Wiki DME denials

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Lynda Wetter

Lynda Wetter

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I am having a hard time getting paid on any DME claims we file.
For example a reib belt when a fracture is confirmed. Or an ankle air brace when there is an injury.

Any help or advice is gretly apreciated. Thanks
 
Yes filing with the apropriate DME carrier. The denial reason is "invalid modifier or a required modifier is missing"
Someone suggested KX modifier but I do not have experience with that. ANd the laterality modifier alone is not sufficent.
And for example code L0140, crvical collar the LCD's have the 59, EY, GA, GW, RA & RB modifiers are the only applicable modifiers. None of them seem applicable.

Thanks for your help.
 
The KX modifier is probably correct, it is stating you have appropriate documentation on file to support the medical necessity for the DME product. KX modifier indicates that the provider has written this order, it was used to order the equipment/drugs/supplies needed to treat the patient. This order must be kept on file by the supplier and made available to the carrier on request. This should indicate the diagnosis/reason for the equipment/medication and the date, the provider's signature as with any other order.
I also found this: KX: SPECIFIC REQUIRED DOCUMENTATION ON FILE. (EFFECTIVE DATE 7/1/2002)This modifier may be used to indicate that specific required documentation is on file in the patient's medical record. Documentation must be submitted upon request. Applicable policies include: Manual and power mobility bases and accessories, Glucose monitors & supplies, PAP devices and accessories, Respiratory Assist Devices (RAD), Commodes, Hospital beds and accessories, Therapeutic Shoes for Diabetics, Heavy duty walkers, Urological Supplies, Epoetin, Support surfaces - Groups 1, 2, and 3, Refractive Lenses - Anti reflective coating, tint, and oversize lenses, polycarbonate lenses, Cervical Traction devices - Codes E0849 and E0855, External infusion (insulin) pumps, High Frequency chest wall oscillation devices, Nebulizers (Brovana or Perforomist) - J7605 and J7606, Negative Pressure Wound Therapy, Patient lifts - E0636 and E1035, Speech generating devices, Wheelchair seating, Orthopedic Footwear, Home Dialysis supplies, Oral Antiemetic - J8502 and J8540.

I hope this helps!!
 
CO denial

I work as a DME biller specifically and while I do not have more complete answer not seeing the EOB or claim in question, I do know that you may get the run around without knowing the real reason for the denial. I have hit that before. For example, I have a patient who has monthly enteral and trach supplies. They denied all the trach supplies for a while, using CO denials, nothing specific, they would say something like this beneficiaries benefit plan doesn't cover (yada yada). When I was handed it to work on, I discovered there were no diagnoses validating the need for trach supplies. I adjusted it, resubmitted it and it went through. If there is ever anything that stumps me, I start at the beginning and work through to the end. Sometimes over and over. I also advise a lot of reading, not just on Medicare, but all the other companies you may handle. I would also suggest always checking same or similar and whether or not patient is in home health before finalizing any claims to ward off any potential denials before they happen.
Happy Billing,
Michelle
 
DME question for Michelle E.

Hi, I have a question that you might be able to answer. I was told by another coder/biller that when billing a non-covered item to Medicare, use this code: A9270GY . Then when the Medicare EOB is received, bill the secondary Medicaid plan with E0240NU for the same item. The Medicaid plan doesn't want to pay because the code has been changed and doesn't match what was billed to Medicare. I am having trouble finding any guidance about this billing scenario, from any source! Are you able to point me in the correct direction?

Thanks
 
Have you checked the carrier's LCD? Some not all DME's have LCDs and I've found them very helpful when trying to determine what is required to receive payment. Some are only covered when certain conditions are met and some are not covered at all no matter what the diagnosis is.
 
you need an ABN and only for the items you can almost be assured will be denied but patient wants it anyway. In typical Medicare fashion, all claims need a KX because that tells Medicare the supplier has all paperwork in patients file. All paperwork needs to include the original encounter form that precipitated the need for the item, the detailed written order which needs to have that specific item on there with the physician NPI, delivery confirmation ticket and CMN (if required). A lot of times Medicare will come back and audit a rental claim after the first month and ask for all these forms that will uphold the KX status. For that reason, I do not submit claims until I have all that paperwork in the chart.
 
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