The E0277 is in the Pressure Reducing Support Surfaces Group 2 LCD (Local Coverage Determination). Denials for this claim ran 22.7 percent in the second quarter this year, and the top denial reason code was CO50: “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”

CO50 denials may be received because the provider has forgotten to add the KX modifier after the company has received all supporting documentation of medical necessity for the E0277. If the denial is due to the missing modifier, billers should take the claim to reopening and ask to add the KX to the claim and reprocess.

Another reason for the CO50 denial is that the claim is lacking the appropriate diagnosis required for the patient to meet the coverage criteria. This diagnosis needs to be listed as the primary diagnosis (aka “diagnosis 1”) on the claim.

A portion of the LCD states the following (but make sure to review your LCD for complete coverage criteria): A Group 2 support surface is covered if the patient meets: a) Criterion 1 and 2 and 3; or b) Criterion 4; or c) Criterion 5 and 6.

1. Multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02 -707.05).

2. Patient has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate group 1 support surface.

3. The ulcers have worsened or remained the same over the past month.

4. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02 -707.05).

5. Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) (ICD-9 707.02 -707.05).

6. The patient has been on a Group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days).

In addition to meeting the coverage criteria, providers must have a Written Order Prior to Delivery (WOPD). Your intake team should be aware that the WOPD must be received before delivery to the patient.

Based on analysis of claims for high-dollar codes — those where the total amount paid exceeds $500,000 during a three-month period — processed for RemitDATA customers during the second quarter of 2009. Source: RemitDATA, 866/885-2974, www.remitdata.com

Read more Working Down Denials columns.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.