Goodbye 2007, Hello 2008. This year we'll take a look at how the four DME MACs measure up against each other on denials for a variety of HCPCS codes.
Tuesday, January 1, 2008

Goodbye 2007, Hello 2008. This year we'll take a look at how the four DME MACs measure up against each other on denials for a variety of HCPCS codes.

We'll analyze the denial rates by jurisdiction for one specific procedure code each month so you can see how your jurisdiction compares with the others. You can also determine whether your company falls within or outside the norm with regard to why that specific code is being denied. RemitDATA Inc., Memphis, Tenn., will provide the data for comparison.

Let's begin with the procedure code E1390, Oxygen Concentrator.

Jurisdiction DME MAC Denial Rate on E1390
Jurisdiction A NHIC Corp. 11.6%
Jurisdiction B National Government Services 16.7%
Jurisdiction C Cigna Government Services 21.3%
Jurisdiction D Noridian 13.3%

Cigna comes in as our big winner, with the highest denial rate on E1390 claims at 21.3%. The No. 1 denial reason code within that denial percentage is CO176 — Payment denied because the prescription is not current. This is also the top denial across the board for all DME MAC jurisdictions.

The variance can be attributed to the transition from Palmetto GBA to Cigna, and the file transfers between the two companies. However, from a billing perspective, remember these three key points when working claims to reduce CO176 denials for E1390 claims:

  1. Focus and work the front-end EDI (electronic data interchange) CMN rejection report.

  2. Pre-qualify patients with IVR (interactive voice response) to see if the CMN already exists for their oxygen to confirm the initial and/or recertification date.

  3. Remember that Group 2 oxygen coverage is only good for three months. If “99” is put in the length of need on the CMN, the CMN is still only good for three months and the patient needs to get retested.

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 claims adjudicated by the Medicare DME MACS and processed for RemitDATA customers. Source: RemitDATTA, 866/885-2974, www.remitdata.com.