Article Detail - JD DME

Posted July 05, 2013

The Comprehensive Error Rate Testing (CERT) Contractor reviews claims and identifies errors in compliance with Medicare payment rules. These errors are reported as the CERT Error Rate. The DME MACs provide information about these errors and actions that may be undertaken to reduce or avoid them.

The highest volume of CERT errors occurring for hospital beds and equipment claims are due to missing or incomplete documentation to demonstrate that the following LCD reasonable and necessary (R&N) criteria were met:

A fixed height hospital bed (E0250, E0251, E0290, E0291, and E0328) is covered if one or more of the following criteria (1-4) are met:

1. The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or

2. The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or

3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or

4. The beneficiary requires traction equipment, which can only be attached to a hospital bed.

A variable height hospital bed (E0255, E0256, E0292, and E0293) is covered if the beneficiary meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.

A semi-electric hospital bed (E0260, E0261, E0294, E0295, and E0329) is covered if the beneficiary meets one of the criteria for a fixed height bed and requires frequent changes in body position and/or has an immediate need for a change in body position.

As these are rental items, there must be evidence of continued medical need and on-going medical management periodically (within 12 months of the date of service) noted in the medical record in order to document sufficient physician oversight of the underlying medical conditions to justify continued rental reimbursement.

Information from the medical record is necessary to provide evidence that the policy requirements are met. This means that DMEPOS suppliers must develop effective communication with their referral sources to ensure that the policy requirements are understood and sufficient information is recorded to justify payment.

The DME MACs have developed a "Dear Physician" letter describing Medicare's documentation requirements. This letter is available on each DME MAC web site. In addition, we suggest that furnishing a copy of the LCD may be helpful.

Suppliers are reminded to monitor use of these items and to discontinue billing if the beneficiary stops using the item. In the event of a claim review, evidence of continued use may be requested. This information may come from the supplier-created records.

Refer to the LCD, related Policy Article and Supplier Manual for additional information on coverage and documentation.