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We + DME/ HME Providers = Pioneers inOutcomes-Based Billing

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Extend Your Team through INUS

If you have better things to do other than reading lengthy Medicare Billing manuals, our rangeof DME billing service can help. If you are talking to yet another customer service personasking why your claim has not been paid, let us help.

It’s our mission to help respiratory equipment providers and other DMEs prosper in the newera of value based care. Our experts helps you to handle the Patient and PayerAuthorizations, Verifications, Billing, Coding, Cash Posting and Collections, who are available24/7 to meet your needs.


DME Billing Service Overview

Inus billing team has experience processing claims in the following areas:

Oxygen and Respiratory EquipmentPAP (Positive Airway Pressure) – CPAP / BIPAPEnteral Nutrition and Parental NutritionMobility EquipmentWheelchair-ScooterDiabetic Supply & Diabetic Shoes

Major areas on which several check points been initiated arePre-Coverage Criteria Appropriate usage of Codes Sales Order Entry

Verification of Delivery Ticket, Purchase Order, AOB, Physician Order ( Accurate CMN and/ orPrescription, Title XIX, Detailed Written Order ) on File before the submission of each and everyclaim

Reduces 35 % of the Denials


Eligibility Verification& Initiate

AuthorizationFast & Immediate EVresponse & along with

Same-Or-Similar check tomake sure the Medicare

Patient hasn’t received theproduct recently.

Authorization is dulyinitiated for commercial

payers. If the Patient is noteligible , or had similar

product recently, orauthorization not on file, thefirst trigger point comes into

play.

Sales Order EntryThe second trigger point

comes into play at the timeof entering a Sales

Order, when Certificate ofMedical Necessity (CMN) or

DME Information Form(DIF) is invalid. An

immediate escalation wouldbe sent to the provider to

stop order delivery orconfirmation if data is

missing, delaying claimsubmission until validdocument is available.

Documentation AuditAfter successfulEV, Benefits and

Authorization initiation, thereis the third trigger point

indicating the manual run orcheck point on DT, CMN

and/or Prescription orDIF, Sleep Laboratory andPolysomnography Reportwhichever required for the

case before claimsubmission.

Three Tier Trigger Points


Gap Analysis Between Pre Inus and Post Inus

1.8265%

0.518%

0.3111%

0.176%

Collectible AR 90+ days -Total Value $2.8 Million ( Federal Payers )

CO 50, CO 4

CO 151

CO 96

Others

Pre Inus

Major Denials

Note : Pre Inus, the Client had a lot of AR piled up in 360+, about 65 % of AR was in 90+. After analyzingfound CPAP is most frequently billed item. Out of the 65% in 90 + days, the major denials had beensegregated with appropriate percentages as shown above.


Invalid Diagnosis Code

Missing Documentation

Invalid Capped Rental Modifiers

CO 50

CO 4

Same/Similar ProductCO 151

CO 96 Non Covered Items

Causes for Denials

327.23 for CPAP and 327.27 for BIPAPshould be appropriately billed

Delivery Ticket, Initial face to face evaluationnotes , CMN, PSG, Detailed written order, Face toFace Re-evaluation notes, Titration testreport, Compliance report and Plan of Care. Allthe above documents should be mandatory on fileto avoid any suspension or VOID during MedicareRAC audit .

For the 1st month rental claim should be billedwith RR, KH, KX. 2nd & 3rd month claim shouldbe billed with RR, KI, KX. From the 4th monthand for rest of the months claim should bebilled with RR, KJ, KX.

A equipment can be replaced only once in every5 years. Henceforth the denial occurs If thepatient had acquired same or similar equipmentduring the course of time. A complete andthorough verification needs to be done during EVstage to emphasize on accurate billing.

An effective HCPCS payer mapping, GAmodifier and ABN validations needs to bedone to avoid these denials on a longer run.

Precautionary Measures


Blue Cross versus Other Commercial Payers

Blue Cross Other Commercial Payers

Horizon NJ, IL pays 3 months rentals withcompliance for CPAP and 4th month asPurchase.

UMR pays 2 months rental and 3rd month asPurchase.

Generally other state plans of Blue Cross pays10 rentals for CPAP.

Aetna will pay only as Rental for CPAP and willpay for 10 rentals.

KX modifier is must when we file for CPAP toBCBS of NJ.

For all commercial payers, Authorization ismandatory for PAP and Oxygen & Respiratoryequipments.

The DME provider must participate with the BluePlan in the state where the DME supplies arebeing purchased or shipped in order to processat the In- Network level of benefits.

Most of the commercial payers pay humidifiersas Purchase when we bill with NU modifier.

Horizon NJ does not accept 3 months supplies. Few Commercial payers pay CPAP/BIPAP as astraight away purchase unlike Blue plans orfederal payers.

If the state plan pays CPAP only for 3 monthsrental, then we need to bill the 4th month asPurchase along with Authorization.

Coventry pays PAP for 15 month rentals.


Impact of trigger points on denials

How trigger points arrest major federal denials ?

First trigger point: Once the provider prescribes the equipment, the account will be immediatelyforwarded by the front office executives to our EV team. Our EligibilityVerification team needs to undergo three level check points under the firsttrigger successfully for the Provider to do further follow up on the particularpatient.

Eligibility inclusive of coverage on supply items.Same or Similar Check for Medicare Patients.Authorization check on file for Commercial Payers.

If any of the above check points is not met i.e. Patient not Eligible / Patient hadsame or similar product recently, immediate trigger will be escalated to theProviders office.

Arrest majority of CO 151 and CO 96denials

Second trigger point:

Arrests majority of CO 50 denials

After necessary EV and Authorization engagements, our front end billingpersonals need to undergo three level check points under the second triggerbefore forwarding the essentials to the Claims transmission team.

Validate CMN / DIF on file.Authenticate Delivery Date or Date of Service (DOS) not to precede the

“Initial Date” or DIF or the start date on the written order.Validate the medical necessity of the item billed by ensuring the Delivery

Date/Date of Service to be within 3 months after the “Initial Date” of the CMN orDIF or 3 months from the date of the physician’s signature.


Third trigger point : Why CO4 denial occurs? The major reason behind this denial is due to missingcapped rental modifiers.How? This majorly occurs in the fourth month rental and usage of KJ modifier.After first 3 months rentals, our billing personals undergoes two mandatorycheck points under this trigger before forwarding the essentials to Claimstransmission team.

Face to Face Re-evaluation notes.Compliance report.

The above check points needs to be met before the Claim is transmitted withKJ & KX modifiers for the fourth month rental and for rest of the months.

Eliminates CO 4 denials for the last 8monthsBrings down CO 50 to the minimal

Other federal denials which are kept in check :

CO 173 – No CMN on fileCO 176 – Invalid CMN / Prescription is not currentPR 16 – ABN modifierCO 97 – Inclusive / Patient in SNFCO B15 – Patient in Hospice


Gap Analysis Between Pre Inus and Post Inus

Post Inus

Collectible AR 90+ days -Total Value $1.1 Million

0%

5%

10%

15%

20%

25%

30%

35%

CO 4 CO 151 CO 50 CO 96

Pre InusPost Inus

With the use of three tier trigger points, AR aging was drastically reduced, especially 90+ AR days was brought down from65% of total AR to 15 % ( Value of $1.1 Million ) in the last eight months. One of the major denial CO4 (Invalid CappedRental Modifier) was totally eliminated and the other major denial CO50 was brought down to minimal during Post Inusperiod. HCPCS Payer Mapping played a significant role in reducing Non coverage denials.


Enteral Nutrition

Two major billable codes are B9000 (Enteral Nutrition Infusion Pump – Without Alarm) andB9002 (Enteral Nutrition Infusion Pump – With Alarm)

Collectible AR 90+ days – Total Value $2.2 Million ( Federal Payers )

32%

21%

17%

11%

CO 50/ Remark Code N115

CO 151/ Remark Code N362

CO 176

CO 109

Major Denial Codes

Above percentages were derived through Pre Inus aging reports. Also note that Claims can be denied for multiplereasons therefore the percentages of reviews may not add upto 100%. Based on review of the report received, thefollowing are the primary reasons for the denial.

Clinical Documentation IssuesDetailed Written Order IssuesDME Information Form (DIF)


Detailed Analysis behind primary reasons

DME Information Form (DIF)

6 % of the denied claims were missing a DIF. 1 % of the denied claims were missing Enteral PumpHCPCS Code on the DIF.

Detailed Written Order Issues

16 % of the denied claims did not include a detailedwritten order.

8 % of the denied claims had date of the detailedorder was incomplete / physician signature could not

be authenticated.

Clinical Documentation Issues

26 % of the denied claims did not have any medicalrecord documentation submitted.

17 % claims had insufficient clinical documentationto justify the LCD criteria.

Apart from the above reasons, there are quite few claims which were denied for no Proof of Delivery (POD) orIncomplete delivery information. With Three Tier Trigger Points System, all the major denial reasonswere eliminated.


Other Enteral Nutrition Billable Codes

Some of the other billable codes are B4149, B4150, B4152, B4153, B4154, B4155, B4158 & B4160.

MajorDenials

• CO 16 / Remark Code N64• CO 151 & CO 151 / Remark Code N362

PrimaryReason

behind thedenial

• Date Span / Number of Units – All the claims were denied for missing date span or forinappropriate number of units.

• Medical Documentation does not support the level of service as per LCD guidelines.

Resolution

• For each nutritional code, date span and number of units needs to be manually checked, inreference with LCD under the third trigger point.

• Henceforth through the above initiative, we had brought down the denial to minimal.

If the number of units or date span was a billing/clerical error, we can reprocess the claimthrough Telephone Re-opening Request for Medicare beneficiaries.

For Commercials, we need to follow the unique appeal process for each and every payer.


Power Mobility Equipments

Some of most frequently billed base items are K0008, K0001, K0800,K0816, K0820, K0821 and K0823.

CO 50 / Medically non necessary

31 % of the denied claims hadinsufficient clinical documentation

to meet the General CoverageCriteria as outlined in LCD.

With the 3rd trigger point, thedenial was drastically brought

down since all items will undergoa manual run or audit on the

documentation before the claim issubmitted.

CO 150 / Remark Code N115

19 % of the denied claims werefound to be decoded from Power

Wheelchair to StandardWheelchair and had been theprimary reason for the denial.

The 2nd trigger point helps tovalidate the medical necessity with

support documentation. Thismeasure has brought down the

denial to minimal.

CO 176

This denial majorly occurs whenwe bill the claim outside of the end

date on a CMN, which could bethe end of capped rental period.

Mostly it occurs when we bill theitem continuously for 12 rentals &we did not bill for the subsequentmonth as the beneficiary was in aSNF. Anticipating this denial, EV

team submits the claim withnarration to increase the rental

period under the 1st trigger.

Major Denials / How we arrest the denials in conjunction with 3 Tier Trigger System

Note : Above numbers or facts derived through a review of 90 claims submitted Pre Inus. FoundAdditional Documentation Request (ADR) were not met for 28 (31%) of the claims. For the remaining62 claims for which requests sent, 12 of the claims were allowed and 50 of the claims were denied.


Oxygen and Oxygen Equipment

Upon review of 1195 claims submitted during Pre Inus, found HCPCS E1390, E0431 and E0439 are frequently billeditems. Below percentages were derived through Pre Inus aging reports. Also note that Claims can be denied formultiple reasons therefore the percentages of reviews may not add upto 100%.

32%

21%

17%

11%

CO 50

CO 35

CO 176 / Remark Code M60

CO A1 / Remark Code N370

Collectible AR 90+ days – Total Value $3.1 Million (Federal Payers)

Major Denials

Note : Out of 1195 claims, found Additional Documentation Request (ADR) were not met for 602 (50%) of the claims. For the remaining593 claims, 175 claims were allowed and 418 claims were denied resulting in a claim denial rate of 70 %.

As the denial percentage was sky high, a lot of analysis and proactive measures were put in to bring down thedenial percentage to minimal. All the ADR’s (Additional Documentation Requests) were first segregated and trackeddown the primary reasons behind the denials.


CO 50 / Medical Necessity /Missing Documentation

Major reasons are missingdetailed description of the item inthe written order and initial CMN

not on file or invalid.

With the 3rd trigger point, thedenial was drastically brought

down since all items ordered willundergo a manual run or audit onthe clinical documentation before

the claim is submitted.

Primary Reasons Behind The Denials / Align 3 Tier Trigger System to Workflow

Oxygen and Oxygen Equipment

CO 35 / Lifetime MaximumBenefit Met

This denial occurs when all 36months of rentals had alreadybeen paid unless we bill for

replacement oxygen.

With the 2nd trigger, our OrderEntry team completely validates

the necessity behind thereplacement and would generate asales order only when a new initial

CMN is on file. Claim will besubmitted with RA modifier to

indicate the replacement.

CO-A1 / Remark Code N370

It occurs when there been anybreak in medical need or the

same equipment beenprovided by another provider.

With Same or Similar checkunder the 1st trigger, item

provided by another providerreason was brought to

minimal. If documentationsupports a break in medical

need, claim will be resubmittedwith narrative info.

CO 176 / Remark CodeM60

This denial majorly occurswhen no recert or revision

Certificate of MedicalNecessity received.

If Oxygen recert CMN isrequired, a trigger or alarmwould alert the Front End

personals and the claim willbe submitted only when

revised CMN is obtained.


Inus’s 5 Phase Audit For Each & Every Claim

All our proactive measures, 3 tier trigger system and strategies have been set up based upon this 5Phase Audit

Our Front EndPersonals can ensureall documentation are

collected as per specificpayers requirements

through Payer Mapping.

Excessive Validationshad been set up in

Payer Mapping whichconsists of HCPCS &

Prompt Documentationfor all payers.

All monthly invoices arelinked to the original

sales order & supportingdocuments. All

documents can beeffectively gathered

incase of audit.

Several Checkpointsbeen installed to trigger

if any document ismissing or

inaccurate, the claimwont be submitted until

the file is complete.

Through well definedprocess and workflowwith checkpoints, all

actions are thoroughlytracked which result in

higher volume ofcleaner claims.

Accurate Intake Validation Set Up Match the Documentation with Billing

Align Document Management to WorkflowThorough Follow-up on All Actions


Few DME Tips and Links……..

Advance Beneficiary Notice ( ABN ) ABN on file ABN not on file

GA modifiershould be

used

GY modifiershould be

used

E0562 ( Heated humidifier )

If Commercial is Primary and Medicare isSecondary, and the equipment is billed as

Purchase, Primary would pay but we need totake a write off for Medicare

PAP

If the equipment is damaged orlost, it can be replaced along

with all new test results.

Use of RA Modifier

If the Patient was done with 5 years andMedicare also paid for 13 rentals and stillPatient needs the equipment, then we canstart afresh again with RR, KH, KX, RA.

E0470 & E0471 ( BIPAP )

If Patient needs to use BIPAP, then there should a CPAPfailure statement on file.


Few DME Tips and Links……..

CMS - Centers for Medicare and Medicaid Services

Department of Health and Human Resources

American Medical Billing Association

NHIC

CGS

NGS

Noridian Medicare

PalmettoGBA

AMA

AHIMA


Send an email to [email protected]

Call us at +1 818 235 5416


mailto:sriram:@inussolutions.com

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Healthcare