The E0181 has an overall 15.2 percent denial rate, and one of the top denial reasons is CO50: These are non-covered services because this is not deemed a “medical necessity” by the payer.
So let's talk about the patient's medical record. The E0181 requires the provider to determine medical necessity compliance. Remember that the E0181 must have a Written Order Prior to Delivery (WOPD) signed by the physician. Once you have determined that the patient meets the coverage requirements, a KX modifier may be attached to the HCPCS code when billing.
But you need to make a business decision about when to go after chart notes to assure that your patient meets the coverage requirements in the local coverage determination. Providers have different policies on this, and here are a few:
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Gain progress notes on all equipment requiring a KX modifier prior to billing.
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Gain progress notes on certain equipment requiring a KX modifier prior to billing, while on others, bill claims for items requiring the KX modifier once the signed, compliant detailed written order is received. Go after the progress notes if these claims are audited and a request is made.
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Bill claims for items requiring the KX modifier once the signed, compliant detailed written order is received, and then go after the progress notes.
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Bill claims for items requiring the KX modifier once the compliant detailed written order is signed, and go after the progress notes if claims are audited and a request is made.
Note that there is risk involved in not getting the documentation prior to billing Medicare. Without it, you cannot be positive that the patient's medical record accurately reflects what is required by the LCD. Intake personnel must be trained on gathering information at the time of referral to determine that the patient meets the coverage criteria. The KX modifier cannot be added if the coverage criteria haven't been verified and the patient doesn't meet the requirements.
Take the time to determine your company's policy by product. Train your employees to know what to look for when evaluating the information they receive and making the determination about whether the patient meets the documentation requirements of the LCD.
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.
