Transcutaneous Electrical Nerve Stimulation (TENS) Devices, HCPCS E0720 and E0730, are challenging items to get paid. According to recent information from RemitDATA, TENS units have a 42.9 percent denial rate. That means nearly half of all claims that are submitted are getting denied. Why is that? The No. 1 denial code for TENS is CO108 - Rent/purchase guidelines were not met. The No. 2 denial is CO50 - These are non-covered services because this is not deemed a “medical necessity” by the payer.
There are specific rules within the medical policy regarding the rental and purchase of a TENS device that both intake and billing personnel must be aware of. Without this knowledge, claims will be sent without meeting the rent-to-purchase guidelines. A TENS must be used for a trial (rental) period before the purchase can be made.
There are two scenarios under which a TENS would be prescribed in Medicare's eyes: 1) for acute post-operative pain, and 2) for chronic pain. A written order prior to delivery (WOPD) must be obtained before dispensing the TENS. The WOPD is a signed written order from the physician.
A Certificate of Medical Necessity (CMN) is required for the purchase of the TENS after the trial/rental period is complete. Additionally, there must be specific documentation regarding the pain in the patient's medical record (narrative notes from the physician, home health agency, nurses, physical therapists, occupational therapists, etc.). Prior to submitting the claim for purchase, make sure the rental has been paid. Medicare will not pay for the purchase if the program has not paid for the rental.
When a TENS unit is used for acute post-operative pain, the medical necessity is usually limited to 30 days from the day of surgery. Payment for more than one month is determined by individual consideration based on supportive documentation provided by the attending physician. Payment will be made only as a rental. A TENS unit will be denied as not medically necessary for acute pain (less than three months' duration) other than post-operative pain.
When used for the treatment of chronic, intractable pain, the TENS unit must be used by the patient on a trial basis for a minimum of one month (30 days), but not exceeding two months. The trial period will be paid as a rental. The trial period must be monitored by the physician to determine the effectiveness of the TENS unit in modulating the pain.
For coverage of a purchase, the physician must determine that the patient is likely to derive significant therapeutic benefit from continuous use of the unit over a long period of time. The physician's records must document a reevaluation of the patient at the end of the trial period and indicate how often the patient used the TENS unit, the typical duration of use each time and the results.
For a purchased TENS unit, a CMN that has been completed, signed and dated by the treating physician must be kept on file and made available upon request. The CMN may act as a substitute for a written order if it contains all the required elements of an order. The CMN for TENS is CMS Form 848 (DME Form 06.03B). The initial claim must include an electronic copy of the CMN. (A CMN is not needed for a TENS rental.)
For chronic pain, the medical record must document the location of the pain, the duration of time the patient has had the pain and the presumed etiology of the pain. The pain must have been present for at least three months. Other appropriate treatment modalities must have been tried and failed, and the medical record must document what treatment modalities have been used. The presumed etiology of the pain must be a type that is accepted as responding to TENS therapy.
Examples of conditions for which a TENS unit is not considered to be medically necessary include (but are not limited to): headache, visceral abdominal pain, pelvic pain and temporomandibular joint (TMJ) pain.
In order to reduce denials of TENS units, your team needs to understand the rental and purchase guidelines as well as what documentation is required to prove medical necessity outside of the WOPD and CMN. Bottom line: Train, train and re-train to ensure that the documentation is available in the event of an audit.
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 firstname.lastname@example.org.