Post

By Kim Turner RN

As a supplier, have you ever billed a claim to Medicare for ostomy supplies only to receive the denial for exceeds usual maximum quantity? If you answered yes, the information provided below will be helpful.

Most ostomy supply claims are denied for overutilization. The Medicare Ostomy Supplies local coverage determination (LCD) or policy provides a chart that indicates the usual maximum quantity for each supply:   

In the event the Medicare beneficiary needs to use more than the usual amounts, the specific medical reason(s) must be clearly documented in the beneficiary's medical record. The documentation is necessary when requesting a redetermination for the initial claim denials and any subsequent appeals.

If the reason(s) in the medical record are not clear and/or not sufficient, or the documentation is not provided, the excess quantities will be denied by Medicare as not reasonable and necessary.

How can we help?

Before billing these HCPCS codes, let our clinical staff prescreen your records to ensure the proper documentation is present that meets coverage criteria. Further, the proactive audit services can review a sample of your claims billed to Medicare and identify areas of weakness needing to be addressed. Proactive audits are completed on a quarterly basis to ensure issues identified are rectified and changes made continue throughout your organization. This proactive approach will allow you to be confident in your claims if you are audited. Contact us today to learn more about the prescreen and proactive audit services.