In August, Jurisdiction A released the results of a prepayment
review of claims for HCPCS codes A4623 (Tracheostomy, Inner
Cannula) and A4629 (Tracheostomy Care Kit for Established
Patients). According to RemitData, the national average denial rate
was 25.5 percent for A4623 and 6.7 percent for A4629. However, when
we look at what is truly required, many of the claims that were
paid might have been denied if they had been part of a prepayment
review such as the one conducted in Jurisdiction A.
The review was initiated due to the results of the quarterly
review of dollars-allowed trends that indicated high volume claims
for these two codes. The review involved a prepayment complex
medical review of 100 claims submitted by 42 suppliers, of which 35
claims were allowed as billed and 65 were denied, resulting in a
claim denial rate of 65 percent.
Based on the DME MAC's review of documentation received, the
following were the two primary reasons for denial:
Service determined to be medically unnecessary (27%):
No MD orders
No medical records from ordering physician(s); other pertinent
documentation that would support the medical necessity of the
item(s) billed
No other substantiating documentation (e.g., delivery tickets
(no date), invoice including manufacturer's name and model
numbers
Duplicate submission
Service denied as duplicate, previously considered
Requested medical documentation not received (38%):
Service denied as requested documentation not received (17 of 42
suppliers did not submit medical records as requested).
The most common problem was that suppliers did not respond to
requests for medical records. Of the services denied as not
medically necessary, there were missing or incomplete records such
as no orders on record; no medical record that contained
information about the items used and/or the underlying medical
condition/documentation that would support the medical necessity;
and missing delivery tickets.
Remember, documentation must be available to the DME MAC upon
request. Suppliers should be aware of the documentation
requirements provided in the DME MAC's Supplier Manual.
It is your responsibility to provide sufficient documentation to
support the medical necessity of the items you bill to the DME MAC.
It is recommended that you maintain these records on file so that
they can be made available if your DME MAC requests them for
specific reviews.
If you receive a documentation request for any product you are
billing, you must respond to those requests in a timely manner upon
notification from the DME MAC.
Based on analysis of 5,217,235 Medicare claims processed for
RemitDATA customers during the second quarter of 2010. Source:
RemitDATA, 866/885-2974, www.remitdata.com
Read more Working Down Denials
columns.
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. You can reach her at 419/448-5332 or sarahhanna@bright.net.
