April 22, 2014

Incorrect Billing of DME Devices

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RAC Region C contractor Connolly posted two automated reviews for Durable Medical Equipment (DME) providers on April 8, 2014, regarding Mechanical In-exsufflation Devices, High Frequency Chest Wall Oscillation Devices, and Urological Supplies.

Per the contractor’s description of these issues, overpayments were identified where ICD-9 codes were not in accordance with billing requirements outlined in Local Coverage Determinations (LCD) for DME devices.

Mechanical In-Exsufflation

HCPCS CODES

Group 1 Codes:

A7020

INTERFACE FOR COUGH STIMULATING DEVICE, INCLUDES ALL COMPONENTS, REPLACEMENT ONLY

E0482

COUGH STIMULATING DEVICE, ALTERNATING POSITIVE AND NEGATIVE AIRWAY PRESSURE

ICD-9 Codes that Support Medical Necessity

Group 1 Paragraph: The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Coverage Indications, Limitations and/or Medical Necessity” for other coverage criteria and payment information.

Group 1 Codes:

138

LATE EFFECTS OF ACUTE POLIOMYELITIS

335.0 - 335.9

WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

340

MULTIPLE SCLEROSIS

344.00 - 344.09

QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

359.0

CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1

HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

359.21

MYOTONIC MUSCULAR DYSTROPHY

359.71

INCLUSION BODY MYOSITIS

High Chest Wall Oscillation

HCPCS CODES

Group 1 Codes:

A7025

HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM VEST, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

A7026

HIGH FREQUENCY CHEST WALL OSCILLATION SYSTEM HOSE, REPLACEMENT FOR USE WITH PATIENT OWNED EQUIPMENT, EACH

E0483

HIGH FREQUENCY CHEST WALL OSCILLATION AIR-PULSE GENERATOR SYSTEM, (INCLUDES HOSES AND VEST), EACH


 

ICD-9 Codes that Support Medical Necessity

Group 1 Paragraph: The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Coverage Indications, Limitations and/or Medical Necessity” for other coverage criteria and payment information.

Group 1 Codes:

011.50 - 011.56

TUBERCULOUS BRONCHIECTASIS UNSPECIFIED EXAMINATION - TUBERCULOUS BRONCHIECTASIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)

138

LATE EFFECTS OF ACUTE POLIOMYELITIS

277.00

CYSTIC FIBROSIS WITHOUT MECONIUM ILEUS

277.02

CYSTIC FIBROSIS WITH PULMONARY MANIFESTATIONS

277.6

OTHER DEFICIENCIES OF CIRCULATING ENZYMES

335.0 - 335.9

WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED

340

MULTIPLE SCLEROSIS

344.00 - 344.09

QUADRIPLEGIA UNSPECIFIED - OTHER QUADRIPLEGIA

359.0

CONGENITAL HEREDITARY MUSCULAR DYSTROPHY

359.1

HEREDITARY PROGRESSIVE MUSCULAR DYSTROPHY

359.21 - 359.29

MYOTONIC MUSCULAR DYSTROPHY - OTHER SPECIFIED MYOTONIC DISORDER

359.4 - 359.6

TOXIC MYOPATHY - SYMPTOMATIC INFLAMMATORY MYOPATHY IN DISEASES CLASSIFIED ELSEWHERE

359.89

OTHER MYOPATHIES

494.0

BRONCHIECTASIS WITHOUT ACUTE EXACERBATION

494.1

BRONCHIECTASIS WITH ACUTE EXACERBATION

519.4

DISORDERS OF DIAPHRAGM

748.61

CONGENITAL BRONCHIECTASIS

 


Urology Supplies

Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in that beneficiary within three months. Specific documentation requirements are also in this LCD for intermittent catheterization.

For HCPCS code A4336:

Group 1 Codes:

625.6

STRESS INCONTINENCE FEMALE

ICD-9 Codes that DO NOT Support Medical Necessity 

Paragraph: For the specific HCPCS codes indicated above, all ICD-9 codes that are not specified in the preceding section.

N/A

RAC Issues for the Week of April 21 – April 25, 2014:

RAC Region C Connolly

DME

  • Incorrect Billing of DME Devices - CGS_C000392014 - Overpayments were identified where ICD-9 codes were not in accordance with billing requirements outlined in Local Coverage Determinations for DME devices.

  • Incorrect Billing of DME Supplies - CGS_C000422014 - Overpayments were identified where ICD-9 codes were not in accordance with billing requirements outlined in Local Coverage Determinations for DME supplies.

About the Author:

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding, with an emphasis on clinical and regulatory guidelines for Medicare, Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article go to editor@racmonitor.com

Margaret Klasa, DC, APN, Bc

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