Incorrect Billing of DME Devices

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

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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

 

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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

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