A6243 Hydrogel Dressing

According to analysis by RemitDATA, the A6243 — hydrogel dressing, wound cover, sterile pad, each — has an overall denial percentage of 19.4. To help reduce this high denial rate, providers need to analyze what’s going on with their A6243 claims.

One of the main reasons for denial of this HCPCS code is the COB15: The authorization number is missing, invalid, or does not apply to the billed services or provider. This denial reason code applies to supplies that were delivered and billed to Medicare while a patient was receiving services from a home health agency (HHA). To reduce this denial, look at how you are processing surgical dressing orders and gaining information about who is involved in the care of the patient.

HME intake staff need to understand that surgical dressings fall under the home health prospective payment system. Under the PPS, an HHA must bill for all home health services except DME. The law requires that all home health services paid on a cost basis be included in the PPS rate, so it will include all nursing and therapy services, routine and non-routine medical supplies and home health aide and medical social services. An HHA is responsible for billing Medicare for all supplies that are categorized as surgical dressings, urological and ostomy while the patient is under their care. If a supplier bills for these products and the patient is under the care of an HHA, then the supplier would receive a B15 denial code with a remark code of N70 (consolidated billing and payment applies).

Your intake personnel must ask whether the patient is utilizing home health services upon referral, especially when the referral is received from a wound clinic, hospital, rehab facility or nursing facility. Those types of facilities usually discharge patients who require the services of an HHA.

Note, however, that when asking a patient or caregiver if an HHA is involved in the patient’s care, they may not understand the meaning of “home health agency” or “HHA.” If that is the case, the intake employee will have to ask more creative questions to determine whether home health is involved. If an HHA is assisting with care for the patient, then you need to notify that HHA that all dressing supplies will be billed to the HHA due to PPS.

Training intake personnel on PPS and the HHA connection, as well as going the next step in gaining the information, should help in the reduction of your COB15 denials for A6243.

Based on anlysis of Medicare claims for RemitDATA customers during the fourth quarter of 2010. The average DSO for A6243 claims is 43 days. Source: RemitDATA, 866/885-2974 or 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].