Has anyone in Region C seen this? Why the E1390 code on Powered Pressure Reduction Air Mattress? Does CMS even have a clue?
June 15, 2010
HCPCS Code E1390 – Service-Specific Pre-pay Review
CIGNA Government Services, the Jurisdiction C DME MAC, will be implementing a service-specific Medical Review edit for Healthcare Common Procedure Coding System (HCPCS) code E1390 (POWERED PRESSURE-REDUCING AIR MATTRESS). This edit is the result of data demonstrating a high claims payment error rate for this product category.
Claims subjected to this edit will be developed for additional documentation. Suppliers receiving a development letter should follow the instructions contained in the letter for the specific documentation requested. Suppliers will be asked to submit documentation including, but not limited to:
- Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order)
- Detailed written order
- Delivery documentation
- Initial CMN plus any required recertification and/or revised CMNs
- Medical records showing initial qualifying arterial blood gas or oximetry test
- Relevant medical records verifying that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy and that alternative treatment measures have been tried or considered and deemed clinically ineffective
- Contemporaneous (within six months of date of service on claim) medical records confirming that the beneficiary continues to use oxygen in the home.
Additional records needed for beneficiaries qualifying under group II criteria:
- Medical records verifying that the patient has dependent edema suggesting congestive heart failure, or pulmonary hypertension or cor pulmonale, or erythocythemia with a hematocrit greater than 56%
- Medical records showing recertification qualifying arterial blood gas or oximetry test (if claim is for a date of service four or more months after initial date of service)
Additional records needed for beneficiaries qualifying with a home sleep oximetry:
- Treating physician’s order requesting an overnight pulse oximetry test written before the test was performed.
- Documentation that the test was performed under the direction and/or instruction of a Medicare-approved Independent Diagnostic Testing Facility (IDTF). This documentation should include the name/address of the IDTF.
- Information identifying the type of test unit used for the testing.
Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient’s condition meets coverage criteria for oxygen equipment. The source of these records may be a physician’s office, hospital, nursing home, home health agency, wound clinic, etc. Evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.
The information must be received within 30 days of the date of the letter or the claim will be denied. Additional information on this and other documentation requirements for code E1390 may be found on the CGS Medical Review web site at
http://www.cignagovernmentservices.com/jc/coverage/MR/index.html
Service Specific Pre Payment Audits
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