National Government Services, the Jurisdiction B DME Medicare Administrative Contractor, has recently completed a widespread prepay review of negative pressure wound therapy (HCPCS E2402) and related supplies.
The review was initiated as the result of an overall continuing disability review of 61 percent in the 2007 widespread probe of new products added in the NPWT policy group.
The major reasons for claim denials were that no medical records/orders from the physician regarding wound treatment were received with the initial coverage criteria (i.e., nutritional status, wound description, measurements and progress notes from the nurse/wound clinician) prior to the initiation of the NPWT. Fifty-one percent of the claims that were examined were denied because Medicare policy criteria were not met. Of the claims that were denied:
- Information received for the date of service conflicted with the original information of the date of service.
- Issues of the location, measurements and wound descriptions in the medical record were conflicting and did not match.
To prevent denials of NPWT claims at your company, make sure the medical documentation that is in your patient's medical record meets the coverage criteria listed in the local coverage determination (LCD) prior to billing. Review the physician orders and progress notes carefully before your claims are submitted. It is important to train billers and medical documentation personnel to make certain they are familiar with documentation requirements and proper billing protocols when processing NPWT claims.
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. She can be contacted at 419/448-5332 or sarahhanna@bright.net.
Based on analysis of 5,617,383 claims adjudicated by the four DME MACs and processed for RemitDATA customers from April-June, 2008. Source: RemitDATA, 866/885-2974, www.remitdata.com
