PR16 Claim service lacks information needed for adjudication

National Government Services, the Jurisdiction B DME MAC, recently addressed issues with claims filing resulting in a PR16 denial code with an M124 remark code. This denial represents equipment that was not paid for by Medicare fee-for-service (only equipment that was paid for by other insurance or by the beneficiary) and supplies that are provided after the patient transitions to Medicare FFS.

For supplies and accessories used with beneficiary-owned equipment that was not paid for by Medicare FFS, all of the following information must be submitted with the initial claim in Item 19 on the CMS-1500 claim form for paper claim submitters or in the NTE segment for electronic claim submitters:

• HCPCS code of base equipment; and,
• A notation that the equipment is beneficiary owned; and,
• Date the patient obtained the equipment.

Example: E0601, Continuous airway pressure device, Beneficiary Owned 01/01/2006

Claims for supplies and accessories must include all three pieces of the information listed. Claims lacking any one of the elements will be denied with the PR16 and a remittance remark code of M124, which indicates the charge is denied because it is missing an indication of whether the patient owns the equipment that requires the part or supply.

In the past, the only course of action providers had to correct these issues was to go through the appeals process. However, on May 8, a change was made to the Medicare claims processing system that allows the opportunity simply to resubmit these claims for payment with the additional information in Item 19 or the NTE segment.

Providers can receive payment quicker if they refile these claims. If you have previously submitted a claim that received this denial to redetermination and would rather resubmit the claim you may do so, as opposed to waiting for a redetermination decision. If you choose to refile your claim(s), NGS will simply dismiss your request for redetermination.

Currently, NGS seems to be the only DME MAC reprocessing these denials in this matter. Jurisdictions A, C and D still require a redetermination. But keep your eyes open for listserv messages from those jurisdictions for any changes. Sometimes when one DME MAC makes a change, the others follow.

Based on analysis of Medicare claims adjudicated by the four DME MACs in the first quarter of 2009, there were 9,350 PR16 denials. Source: RemitDATA, 866/885-2974, www.remitdata.com

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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].