This month in our DME MAC comparison, Jurisdiction C barely made it out of the No. 1 spot and has turned over the title to Jurisdiction D for claim denials of E0260 — semi-electric hospital bed with mattress. Noridian, the MAC for Jurisdiction D, comes in with a 20.7 percent denial rate on this code. Cigna's denial rate is 20.5 percent, which still doesn't bode well for our provider friends dealing with the transitional challenges from Palmetto GBA in Jurisdiction C.
What is interesting about these denials is that Jurisdictions A, B and C all have the same top two denial reasons adding to their overall denial percentage. These top two denial reasons are OA109 (Claim not covered by this payer/contractor. You must send the claim to the correct payer/contractor) and CO18 (Duplicate claim). However, the top denial reason code for Noridian is CO176 (Payment denied because the prescription is not current). For Noridian, the OA109 and CO18 reason codes do come in at second and third, respectively.
The CO176 denial can be attributed to situations where the claim is being billed outside of the original 13-month capped rental period that was set up. Examples of these situations include but are not limited to:
The patient may have had a break in service that was over 60 days and there is a new medical condition. Rebill the claim with a note in the NTE field using the BIS abbreviation, the pick-up date and the new delivery date, and request that a new capped rental period be started.
There was a break in service during the rental period because the patient entered a skilled nursing facility. Rebill the claim with a note in the NTE field using the BIS abbreviation and requesting an extension to the capped rental period for the number of months the patient was in the SNF.
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 2,190,272 claims adjudicated by the Medicare DME MACs and processed for RemitDATA customers in January 2008.
Source: RemitDATA, 866/885-2974, www.remitdta.com
| Jurisdiction | DME MAC | Denial Rate on A4253 |
|---|---|---|
| Jurisdiction A | NHIC Corp. | 15.3% |
| Jurisdiction B | National Government Services | 14.9% |
| Jurisdiction C | Cigna Government Services | 20.5% |
| Jurisdiction D | Noridian | 20.7% |
