Tools and Tips
- By W. David Yates, Roger E. Meiners
- Oct 01, 2005
The following is a Medicare denial cheat sheet outlining the more common denials received from the DMERCs and suggested strategies for dealing with denials.
1. CO-16 Claims/service lack information that is needed for adjudication.
Resubmit claim with a complete HAO (narrative) record.
Example One: If you are billing K0108, which is a miscellaneous code, you will need the make, model, manufacturer, MSRP and the medical necessity of the item entered into the HAO record.
If you are billing an E0910, hospital bed trapeze bar, and Medicare does not have a record of a hospital bed on file, you will need to add a HAO record--see information needed in Example One. You will need to prove medical necessity if Medicare does not have the main piece of equipment on file.
You also will get this denial if the CMN is missing information or illegible. Obtain a corrected CMN if needed, or verify that the information on the CMN was entered completely. If you sent the CMN hard copy, you will need to obtain a legible CMN.
Resubmit the claim: Technical denial.
2. CO-B17: Payment adjusted because this service was not prescribed by a physician, not prescribed prior to delivery, the prescription is incomplete or the prescription is not current.
Call DMERC customer service to find out why the claim is being denied. If the initial CMN is not on file, the claim needs to be resubmitted with the initial CMN.
If Medicare is requesting a revised or recertification CMN, check the LON on the CMN to see if a revised or recertification CMN is needed. Customer service needs to be contacted for the initial date on file if there may be a previous provider.
For the above two cases, resubmit the claim: Technical denial.
If the claim is denied for falling outside of the 15 months of the CMN (for capped rental items), contact customer service for the initial date on file and the name and phone number of the previous provider. Then contact the previous provider to obtain a copy of the pickup ticket. If there was at least a 61 day or more break in service, a Medicare Written Adjustment Request Form should be completed stating why the previous equipment was no longer needed and how the patient?s condition deteriorated to the point that the equipment was again required. A copy of the pickup ticket needs to be submitted with the Written Adjustment Form.
3. PR-22: Payment adjusted because this care may be covered by another payor per coordination of benefits.
Call the patient to verify if Medicare should be secondary. Also verify the primary insurance information. If Medicare should be secondary, bill the patient?s primary insurance. If the patient states that Medicare should be primary, he or she should contact Medicare to update the information.
Resubmit to Medicare only if the problem has been corrected.
4. CO-50: Non-covered services because it is not deemed a medical necessity by the payor.
Does the diagnosis submitted with the claim qualify the patient for the supply or equipment? Certain items require a specific diagnosis. Check the Medicare Manual for coverage criteria for the item.
If the diagnosis does not qualify the patient for the item, obtain something in writing from the physician verifying the qualifying diagnosis to be submitted with your Re-determination.
If the denial is for something other than the diagnosis, call Medicare and speak with a customer service representative. Ask why the claim was denied and what additional documentation is needed.
Then submit your additional documentation to Re-determination: Non-technical denial.
5. CO-57: Payment denied/reduced because the information submitted does not support this level of service, this many services, this length of service, this dosage or day's supply.
Call DMERC customer service to find out why the claim is denying.
If the denial is for the same or similar, ask for the initial date on file with Medicare, and the name and phone number of the previous provider. Contact the previous provider to obtain a copy of the pickup ticket. Contact the patient to obtain the medical necessity for the previous equipment, why it was returned and the medical necessity for the current equipment. Complete a Medicare Re-determination Request Form with this information and attach a copy of the pickup ticket. If the equipment was previously purchased and has not met its maximum lifetime expectancy of five years, obtain a letter from the patient stating what happened to the previous equipment, such as being stolen, lost or broken beyond repair. Submit a Re-determination Request Form with a copy of the patient letter.
If denial is for down-coded equipment (K0003 billed and Medicare allowed payment for a K0001 as Question 8 on the CMN is answered Y), the patient is not responsible for the difference in charges between the equipment billed and the equipment on which Medicare allowed payment.
If denial is for overutilization, find out what quantity is allowed per month. If the documentation on file proves medical necessity for a greater quantity, submit the documentation to Medicare Re-determinations to try to obtain additional payment. If there is no documentation supporting the additional quantity, the difference will need to be written off.
These denials are always sent to Re-determination ? Non-technical denial.
6. CO-96: Non-covered charges
This denial indicates that accessories were billed before the main piece of equipment was billed to Medicare. For example, a CPAP accessory was billed before the actual CPAP was billed.
Resubmit the accessory after you have billed and received payment for the CPAP.
You may also receive this denial if Medicare does not have the main piece of equipment on file. Provide Medicare with the information regarding the main piece of equipment make, model, manufacturer, serial number, who purchased the main equipment, date of purchase and the supplier's name.
If Medicare does not have main piece of equipment on file, you will need to prove medical necessity.
The claims must go to Re-determination: Non-technical denial.
7. PR-96: Non-covered charges
This denial indicates that the item is non-covered by Medicare. Submit charges to the secondary insurance, and then to the patient if the secondary insurance does not reimburse.
This article originally appeared in the October 2005 issue of HME Business.
About the Authors
W. David Yates, Ph.D., CSP, CHMM, is the Corporate Safety Manager for Bodine Services of the Midwest, a leading industrial maintenance company serving Illinois, Indiana, Iowa, and Kentucky. For further information, call 217-428-4381.
Roger Meiners, Ph.D., is a professor of law and economics at the University of Texas at Arlington. He is a senior associate of the Political Economy Research Center (PERC) in Bozeman, Montana.