In December, the DME MACs were instructed by CMS that they can
no longer make partial payment for claims based on a “least
costly alternative” (LCA) determination. For claims with
dates of service on or after Feb. 4, 2011, the following rules
apply under this new guidance:
1) If the Local Coverage Determination (LCD) currently states
that an item will always be paid based on allowance for the least
costly item (if the criteria for the less costly item are met),
then under the new policy, a claim for that item will always be
denied as not medically necessary (Type 1 LCA denial).
2) If the LCD currently states that an item will be paid in full
if specific additional coverage criteria are met but will be paid
based on the allowance for the least costly item if the additional
coverage criteria for the billed item are not met (and if the
criteria for the less costly item are met), then under the new
policy, a claim for that item will be denied as not medically
necessary if all of the additional coverage criteria for that item
are not met (Type 2 LCA denial).
The claim will be paid in full if the additional coverage
criteria are met.
If a KX modifier is required to attest to the additional
coverage criteria being met, claims without a KX modifier (and with
a GA, GY or GZ modifier) will be denied.
Billers need to be aware of this change so they can gain
additional documentation to prove the medical necessity of the item
being dispensed/billed — and know how to work these denials
when they are received. If a base code for an item of DMEPOS is
denied as not medically necessary, all related accessories,
supplies, additions and drugs also will be denied as not medically
necessary.
Least costly alternative statements are found in the following
LCDs (note that the information may not be all-inclusive, so refer
to each LCD for details): ankle-foot/knee-ankle-foot orthoses;
canes and crutches; cervical traction devices; commodes; enteral
nutrition; external breast prostheses; external infusion pumps;
glucose monitors; hospital beds; knee orthoses; manual wheelchairs;
nebulizer equipment and related drugs; patient lifts; pneumatic
compression devices; PAP devices; power mobility devices;
respiratory assist devices; seat lift mechanisms; surgical
dressings; therapeutic shoes for persons with diabetes;
tracheostomy supplies; urological supplies; walkers; wheelchair
options and accessories; and wheelchair seating.
One thing to be aware of regarding capped rental DME items:
Elimination of LCA determinations will apply only to claims in
which the date of service for the initial rental month is on or
after Feb. 04, 2011. If an LCA determination is made on an item
with an initial rental month DOS prior to that date, subsequent
claims for that item will continue to be adjudicated using the LCA
determination for the duration of that rental period. If an item is
denied in full due to elimination of the LCA, partial payment based
on the LCA will not be possible through the appeals process.
For items that were previously paid based on an LCA
determination, suppliers can receive partial payment at the time of
initial determination if they elect to bill using one of the
upgrade modifiers, GK or GL.
Thanks to RemitDATA, 866/885-2974 or www.remitdata.com,
for supporting data for this column.
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.
