In August, Jurisdiction A released the results of a prepayment review of claims for HCPCS codes A4623 (Tracheostomy, Inner Cannula) and A4629 (Tracheostomy Care Kit for Established Patients). According to RemitData, the national average denial rate was 25.5 percent for A4623 and 6.7 percent for A4629. However, when we look at what is truly required, many of the claims that were paid might have been denied if they had been part of a prepayment review such as the one conducted in Jurisdiction A.
The review was initiated due to the results of the quarterly review of dollars-allowed trends that indicated high volume claims for these two codes. The review involved a prepayment complex medical review of 100 claims submitted by 42 suppliers, of which 35 claims were allowed as billed and 65 were denied, resulting in a claim denial rate of 65 percent.
Based on the DME MAC's review of documentation received, the following were the two primary reasons for denial:
-
Service determined to be medically unnecessary (27%):
-
No MD orders
-
No medical records from ordering physician(s); other pertinent documentation that would support the medical necessity of the item(s) billed
-
No other substantiating documentation (e.g., delivery tickets (no date), invoice including manufacturer's name and model numbers
-
Duplicate submission
-
Service denied as duplicate, previously considered
-
-
Requested medical documentation not received (38%):
-
Service denied as requested documentation not received (17 of 42 suppliers did not submit medical records as requested).
-
The most common problem was that suppliers did not respond to requests for medical records. Of the services denied as not medically necessary, there were missing or incomplete records such as no orders on record; no medical record that contained information about the items used and/or the underlying medical condition/documentation that would support the medical necessity; and missing delivery tickets.
Remember, documentation must be available to the DME MAC upon request. Suppliers should be aware of the documentation requirements provided in the DME MAC's Supplier Manual.
It is your responsibility to provide sufficient documentation to support the medical necessity of the items you bill to the DME MAC. It is recommended that you maintain these records on file so that they can be made available if your DME MAC requests them for specific reviews.
If you receive a documentation request for any product you are billing, you must respond to those requests in a timely manner upon notification from the DME MAC.
Based on analysis of 5,217,235 Medicare claims processed for RemitDATA customers during the second quarter of 2010. 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.
