Blues highlight medical, benefit policy changes

Inclusionary Guidelines
Gastric Suction
A gastric suction pump (E2000) is used to remove gastrointestinal fluids under continuous or intermittent suction via a tube. Use of a gastric suction pump and related supplies are covered for members who are unable to empty gastric secretions through normal gastrointestinal functions. Use of a gastric suction pump for other conditions will be denied as not reasonable and necessary.

Supplies (tubing, tape, dressings, etc.) are covered and are separately payable when they are medically necessary and used with a medically necessary E2000 pump. Supplies used with DME that is denied as not reasonable and necessary will also be denied as not reasonable and necessary.

Respiratory Suction
A respiratory suction pump (E0600) is covered for members who have difficulty raising and clearing secretions secondary to:

• Cancer or surgery of the throat or mouth
• Dysfunction of the swallowing muscles
• Unconsciousness or obtunded state
• Tracheostomy

Use of a respiratory suction pump for other conditions will be denied as not reasonable and necessary.

Suction catheters (A4605, A4624, A4628) and sterile water or saline (A4216, A4217) are covered and are separately payable when they are medically necessary and used with a medically necessary E0600 pump. Supplies used with DME that are denied as not reasonable and necessary will also be denied as not reasonable and necessary.

Procedure codes A4605 and A4624 are only covered for members with a tracheostomy (ICD-9 codes 519.00, 519.01, 519.02, 519.09, V44.0 or V55.0) as described below:

• Tracheal suction catheters (A4624) are reasonable and necessary only when all of the following are met:
• The member has a tracheostomy described by the listed diagnosis codes.
• The member requires the use of a covered respiratory suction pump (E0600) as described above, for tracheostomy suctioning.
• Closed system catheters (A4605) are reasonable and necessary only when all of the following are met:
• The member has a tracheostomy described by the listed diagnosis codes.
• The member requires the use of a covered respiratory suction pump (E0600) as described above, for tracheostomy suctioning.
• The member requires the use of a covered ventilator. (Refer to CMS’ Internet Only Manual 100-3, CH 1, §280.1 for information about the coverage of ventilators.)

Claims for A4605 and A4624 suction catheters that do not meet all of the criteria above will be denied as not reasonable and necessary.

More than three A4624 catheters per day will be denied as not reasonable and necessary for tracheostomy suctioning.

Non-tracheal suction catheters (A4628) are reasonable and necessary for suctioning in the oropharynx. The oropharynx is not sterile, therefore the catheter can be reused if properly cleansed or disinfected. More than three catheters (A4628) per week will be denied as not reasonable and necessary for oropharyngeal suctioning.

Sterile water or saline solution (A4216, A4217) is covered when used to clear a suction catheter after tracheostomy suctioning. Sterile water or saline will be denied as not reasonable and necessary when used for oropharyngeal suctioning.

Wound  Suction
Use of suction on wounds (A9272, K0743) is only appropriate in those clinical scenarios where the quantity of exudate exceeds the capacity of conservative measures such as surgical dressings and wound fillers to contain it. However, wound suction to remove exudate can be accomplished with the use of noncovered disposable, suction devices (A9272) or with covered DME devices (K0743). When a noncovered alternative exists (A9272), it is not reasonable or necessary to use a covered DME item (K0743). Therefore, when K0743 is billed, it will be denied as not reasonable and necessary. Refer to the Local Coverage Article for Suction Pumps for additional information about the statutory requirements for disposable wound suction items (A9270, A9272).

Wound suction pumps and their associated supplies, which have not been specifically designated as being qualified to use HCPCS code K0743 via written instructions, will be denied as not reasonable and necessary.

Supplies (dressings, tubing, etc.) are covered and are separately payable when they are medically necessary and used with a medically necessary K0743 pump. Supplies used with DME that are denied as not reasonable and necessary will also be denied as not reasonable and necessary.

Refill Requirements
For durable medical equipment, prosthetics, orthotics, and supplies provided on a recurring basis, billing must be based on prospective, not retrospective use. For DME/P&O products that are supplied as refills to the original order, suppliers must contact the member prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member. This shall be done to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion and to confirm any changes or modifications to the order. Contact with the member or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery or shipping date. For delivery of refills, the supplier must deliver the DME/P&O product no sooner than 10 calendar days prior to the end of use for the current product. This is regardless of which delivery method is used. (CMS Program Integrity Manual, Internet-Only Manual, CMS Pub. 100-8, Chapter 5, Section 5.2.6).

For all DME/P&O items that are provided on a recurring basis, suppliers are required to have contact with the member or caregiver prior to dispensing a new supply of items. Suppliers must not deliver refills without a refill request from a member. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a three-month quantity at a time. 
Diagnoses required for A4605 and A4624:
519.00 – Tracheostomy complication unspecified
519.01 – Infection of tracheostomy
519.02 – Mechanical complication of tracheostomy
519.09 – Other tracheostomy complications
V44.0 – Tracheostomy status
V55.0 – Attention to tracheostomy

Effective March 1, 2013, Medicare-eligible retirees of the Charter Township of Chesterfield will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 60022 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

Jackson County Medical Care Facility

Effective March 1, 2013, Medicare-eligible retirees of the Jackson County Medical Care Facility will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 59981 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.

Van Buren County Road Commission

Effective March 1, 2013, Medicare-eligible retirees of the Van Buren County Road Commission will have Blue Cross Blue Shield of Michigan’s Medicare Advantage PPO plan, Medicare Plus Blue Group PPO^SM, for their medical, surgical and prescription drug benefits. The group number is 59993 with suffix 600. You can identify members by the XYL prefix on their ID cards, like those of other Medicare Plus Blue Group PPO plans.