caremark, Express Scripts, Humana, Medicaid, OptumRx, Prime Therapeutics., and more. PAAS assists on all third-party audits, including: desktop audits, onsite audits, invoice audits, OIG/Medicaid audits, Medicare B audits. The PAAS team is dedicated to helping you! We have five pharmacists and a complement of technician analysts with over 50 years of dedicated audit assistance experience. PAAS continuously updates their database with every audit received — in fact, we even keep a scorecard on individual auditors.
  • Get answers to your questions on days’ supply calculations, drug substitutions, billing practices, required documentation, prior authorization requirements, record retention, and internal audit procedures – just to name a few. As a trusted partner, we will provide tailored guidance to help you proactively prevent audits. Remember, the prescription claims you submit today are the audits of the future.
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Eric Hartkopf, PharmD
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