Stay aware of medical coverage changes and what written proof you need upon request.
by Sarah Hanna
July 15, 2014

With the advent of competitive bidding, many providers have changed their focus from traditional DME and respiratory products to supply items. 
However, suppliers need to be aware that the DME MAC’s Medical Review Departments are performing widespread prepayment probes on such items. 
Therefore, you need to be aware of the medical coverage policy for those HCPCS. 
These reviews come in the form of additional documentation requests (ADRs) which most of us are unfortunately far too familiar. 
The Jurisdiction B DME MAC, National Government Services (NGS) performed 
a widespread prepayment medical review of intermittent catheterization kits - A4353, during the timeframe of January 1 through March 31. 281 claims were developed for additional documentation and out of those claims, 245 claims were denied resulting in a claim error rate of 87.3 percent. 
That denial percentage is too high for you to not pay attention to ways to prevent the same denials in your organization. Twenty-seven claims were denied because the requested documentation was not returned within the required timeframe. One of the biggest mistakes suppliers make is not responding to ADRs. 
Many don’t respond due to the fact that 
they discover they do not have the appropriate documentation to prove medical necessity. By not replying you are in 
violation of supplier standard #28, which states the following: “Medicare regulations (42 C.F.R §424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of the Centers for Medicare & Medicaid Services (CMS) or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial or recoupment of a previously paid claim, but also referral to the National Supplier Clearinghouse (NSC) for possible sanctions.” Even if you do not have the information requested in your charts, respond with the documentation that you do have. When the Medical Review Department receives and evaluates your documentation, then the claim will be denied. If you want 
to pursue payment of the claim, this 
could provide you with more time to gain the necessary documentation and then once received you can start the process of appeal. During the NGS probe, the most common denial reasons were associated with coverage criteria. Below outlines the top denial reasons.

  • Failure to meet one of the five coverage criteria outlined within the medical policy
  • No history or documentation to show use of sterile intermittent catheter and an individual packet of lubricant
  • A valid refill request from the beneficiary was not documented
  • Documentation did not show two urinary tract infections within 12 months prior to start of use of A4353

Beneficiaries must have a permanent impairment of urination to meet basic coverage for use of intermittent catheters. In order to qualify for intermittent catheter kits, the beneficiary must meet one of more of the following criteria.

  • The patient resides in a nursing 
facility.
  • The patient is immunosuppressed.
  • The patient has a radiologically documented vesico-ureteral reflux while 
on a program of intermittent catheterization.
  • The patient is a spinal cord injured female with neurogenic bladder who is pregnant (for duration of pregnancy only).
  • The patient had distinct, recurrent urinary tract infections while on a program of sterile intermittent catheterization with A4351/A4353 and sterile lubricant A4332, twice within 12 months prior to the initiation of sterile intermittent catheter kits.

Your staff needs to be well versed in the coverage criteria and understand the documentation necessary to prove medical need. Moving to the supply business may allow your company to dodge competitive bidding for the time being but it doesn’t protect you from the long arm of the auditing bodies. Be proactive and vigilant when evaluating your patient’s medical documentation.