This month we will look at two tracheostomy items that have been hit with high rates of denial and are causing providers major headaches.
RemitDATA has provided overall denial rate information for claims, which have been processed through the four Durable Medical Equipment Medicare Administrative Contractors (DME MACs.)
• A7505 – HMES or trach valve housing has a 50.3 percent denial rate.
• A7527 – trach/larynx tube plug/stop has a 47.3 percent denial rate.
One of the top reasons these claims are being denied is the CO151 denial, which is associated with supply overutilization. These claims are being denied when they are first billed due to a Medically Unlikely Edit (MUE).
CMS developed the Medically Unlikely Edit (MUE) to reduce the paid claims error rate for Part B benefits. An MUE for an HCPCS code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. All HCPCS codes do not have an MUE. The MUE was implemented Jan. 1, 2007, and is used to adjudicate claims at carriers, fiscal intermediaries and DME MACs.
Upon receiving this denial, you will need to get chart notes from the patient’s medical record supporting the need for the item.
Remember, you have only 120 days from the date of the denial to file the redetermination. Track the date you sent the chart note request and be diligent about gaining its return.
Based on analysis of 5,690,487 Medicare claims processed for RemitDATA customers during the fourth quarter of 2011. Source: RemitDATA, 866-885-2974, www.remitdata.com.
