Data shows that the CPM has an overall denial rate of 32.7
percent for Medicare. The top denial reason code is CO50:
“These are non-covered services because this is not deemed a
‘medical necessity’ by the payer.”
The CPM can be tricky to bill as there is no local coverage
determination (LCD) to refer to for guidance. However, coverage for
E0935 is outlined in Section 280.1 of the National Coverage
Determinations Manual as follows: “Continuous passive motion
devices are devices covered for patients who have received a total
knee replacement. To qualify for coverage, use of the device must
commence within two days following surgery. In addition, coverage
is limited to that portion of the three-week period following
surgery during which the device is used in the patient's home.
There is insufficient evidence to justify coverage for longer
periods of time or for other applications.”
Important reminders:
The day of surgery counts as the first day of usage.
Only 21 days (three weeks) in total are covered.
Sheepskin pads are denied as included in the rental of the
device.
Bill the dates of usage, the “From” and
“To” dates, in Item 24A on the CMS-1500 claim form, and
bill the corresponding number of units in Item 24G.
To process E0935 claims correctly and efficiently, the following
information is required in Item 19 on the CMS-1500 form or in the
NTE segment (2400 loop) for electronic claims:
Date of surgery (DOS),
Onset date (OD), and
Date of discharge (DOD).
Failure to include the start date of usage of the CPM machine,
the date of surgery and the discharge date will result in claims
being denied as unprocessable for missing information. Claims will
need to be corrected and resubmitted, rather than reopened or
appealed.
Here's an example of how the information in Item 19 or the NTE
segment can be abbreviated: DOS 1/15/08, OD 1/16/08, DOD
1/17/08.
The important thing is that these three key pieces of
information — date of surgery, onset date and date of
discharge — are reported.
Based on analysis of 8,945,016 claims processed for
RemitDATA customers during the fourth quarter of 2009. 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.
