The Record - Here are the most common causes of DME/P&O audit findings in 2014

Here are most common causes of DME/P&O audit findings in 2014

Blue Cross Blue Shield of Michigan is encouraging our providers to carefully review all claims related to durable medical equipment and prosthetics and orthotics before submitting them to us for processing. A careful review of claims prior to submission should result in a decrease in audit findings.

Here is a list of the most common causes of DME/P&O audit findings in 2014.

Findings code

Short description

Complete description of finding

Solution

OBQ

Over-billed quantity

The quantity billed or dispensed exceeded the amount ordered by the prescribing physician or the benefit limitation designated by Blue Cross.

Prior to dispensing supplies or equipment, verify quantity limits on web-DENIS by clicking on the Benefit Policy for a Code link. The link can be found under BCBSM Provider Publications and Resources.

Duplicate billing

The same procedure was reported and paid more than once for the same date of service.

Prior to dispensing supplies or equipment, verify quantity limits and capped rental policy on web-DENIS by clicking on the Benefit Policy for a Code link.

NO4

No order

There was no certificate of medical need, order or prescription for the reported service in the patient's record.

A CMN, order or prescription is required for all supplies or equipment dispensed and billed for payment

Incomplete order

The CMN, order or prescription did not include all of the required information or did not meet the prescription requirements.

Refer to the “Documentation Requirements” section of the Blue Cross DME provider manual for required elements of a CMN, order or prescription.

Patient receipt not documented

There was no documentation of the patient’s receipt of the service in the patient’s record.

All services require a proof of receipt signed and dated by the member or caregiver. Refer to the “Proof of Delivery” section of the Blue Cross DME provider manual for proof of receipt requirements.

ECR

Exceeded capped rental

Payments for the capped rental item exceeded the monthly rental period.

Most rental items have a 10-month rental cap period. Do not submit claims for rental months exceeding the 10th month.

NSP

Not payable as a separate procedure

This procedure is not payable as a separate benefit because it is included in the payment of a previously performed procedure.

Most rental items include all supplies or accessories needed to maintain equipment. Do not bill accessories or supplies unless indicated in the Benefit Policy for a Code link on web-DENIS.

DG1

Documentation guidelines not met

Documentation in the patient's records for services billed to Blue Cross did not meet the requirements for payment.

Some services require supporting documentation be kept in the member record. A CPAP device is the most common example.

EFL

Exceeded frequency limitation

The frequency limitation was exceeded for this service.

Prior to dispensing supplies or equipment, verify frequency limits using the Benefit Policy for a Code link on web-DENIS.

Incomplete or missing modifier

The modifier that appropriately describes the type of service rendered was not reported.

Reference the Benefit Policy for a Code link on web-DENIS and the Blue Cross DME provider manual for the correct appendage of modifiers.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.