Documentation woes are surfacing across all product categories.
The need to prove the medical necessity of the equipment and
supplies you provide is high priority when your claims are under
scrutiny by Medicare auditors.
For example, the Jurisdiction A DME MAC completed a prepayment
review of nebulizer claims (E0570) based on the local coverage
determination in November 2010. Of 211 claims that were evaluated
from 101 suppliers, the DME MAC found a 67.7 percent claim denial
rate. According to RemitDATA, the overall denial rate on such
claims that go through and are not audited in detail is 15 percent.
But if all the claims were scrutinized at the same level as in the
prepayment review, the denial rate would increase considerably.
You need to pay close attention to the reasons for denial of
your claims based on clinical documentation. Obtaining
documentation prior to dispensing and/or billing is going to become
the new norm as more and more providers fall prey to the various
auditing bodies and their decisions, which can lead to devastating
take-backs.
The problem is counting on physicians to know how to chart based
on the various LCDs. This means you usually don't know what is in
the charts until it is too late and the audit is in full swing, so
you are relegated to notes that may not meet compliance in the eyes
of the auditors.
Based on the review of documentation received in the
Jurisdiction A prepay review of nebulizer claims, the primary
reasons for denial were:
Insufficient clinical documentation in medical records to
support medical necessity:
- No reference to payable diagnosis or condition requiring
nebulizer use; - No physical findings on exam justifying use of a
nebulizer; - Documentation states patient is no longer using nebulizer by MD
advice or non-compliance; - Documentation focuses only on other medical issues unrelated to
nebulizer treatment; - Physician did not sign clinical documents, exam reports or
progress notes.
No medical records were received with the claim for clinical
review.
No proof of delivery to support the item ordered was received by
the beneficiary.
No detailed order was available, or the detailed order received
was incomplete, i.e., no patient name, no MD signature, incomplete
description of the items ordered and orders undated.
The information you receive from your DME MAC about the findings
of prepayment probes should serve as checklists for what to
evaluate when qualifying a patient into admission. This will ensure
that you have the appropriate information in your charts to be
prepared in case of an audit. If you ask any provider who has
survived an audit whether they get clinical documentation up front,
their answer would be a resounding “Yes.” Take
the advice of those who have gone before and get that information
before it's too late.
Based on analysis of 5,217,235 Medicare claims processed for
RemitDATA customers during the second quarter of 2010. Source:
RemitDATA, 866/885-2974,
target="_blank">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 sarahhanna@bright.net.
