As patients become eligible for Medicare, they may be using equipment paid for by previous primary insurance. Denials can occur when the equipment must be serviced with new items, as is often the case with patients who are on CPAP therapy.
One such item is an A7031 face mask interface, replacement for full face mask, each. RemitDATA reports a denial rate for this item of 10.4 percent. One of the top codes cited for denial is a 16 (claim/service lacks information needed for adjudication). This denial is usually accompanied by a remark code of M124 (missing indication of whether the patient owns the equipment that requires the part or supply).
For supplies and accessories used with equipment paid by other insurance or by the beneficiary, all of the following information must be submitted with the initial claim in the 2400 NTE segment for electronic claims:
- Healthcare Common Procedure Coding System (HCPCS) code of base equipment
- A notation that this equipment is beneficiary-owned
- Date the patient obtained the equipment
Claims for supplies and accessories must include all three pieces of information listed above. Claims lacking any one of the above elements will be rejected with the PR-16 denial code. When a 16 denial code is received for this reason, the supplier must resubmit the claim with the correct information in the NTE segment.
Remember that Medicare requires that supplies and accessories only be provided for equipment that meets the existing coverage criteria for the purchased base item. In addition, if the supply or accessory has additional, separate criteria, these must also be met. In the event of a documentation request from the contractor or a redetermination request, suppliers should provide information justifying the medical necessity for the base item and the supplies and/or accessories.
To ensure that the patient meets the medical necessity requirements, refer to the applicable local coverage determinations (LCD) and related policy articles for information on the relevant coverage, documentation and coding requirements.
(Source: Based on analysis of 5,690,487 Medicare claims processed for RemitDATA customers during the fourth quarter of 2011. Contact RemitDATA at 866-885-2974 or visit www.remitdata.com.)
