Data shows that the CPM has an overall denial rate of 32.7 percent for Medicare. The top denial reason code is CO50: “These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.”
The CPM can be tricky to bill as there is no local coverage determination (LCD) to refer to for guidance. However, coverage for E0935 is outlined in Section 280.1 of the National Coverage Determinations Manual as follows: “Continuous passive motion devices are devices covered for patients who have received a total knee replacement. To qualify for coverage, use of the device must commence within two days following surgery. In addition, coverage is limited to that portion of the three-week period following surgery during which the device is used in the patient's home. There is insufficient evidence to justify coverage for longer periods of time or for other applications.”
Important reminders:
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The day of surgery counts as the first day of usage.
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Only 21 days (three weeks) in total are covered.
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Sheepskin pads are denied as included in the rental of the device.
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Bill the dates of usage, the “From” and “To” dates, in Item 24A on the CMS-1500 claim form, and bill the corresponding number of units in Item 24G.
To process E0935 claims correctly and efficiently, the following information is required in Item 19 on the CMS-1500 form or in the NTE segment (2400 loop) for electronic claims:
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Date of surgery (DOS),
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Onset date (OD), and
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Date of discharge (DOD).
Failure to include the start date of usage of the CPM machine, the date of surgery and the discharge date will result in claims being denied as unprocessable for missing information. Claims will need to be corrected and resubmitted, rather than reopened or appealed.
Here's an example of how the information in Item 19 or the NTE segment can be abbreviated: DOS 1/15/08, OD 1/16/08, DOD 1/17/08.
The important thing is that these three key pieces of information — date of surgery, onset date and date of discharge — are reported.
Based on analysis of 8,945,016 claims processed for RemitDATA customers during the fourth 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.
