Medicare Compliance & Reimbursement

Avoid denials with this official guidance. If you're getting denied for osteoporosis drug injections, you aren't alone -- and the Centers for Medicare & Medicaid Services has taken note. Problem: Many claims submitted for covered osteoporosis drugs don't provide a date of service that falls within the start and end dates of an existing prospective payment system (PPS) episode, according to a recent MLN Matters article. Medicare outlines three criteria for covering injectable osteoporosis claims: • Patients are eligible for home health services; • Physicians certify that the individual sustained a bone fracture related to post-menopausal osteoporosis; and • Physicians certify that the female patient can't selfadminister the drug and no caregivers are able to administer it for her. That first criterion is where most agencies stumble, CMS says. Crucial: Eligibility hinges on agencies providing the service during the health care episode -- for instance, if the claim contains HCPCS codes J0630, [...]