Common Claim Denials for Medicare Part B

In the PAAS National® August 2019 Newsline article, Medicare Part B/DMEPOS Audits – Who are All These Contractors?, we explained that Medicare and Medicaid use a number of audit contractors to perform medical review audits on pharmacies. The three main contractors PAAS sees carrying out these audits are: DME Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and Supplemental Medical Review Contractors (SMRCs).

Many of the denied claims are due to not meeting medical necessity, frequency limitations, lacking supporting medical records and even basic coding mistakes. See PAAS Tips for links on billing specific DMEPOS items and required documentation for Medicare Part B claims.

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  • General reasons for claim denials on any audit:
    • Date of service and date of delivery do not match
    • Missing proof of refill request
    • Medical records are not signed by the physician
  • Glucose Meter Testing strips
    • Patient is testing outside guidelines and medical records do not support a valid reason why
    • No testing logs to prove patient is testing outside guidelines
    • Wrong modifier attached to claim based on insulin-dependent and non-insulin dependent
  • Immunosuppressive drugs
    • Not a covered transplant = must be kidney, heart, liver, bone marrow/stem cell, lung, intestinal and pancreas (limited situations)
    • Transplant was not performed in a Medicare approved facility
    • Missing transplant date and/or location
    • Patient was not enrolled in Medicare A at the time of transplant
  • Therapeutic Shoes
    • Missing medical records all together
    • Medical records do not support one or more of the qualifying conditions listed on the certifying statement
    • Missing in-person evaluation of the patient’s feet conducted by the supplier prior to ordering including measurements and deformities
    • Foot examination performed by the supplier does not contain an objective in-person assessment of the patient wearing the shoes/inserts

PAAS Tips:

Jennifer Ottman, CPhT