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.