When denial code CO176 is accompanied by an M60 remark code, the Certificate of Medical Necessity is missing from the claim. If this is the case, attach the CMN and resubmit the claim. The missing CMN may also be attributed to the fact that the recertification CMN is not on file and needs to be obtained/sent.
When the M60 remark is not on the claim, you are probably dealing with a capped rental issue, most likely because the patient has previously received the same equipment from another supplier.
For denials where there is a CMN/Physician Order on file from a previous supplier and there was a break in service over 60 days, the denial needs to be sent to Reopenings (depending on your jurisdiction's DME MAC policy) with a request that your CMN be the new initial CMN within the Common Working File. A CMN/PO extension would be requested if the break in service was less than 60 days.
For CO176 denials in Jurisdictions B and C, these denials cannot go through Reopenings. Requests need to be sent to the Redetermination department with a copy of the CMN, Remittance Advice and the Redetermination form outlining the request.
In Jurisdiction A, a copy of the CMN, Remittance Advice and the Region A fax cover sheet are required to be sent for the CO176 denial.
For Jurisdiction D, Noridian requests a copy of the pick-up slip from the previous supplier in addition to the CMN and Remittance Advice when the supplier is requesting a new initial start date. If a pick-up slip is not obtainable, try a letter from the beneficiary stating that he or she had the equipment previously but that it was picked up and there was a break in service. This letter might help, but it is no guarantee of an affirmative Reopening decision.
Be sure to use your jurisdiction's DME MAC Reopening or Redetermination form. Visit their Web sites for copies. Once the CMN has been corrected in the system, additional claims that were denied for a missing or expired CMN can be resubmitted.
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 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.
