NHIC, the Jurisdiction A DME MAC, has informed suppliers that it
has identified many Medicare beneficiaries who have received
diabetic supplies that exceed the policy's utilization amounts.
Denials for overutilization are identified with the denial code
CO151 - Payment adjusted because the payer deems the information
submitted does not support this many/frequency of services.
The policy recognizes that there could be occasions when a
beneficiary may require greater than expected amounts. However,
providers need to be aware of the policy limits and when to get an
ABN (Advanced Beneficiary Notice). To avoid these denials, make
sure your intake/customer service personnel are trained on the
limits and on ABN requirements. They need to inform the patient of
the overutilization, obtain a signed ABN and notify billing/medical
documentation employees to get the patient's medical records to
prove the medical necessity of the extra supplies.
According to the local coverage determination for diabetic
supplies, here are the allowed amounts:
- Insulin treated group, indicated by the KX modifier, at 100
strips/lancets per month (300 per three months); and - Non-insulin treated group, indicated with a KS modifier, at 100
strips/lancets per three months.
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. She can be contacted at 419/448-5332 or sarahhanna@bright.net.
Across the four Medicare jurisdictions for claims with
diabetes-related HCPCS codes, the denial rate jumped from 8.5
percent in the year's first quarter to 11.8 percent in the second
quarter, based on analysis of 1,279,711 such claims adjudicated by
the DME MACs and processed for Remit DATA customers from
January-June, 2008.
Source: RemitDATA, 866/885-2974, www.remitdata.com
