NHIC, the Jurisdiction A DME MAC, has informed suppliers that it has identified many Medicare beneficiaries who have received diabetic supplies that exceed the policy's utilization amounts. Denials for overutilization are identified with the denial code CO151 - Payment adjusted because the payer deems the information submitted does not support this many/frequency of services.
The policy recognizes that there could be occasions when a beneficiary may require greater than expected amounts. However, providers need to be aware of the policy limits and when to get an ABN (Advanced Beneficiary Notice). To avoid these denials, make sure your intake/customer service personnel are trained on the limits and on ABN requirements. They need to inform the patient of the overutilization, obtain a signed ABN and notify billing/medical documentation employees to get the patient's medical records to prove the medical necessity of the extra supplies.
According to the local coverage determination for diabetic supplies, here are the allowed amounts:
- Insulin treated group, indicated by the KX modifier, at 100 strips/lancets per month (300 per three months); and
- Non-insulin treated group, indicated with a KS modifier, at 100 strips/lancets per three months.
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.
Across the four Medicare jurisdictions for claims with diabetes-related HCPCS codes, the denial rate jumped from 8.5 percent in the year's first quarter to 11.8 percent in the second quarter, based on analysis of 1,279,711 such claims adjudicated by the DME MACs and processed for Remit DATA customers from January-June, 2008.
Source: RemitDATA, 866/885-2974, www.remitdata.com
