E0463 Pressure Support Ventilator

HCPCS code E0463 (pressure support ventilator) is a standout as one with a higher-than-average denial rate — 33.5 percent overall. More than a third of all of these claims result in denials!

The major reason for the high denial rate is for CO18 – duplicate claim. This particular denial for E0463, however, doesn’t follow the traditional CO18 denial model. What I mean is that for other product codes that receive CO18 denials, the main reason is that the claim was billed, denied and then resubmitted without research about what needed to be done based on the initial denial.

Many ventilator patients require two vents and, when billed, Medicare denies as a duplicate claim. Medicare has no written LCD (local coverage determination) for ventilators. So, if you are billing two ventilators, keep in mind that reimbursement for a secondary or back-up mechanical ventilator for a medically necessary mechanical ventilator may be allowed for the following reasons with appropriate documentation in the patient medical record:

• Statement from the prescriber that the consumer cannot maintain spontaneous ventilation for four or more hours; or
• Statement from the prescriber that the consumer requires mechanical ventilation during regular mobility as prescribed in his or her plan of care and needs a second ventilator attached to the wheelchair or mobility device; or
• Statement from the supervisor of the emergency team(s) responsible for serving the consumer’s address that the emergency medical team estimated response time is more than two hours.

When billing for two vents, use the NTE field to note the reason for the second ventilator. Sometimes the NTE is missed during claim processing and a CO18 denial is received. If you receive a CO18 denial in this situation, perform a redetermination stating the reason why the second ventilator is necessary and provide additional documentation based on the reasons described.

Based on analysis of claims for high-dollar codes — those where the total amount paid exceeds $500,000 during a three-month period — processed for RemitDATA customers during the second 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 [email protected].