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Corporate
CGS Administrators, LLC

Serving the states of MN, WI, IL, IN, OH, KY and MI

February 8, 2017

Reopenings for Nebulizer Claims Due to Diagnosis Codes

CGS saw an increase in the 2016 4th quarter for nebulizer claims being adjudicated through the reopenings process. Suppliers submitted noncovered or incorrect ICD-10 diagnosis codes, and through the reopenings process, requested covered diagnosis codes to be added to the claim. Suppliers could avoid the reopenings process and payment delays by reviewing the claim for the appropriate covered diagnosis code prior to submission to the Jurisdiction B and C Durable Medical Equipment Medicare Administrative Contractors (DME MACs).

The nebulizer policy is a diagnosis-driven policy; therefore, when a diagnosis does not support the medical necessity, the claim line will be denied with American National Standard Institute (ANSI) CO-50. CO-50 denials relieve beneficiaries of financial liability and  suppliers cannot resubmit the claim with the appropriate covered diagnosis code because of the medical necessity denial. As such, suppliers are utilizing the reopenings process to add the appropriate covered diagnosis code which causes a delay in payment. Suppliers are reminded that CGS must complete reopening requests within 60 calendar days of receipt of the request.

Suppliers are encouraged to work with their software vendors to have edits in place for nebulizer claims due to the specified diagnosis codes for each item listed in the nebulizer medical policy. By submitting claims initially with the appropriate covered diagnosis codes, suppliers are able to avoid the delay in payment associated with filing reopenings.

For information regarding the coverage, medical necessity, documentation requirements, and coding guidelines for nebulizers and accessories, please read the nebulizers LCD and related policy article. CGS also provides additional policy education in the Online Education Welcome Center at CGSMedicare.com.

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