Billing Multiple Units for 60- or 90-Day Supply Items - Narrative Required to Avoid Denials

When submitting a claim for a 60- or 90-day supply, when permitted by the policy, of items with a single HCPCS code and identical modifiers, it is crucial to ensure that all units of service are consolidated on one claim line. Additionally, a narrative indicating the specific supply duration (60-day or 90-day) must be included in the NTE segment of the electronic claim. This is necessary to prevent denials related to policy frequency limits, as stated in the Standard Documentation Requirements under claim narratives. A similar scenario can arise when submitting duplicate claim lines with the same HCPCS code, provided there is a valid justification - for example, different strengths (J codes) that necessitate the inclusion of a narrative for explanation.

In the event that the claim lacks the required narrative specifying the number of months being billed or the reason multiple claim lines are being billed, it may be denied, and further action will be needed to resolve the issue. This could involve reopening the claim through a telephone or written request. To illustrate, when billing a three-month supply of PAP accessories (e.g., mask, tubing, or cushions), a narrative must be included in the claim narrative in Item 19 of the 1500 hard copy claim form or the 2400/NTE segment of an electronic claim "90-day supply" or "three-month supply", when permitted by the specific policy.

It is essential to note that this requirement applies only to claims that have the exact same modifiers and does not impact claims with bilateral modifiers. To avoid denials, it is strongly recommended to refrain from billing one HCPCS code with the exact same modifiers on multiple claim lines.

By adhering to these guidelines and ensuring the inclusion of accurate narratives, the DME MACs can process claims correctly without encountering denials, providing smoother and more efficient claim processing. Denials arising from failure to meet these requirements will be accompanied by reason code 150 (information submitted does not support this level of service, remark code N115 (decision based on an LCD).

Last Updated Aug 17 , 2023