The data has been analyzed, the reports have been completed and the results are in. RemitDATA has provided the information which has given us our product of the month, and the lucky winner is—insert drum roll here—the A7035 headgear used with positive airway pressure device. This product category came in with a 17.9 percent overall denial rate. What amount of money could you bring in if you could lower the denial rate to 10 percent or less? I’m sure it would help the bottom line. So let’s talk about why providers are getting denied on this product. The number-one denial code is 151, service period end.
A7035 is an item that Medicare only allows for the refill to be given once every six months. Monitoring the timing of the refill is important. If the resupply is dispensed more than 10 days prior to the six-month reasonable and necessary timeframe set by Medicare, your claim will be denied with a 151 code. For items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.
Many providers have contracted with an outsource resupply company. These companies assist in following up with patients to determine if they require supplies. Whether your company outsources this function or you are responsible for it internally, you must be aware of the documentation requirements associated with such patient contact. These records will be called upon in the event of an audit.
For items that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between the supplier and beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient. The refill record must include:
Beneficiary’s name or authorized representative if different than the beneficiary
Description of each item that is being requested
Date of refill request
For non-consumable supplies, i.e., those more durable items that are not used up but may need periodic replacement (e.g., PAP and RAD supplies), the supplier should assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. Document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).
The key to reducing the 151 denial is carefully tracking the date of the resupply to ensure that the refill doesn’t occur prior to the 10-day window before the six-month timeframe. Your software system may be able to assist you in the tracking of these dates. Once you determine that the patient does require a new headgear, then you should confirm that you have all of the documentation required to complete the refill to prove the necessity for the new item and that the patient wants the product.