While RemitDATA recorded a 17.6 percent denial rate from Medicare for the E1390 (oxygen concentrator) for the first quarter of this year, the company's customers fared much better than providers overall who submitted these claims in Jurisdiction A. Let's review the results of the DME MAC's prepayment complex medical review of oxygen and oxygen equipment, posted June 8 on the NHIC website (www.medicarenhic.com).
If a claim is selected in a prepayment complex medical review, the DME MAC will send an additional documentation request (ADR) to the provider requesting documentation to prove the validity of the claim(s) submitted prior to adjudication. Once the documentation has been reviewed, a decision of denial or payment is rendered.
NHIC's review was conducted on claims submitted from Jan. 1 through March 31 of 2010 based on the oxygen and oxygen equipment LCD. The review involved 376 claims submitted by 39 suppliers. Of those claims, 89 were allowed and 287 were denied, resulting in a 76.33 percent denial rate.
Based on its review of the documentation received, the DME MAC gave the following as primary reasons for denial:
-
No in-person examination 30 days prior to date of initial CMN (34.5 percent);
-
No in-person examination 90 days prior to date of recertification CMN (12 percent);
-
Oxygen saturation level could not be validated (7.3 percent);
-
No initial CMN; only a recertification CMN completed and signed according to the recertification date (1.5 percent);
-
Physician in-person visit or physician orders were illegible or name stamped (1.4 percent);
-
Billed in error (1.4 percent); and
-
Section “D” of CMN (physician attestation section) was not dated in an appropriate time frame or was dated before the initial CMN or recertification date (0.7 percent).
When billing for oxygen and oxygen equipment, keep these reasons for denial in mind and review your documentation to make sure you have the information required to prove the medical necessity of your claim.
Based on analysis of 8,945,016 claims processed for RemitDATA customers during the first 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.
