How are your enteral denials looking? For some Medicare enteral providers, it’s not looking good. According to our friends at RemitDATA, the B9000 enteral nutrition infusion pump (without alarm) showed a 39.1 percent denial rate. This is a staggering denial percentage. A 39 percent denial rate can bring a company to its knees, from a cash flow standpoint.
So why are enteral pump claims being denied? One reason that the denial rate for the B9000 is so high is due to the 173 denial code (service was not prescribed by a physician). This denial is most commonly associated with a missing DIF (DME Information Form). The DIF must be attached to both the enteral formula and the pump when billing for a pump. The method of administration on the DIF must be identified as “pump,” as well, and not gravity or syringe.
There is another unique quality about billing the B9000. Providers still have to give the beneficiary the maintenance and service option. The supplier must notify the beneficiary of the option to purchase the pump with the initial claim. The beneficiary has the length of the rental period to decide to purchase or rent. Between the 10th and 13th month, the patient should decide whether they want to purchase the pump at 13 months or continue renting for a full 15 months. The beneficiary’s decision to rent or purchase should be reflected by the appropriate modifier on the 13th month’s claim. If the beneficiary does not respond, then it would be determined that the beneficiary is “undecided” and the pump will continue to rent. The modifiers are: BP for purchase, BR for rental and BU for undecided.
If the patient chooses to continue renting, or they do not respond and the BU modifier is used, the provider will receive maintenance and service payments every six months thereafter. If the dates of service for the maintenance and service are not billed in the correct months, it could cause payment issues.
Another problem regarding enteral pumps is that some DME MACs (Medicare Administrative Contractors) have had them under prepayment review, and the denials revolve around the documentation associated with proving the medical necessity of the claim. Claims were denied because they had insufficient clinical documentation to justify the need for enteral nutrition or the enteral infusion pump as defined in the LCD (Local Coverage Determinations). Another reason could be that the clinical documentation was missing from the requested documentation to support medical need.
The DWO (Detailed Written Order) and DIF are billing documents and the chart notes from the patient’s medical record will be used to determine the medical necessity of the item(s) being billed. The medical record is reviewed to determine whether the patient meets the intent of the Indications and Limitations of Coverage and/or Medical Necessity, as defined in the LCD.
One surprising reason for denial was that the claims were missing DWOs. If they did have a DWO, it was incomplete. Providers need to understand that even though they can complete, sign, date and submit the DIF with the initial claim, providers are required to obtain a DWO from the physician. The DIF does not replace the DWO. The DIF is provided in addition to the DWO, and the DWO must be received complete from the physician prior to billing.
Source: Based on analysis of 5,690,487 Medicare claims processed for RemitDATA customers during the fourth quarter of 2011. Contact RemitDATA at 866-885-2974 or visit www.remitdata.com.
