CO35 Lifetime benefit maximum reached

This month we look at the ever-discouraging and challenging CO35 denial: lifetime benefit maximum has been reached. This code states that Medicare has paid for the maximum 13 rental months for the patient’s capped rental equipment — and you cannot bill for any more rentals.

It is possible in this situation that the patient previously received the same piece of equipment from another provider. If so, Medicare would have paid a number a months in the 13-month capped rental period to that provider, so the current provider would not receive all 13 monthly payments.

Call customer service to determine which month was the 13th month according to their records. The capped rental months should be adjusted in your software system to reflect this information.

If the patient’s condition has changed and he or she needs the equipment for a different medical reason as documented in the medical record, then Medicare will restart the capped rental period for the new equipment and allow the current provider to bill for all months of the cap. With this scenario, however, there has to be a break of more than 60 days along with the new medical condition, and providers would request a new initial start date. If the patient’s condition did not change, then the capped rental period will not be restarted; the new provider will be paid only for the remaining months.

These CO35 denials will need to be sent to your DME MAC’s Redetermination department.

Based on analysis of 3,680,443 claims adjudicated by the Medicare contractors between July 1, 2006, and Sept. 30, 2006, and processed for RemitDATA customers. Source: RemitDATA, 866/885-2974, www.remitdata.com.

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 [email protected].