The HME industry has been hit hard with audits and Additional Documentation Requests (ADRs) from Medicare. The administrative cost involved with getting claims out of the door has drastically increased for our industry as reimbursement has declined. In order to ensure that claims will pass the muster of Medical Review, suppliers need to get the documentation at the outset of the admission process. The three Rs—requesting, receiving and reviewing chart—note documents for compliance with the national coverage determination (NCD) and local coverage determination (LCD) has become a process that is done prior to billing and with the ACA requirements prior to delivery. That being said, RemitDATA has provided us with the average denial rate for oxygen concentrators, E1390, to be 16.1 percent. The number one denial code is 50—not deemed a medical necessity by the payer. This stands to reason because oxygen concentrators are a focal point for Medical Review at the DME MACs for prepay audits. Providers across the nation receive ADRs on a regular basis to prove the medical necessity of the equipment. Recently, the DME MACs made information available regarding the biggest errors by suppliers when sending documentation with the ADR. The Oxygen and Oxygen Equipment LCD requires that the beneficiary be seen and evaluated by the treating physician within 30 days prior to the date of Initial Certification. Data analysis by the DME MACs showed the most prevalent reason for denial of oxygen claims reviewed by the Medical Review department was related to missing, invalid or incomplete documentation of a physician office visit within 30 days prior to the Initial Certification date. Physician visit documentation must include (at a minimum) the following elements:
- Visit must be dated and within 30 days of the Initial Certification date
- Beneficiary’s first and last names
- Medical necessity information
- Beneficiary’s condition
- Prognosis
- History
- Need
- Legibly signed and dated physician visit/medical records, from the treating physician or qualified practitioner
- The errors found and resolutions to those errors are as follows:
- Visit documentation is greater than 30 days prior to the Initial Certification date
- If the visit occurred one or two days beyond the required time frame, the documentation is not acceptable.
- Resolution: Contact physician to see if another visit occurred within 30 days prior to the date of Initial Certification. If not patient does not meet coverage criteria— supplier may re-qualify the patient and start coverage over.
- The physician visit/medical records were not signed or not legibly signed by the treating physician or qualified entity. Reminder: The signature of a respiratory therapist or nurse is not acceptable.
- Resolution: Obtain a signature log to authenticate illegible signature.
If the DME MAC determines the documentation is insufficient to support payment of the claim, the claim will be denied with ANSI Denial CO-50, ANSI Remark Code-N115. This allows your appeal rights to remain in effect. If you still disagree with the claim determination you may request a redetermination (first level appeal) and submit all pertinent, supporting documentation.
