Article Detail - JD DME

Original Effective Date: 07/24/2002
Revision Effective Date: 11/01/2013

CMS requires contractors' Medical Review staff to deny payment on claims whenever there is evidence that a service was not billed in compliance with national and local coding requirements (Medicare Program Integrity Manual, Chapter 3, section 4.2). Effective immediately, claims submitted with valid HCPCS codes and/or modifiers that do not correctly represent the DMEPOS items billed may be denied. The Medicare Remittance Advice message for this denial is ANSI Reason Code B18, "Payment denied because this procedure code/modifier was invalid on the date of service or claim submission." This is the same message that is used when an invalid HCPCS code and/or modifier is submitted. To further clarify the reason for denial, a second message, ANSI Remark Code N56, "Procedure code billed is not correct for the service billed," is also included.

Suppliers whose claims are denied because an incorrect HCPCS code and/or modifier is used for the item provided are encouraged to resubmit the claim with the correct HCPCS code and/or modifier. Claims that are resubmitted with the same code/modifier as previously submitted will be denied as duplicate claims.

Suppliers should refer to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) Web site at http://www.palmettogba.com/ or contact the SADMERC for guidance on the correct coding for DMEPOS items.