The E0277 is in the Pressure Reducing Support Surfaces Group 2
LCD (Local Coverage Determination). Denials for this claim ran 22.7
percent in the second quarter this year, and the top denial reason
code was CO50: “These are non-covered services because this
is not deemed a ‘medical necessity’ by the
payer.”
CO50 denials may be received because the provider has forgotten
to add the KX modifier after the company has received all
supporting documentation of medical necessity for the E0277. If the
denial is due to the missing modifier, billers should take the
claim to reopening and ask to add the KX to the claim and
reprocess.
Another reason for the CO50 denial is that the claim is lacking
the appropriate diagnosis required for the patient to meet the
coverage criteria. This diagnosis needs to be listed as the primary
diagnosis (aka “diagnosis 1”) on the claim.
A portion of the LCD states the following (but make sure to
review your LCD for complete coverage criteria): A Group 2 support
surface is covered if the patient meets: a) Criterion 1 and 2 and
3; or b) Criterion 4; or c) Criterion 5 and 6.
Multiple stage II pressure ulcers located on the trunk or pelvis
(ICD-9 707.02 -707.05).
Patient has been on a comprehensive ulcer treatment program for
at least the past month which has included the use of an
appropriate group 1 support surface.
The ulcers have worsened or remained the same over the past
month.
Large or multiple stage III or IV pressure ulcer(s) on the trunk
or pelvis (ICD-9 707.02 -707.05).
Recent myocutaneous flap or skin graft for a pressure ulcer on
the trunk or pelvis (surgery within the past 60 days) (ICD-9 707.02
-707.05).
The patient has been on a Group 2 or 3 support surface
immediately prior to a recent discharge from a hospital or nursing
facility (discharge within the past 30 days).
In addition to meeting the coverage criteria, providers must
have a Written Order Prior to Delivery (WOPD). Your intake team
should be aware that the WOPD must be received before delivery to
the patient.
Based on analysis of claims for high-dollar codes —
those where the total amount paid exceeds $500,000 during a
three-month period — processed for RemitDATA customers during
the second quarter of 2009. Source: RemitDATA, 866/885-2974,
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.
