June 10, 2009
Helpful Hints for Nebulizer Drug Claims
At CIGNA Government Services, we are committed to providing the most proficient and timely service possible. To improve our level of service and exceed customer expectations, we continuously evaluate data to identify opportunities for improvement. One issue we have identified is an increase in the number of appeal requests received for nebulizer drugs. Therefore, we would like to share some pointers to help ensure your nebulizer drug claims are processed timely, accurately, and without the need for an appeal.
- Submission of inadequate prescriptions. Problems range from physicians' illegible handwriting to absence of a prescription. Per the DME MAC Jurisdiction C Supplier Manual, Chapter 3, "detailed written orders are required for all transactions involving DMEPOS…If the supply is a drug, the order must specify the name of the drug, concentration (if applicable), dosage, frequency of administration, and duration of infusion (if applicable)…the treating physician must review the detailed description and personally sign and date (handwritten or electronic only—signature and date stamps are not acceptable) the order to indicate agreement." If you do not have a prescription that is signed and dated by the treating physician before billing the Medicare program, the drug will be denied as not reasonable and necessary. Also please note that all prescriptions must be legible.
- The dosage and frequency ordered by the physician is less than the units of service billed on the claim, and/or the physician's order and/or the amount billed by the supplier exceeds the maximum medically necessary milligrams/month amount. Please refer to the Nebulizer LCD (L5007) and Policy Article (PA) (A24623). The LCD and PA contain tables showing the maximum milligrams per month that is medically necessary for each nebulizer drug and guidelines for correct coding and calculation of units of service. Drug claims for more than the specified amounts will be denied as not medically necessary.
Additional education and assistance are available through the NetCourses located on the CIGNA Government Services Online Education Center.
Documentation checklists are also available to assist you. These checklists are found in the Medical Review section of the DME MAC Jurisdiction C Web site.
