Teamwork and Training

The leaves’ colors changing to beautiful reds, yellows and oranges signals the fall season. Winter follows and with it come increases in respiratory conditions in the people we serve. This month we will look at the E0570 nebulizer with compressor. This HCPC carries with it an average denial rate of 14.1 percent, according to our friends at RemitDATA. In previous articles we have reviewed how to work through the top two denials that are attributed to the E0570. Those denials are, first, number 109 (incorrect payer/contractor), and second, number 18 (duplicate claim). This month we will focus on how to work the third-highest denial reason code.

The number-three denial code is 50 (noncovered item because it is not deemed medically necessary). The 50 denial is most often related to the diagnosis code. The nebulizer LCD (Local Coverage Determination) ties the diagnosis code with the medical reason for the medication that needs to be used with the nebulizer. If the medication is not medically necessary, then the nebulizer is not medically necessary. If providers fail to bill with a diagnosis code that’s listed in the LCD and is associated with the medication, then the organization will receive a 50 denial. The LCD is very specific in the listing of the ICD-9 code and the HCPC of the medication. Billers and intake personnel need to be trained on this fact and reference the LCD to ensure that the patient meets the medical necessity requirements. These combined efforts will assist in preventing the 50 denial code. You will find an example of how the LCD ties the HCPC to the diagnosis code in the table on this page.

Verification that the diagnosis code matches the medication prescribed should be initially completed by intake personnel at the time of the referral. If there is a Quality Assurance (QA)/Confirmation employee in your organization, that person can check the diagnosis and medication HCPCS codes before confirming the order and moving the claim to the next step in the billing process. The third check is through the billing edit/review process before claims are uploaded to Medicare. Billers would review the claims for the codes as well. With two to three review processes within an organization, this denial should reduce dramatically.

However, the key to decreasing the 50 denial is training on the front end. Providing the intake team with access to the LCD and support to help them understand its guidelines is crucial in helping them guard against future denials.

If you receive this denial send the claim to redeterminations with documentation to support the medical need within 120 days of the receipt of the initial determination notice. This seems like a long time, but many suppliers wait too long and miss the deadline.

One obstacle to filing the redetermination within that time frame is obtaining the documentation from the patient’s medical record. Establishing good contacts within those prescribing medical facilities and possibly obtaining the documentation prior to dispensing the equipment are ways to facilitate your ability to file the redetermination and overturn denials.

Working as a team with regular training, establishing intake protocol and addressing denials in a timely manner will improve cash flow and result in decreased denials.