CO 151/PR-151 Denial Guide

Hi All in  this Post We will try to provide you the Information Regarding CO-151/PR-151 Denial . Though , the subject is vast but yet we will try to cover all the possible areas.

The denial usually pertains to Same or Similar/Overutilization, or sometimes to Item Capped out scenarios.

Important thing to keep in mind is the claims with such denial can be resubmitted.

For the rental items with such denials the procedure we follow is same as in case of CO-150/PR-150 already posted earlier.

The only difference is that these denials can be submitted viz for BIB/BIS/BIN scenarios, we can simply resubmit the item with proper NTE notes (PUD in MMDDYY  Previous DX without any decimal in between  DD in MMDDYY  Current DX without any decimal in between).

If there is ABN on file we can simply resubmit the claim with GA modifier appended. Sometimes, for accessories or supplies we need to provide the basic equipment info viz "ABN executed HCPC Code DOP in MMDDYY"

Generally, we recieve this denial on those supplies or accessories wherein there is a specific units, Medicare allow. If we bill the units which exceeds Medicare allowed units, we need to add NTE notes specifying the duration of the supply prescribed for, viz,  A7028 (CPAP supply) is allowed 2 every one month but we billed 6 units, we need to check documents for the prescription, if A7028 prescribed for the duration of 90 days, it means we are billing per Medicare allowed, we can rebill the item with NTE notes "This is a three month or This is the 90 days supply"

A-codes dont require a span date or 'to' and 'from' dates.

Another significant thing is that we have to avoid overlapping in DOS'S billed. If there is an overlapping we need to notify  Store or client concerning the issue. For instance, we billed 6 units on A7028 and we have prescription for three months on file. Our DOS is 01/01/2014, we need to ascertain that there is no billing of the item until after 04/01/2014 such that overlapping can be avoided or refill cycle remain unaffected.

Medicare allowed units for the items can be downloaded on CMS Medicare websites under Medicare unlikely units or MUE,

if we are billing for the number of units beyond Medicare allowed we need to have documentation to take such claims to redetermination as if to justify the exceeding number of units billed.

Such denials when received on Parenteral or Enteral nutrition codes (B-codes), we need to have a look at DIF logged in BT or scanned in Documents, for calculating the allowed number of units or the span for which the code should have been billed. It could be calculated based on the number of calories submitted on DIF. Calculation method is elaborated with examples.

No. of units allowed on B4152 or B4150 = (No. of calories submitted in DIF*No. of days item billed for)/100

No. of days item billed for=(Number of units billed for B4152 or B4150 *100)/No. of calories submitted in DIF

Such denials on Enteral and Parentral nutrition are accompanied with another denial for Allowable Discrepancy. We cant simply adjust off the outstanding balance as allowable adjustment.

If the DIF seems invalid as per the date span or number of units billed, we can task store for revised DIF or can take the permission from client with a Write Off Task ( Approval To adjust the balance) for frequency not supported else these denials can be re-opened over telephone re-openings. We can change the date span or number of units billed over telephone re-openings. Again while re-opening we need to avoid overlapping of dates billed or refill cycle should remain uneffected.

Hope, we will get benefitted from this.

In case of any Query or the new scenarios, feel free to comment.

Co-150 and Pr-150 Denial Guide

Hi All,

In this Post we will try to provide you some information about CO-150 and Pr-150 Denial in Medicare.

Though, the subject is vast but yet we tried our best to cover all the possible areas.

The denial usually pertains to Same or Similar/Overutilization, or sometimes to Item Capped out scenarios.

Important thing to keep in mind is the claims with such denial cant be resubmitted. We'll have to file an appeal to prove item's necessity.

First, we need to ascertain the reason for the denial. Usually Medicare deny SOS when the item is billed/paid prior to RUL, either by our or other supplier. The information could be obtained via IVR, over Same/Similar or CMN status option.

In this case, we need to have HCPC code of the item against which our item is being denied, initial and last paid DOS, number of rentals paid, contact info of the provider paid for the services. Next step would be to check documentation in scanning/BT documents/Medforce.

HCPC code of the item (against which our item is being denied) is needed because in case we appeal, and the item's HCPC codes are different, we'll have to prove why the patient is provided with an upgrade/downgrade or documents relating to Patient's medical condition which made him/her to switch to a different model of the item, now.

If the other provider is involved, item ain't been capped and the provider is no longer billing, we need to have pickup ticket from that provider, delivery ticket from our provider and the documents demonstrating Medical necessity for the item rendered. If the billing of the item is within the BIS/BIN window criteria, that is, the last paid date and the date of service with CO-150 is not within 60 or 90 days, we could file Redetermination to start a new capped rental all over again with Medical necessity documents and documents justifying break in billing.

If the documents are not available, we need to check for ABN, which will indicate that our supplier is aware of SOS item on file and thus have ABN signed. In this case usually we recieve denial PR-150 (if the item is billed with GA modifier appended), we just need to roll down the balance to next payer. If we have ABN on file but we received CO-150 because GA modifier was not appended with the claim, we will have to take the claim to redeterminations with signed ABN. Significant thing is that we can't simply resubmit the denied item with GA modifier as CO-150 denials can't be resubmitted.

If non of the above mentioned documents are not available , Medical Necessity documents and ABN, we need to stop the Sales Order if and only if the billing of other item which is in payable status, billed under the same sales order is not affected. Then raise the task to store for requisite documents.

If the billing of the item is within RUL, item being capped and BIS/BIN is not greater then 60 or 90 days. In this case we need to check for the first DOS our supplier billed, if that claim had a partial reversal which means that item is being paid by Medicare and they are allowing payments for the remaining rentals, we just need to adjust off the balance as Item capped else we need to file redetermination request to indicate what happen to the previously rendered equipment viz it was theft, stolen, lost or beyond repair. Again documents could be requested form store if not available.

These are the most common denial reasons for CO-150.

Hope, we will get benefited from this.

In case of any Query or the new scenarios, Please comment.

Skilled Nursing Facility/Home Health/Hospice Consolidated Billing HCPCS Look-up

Skilled Nursing Facility/Home Health/Hospice Consolidated Billing HCPCS Look-up

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HCPCS Code:

Home Health Consolidated Billing: Skilled Nursing Facility (SNF) Consolidated Billing During Part A Covered Stay*: Hospice:

Enter a valid HCPCS code including one letter and 4 numbers. (Example: A4253) This tool is specific to HCPCS billable to the DME MAC and may not be accurate for items that are billed to the A/B MAC Contractor. * This tool includes items payable during a Part A Covered Stay (typically the first 100 days) in a Skilled Nursing Facility. Additional items are payable once the Part A Stay has ended. To identify which items are payable outside the Part A Stay, refer to the DME MAC A Fee Schedule and check the category field next to the HCPCS. Categories CR, FS, IN, OX, SU, and TE are never payable in a SNF since they are classified as Durable Medical Equipment (DME). Categories OS, PE, PO, SD and TS are separately payable outside the Part A Covered Stay in a SNF. Created By Ank ( Team Medicare)

02/12/2015