Let's be honest. Sometimes filing claims feels a bit like being guilty-until-proven-innocent. Nowhere is that more so than denials for same and similar equipment. Fortunately, suppliers can make a strong case for reimbursement right out of the gate with clear and concise claim form narratives. In this article, the last in our narrative series, we offer examples designed to avoid same and similar denials related to oxygen restarts, breaks in service, and breaks in need.
Break in Service or Interruption in Billing
For capped rentals and the first 36 months of oxygen rentals, reimbursement gaps due to the following are considered breaks in service (BIS) or interruptions in billing:
By default, the payer will deny the claim as billed past the expected cap. The narrative must explain why the supplier stopped billing the rental and request the payer approve an extension of the payment cycle.
Break in service sample narrative (24 characters):
Break in Service or Interruption in Billing
For capped rentals and the first 36 months of oxygen rentals, reimbursement gaps due to the following are considered breaks in service (BIS) or interruptions in billing:
- Hospitalization.
- Skilled nursing facility admission.
- Policy switches (e.g. between Medicare and Advantage plans).
- Non-compliance.
- Patient refusal to use equipment.
By default, the payer will deny the claim as billed past the expected cap. The narrative must explain why the supplier stopped billing the rental and request the payer approve an extension of the payment cycle.
Break in service sample narrative (24 characters):
Break in Medical Need or Change in Condition
If a beneficiary has equipment for a condition that substantially improves and, for three months or more, no longer needs their equipment, Medicare classifies the patient as having a break in medical need. If the same beneficiary has a new need for the same or similar equipment, Medicare can approve a new rental even though the patient used the same or similar equipment during a prior episode. To qualify, the medical record must clearly document the medical need from the prior episode ended.
By default, the payer will deny the claim as billed past the expected cap or same and similar to equipment in history. The narrative must clearly establish a break in need pathway, the end date of the first episode which prompted pickup of the equipment, the original diagnosis, the delivery date for the second episode, and the new diagnosis.
Break in medical need sample narrative (60 characters):
If a beneficiary has equipment for a condition that substantially improves and, for three months or more, no longer needs their equipment, Medicare classifies the patient as having a break in medical need. If the same beneficiary has a new need for the same or similar equipment, Medicare can approve a new rental even though the patient used the same or similar equipment during a prior episode. To qualify, the medical record must clearly document the medical need from the prior episode ended.
By default, the payer will deny the claim as billed past the expected cap or same and similar to equipment in history. The narrative must clearly establish a break in need pathway, the end date of the first episode which prompted pickup of the equipment, the original diagnosis, the delivery date for the second episode, and the new diagnosis.
Break in medical need sample narrative (60 characters):
Oxygen Restart Because of Prior Supplier Bankruptcy
Bankruptcy is another exception to the useful lifetime protocol. If a company stops servicing an oxygen beneficiary after filing for bankruptcy, Medicare can make an exception and start a new rental. Bankruptcy effectively renders the equipment lost. The payer will require proof of court documents to verify the bankruptcy claim.
By default, the payer will deny claims for new equipment as billed past the expected cap or same and similar to equipment in history. New suppliers are instructed to append the RA modifier on the first replacement claim. The narrative must clearly identify the equipment, invoke special consideration under the bankruptcy protocol, and confirm the type of bankruptcy as Chapter 11 (reorganization) or a Chapter 7 (liquidation).
Oxygen restart due to bankruptcy sample narrative (39 characters):
Bankruptcy is another exception to the useful lifetime protocol. If a company stops servicing an oxygen beneficiary after filing for bankruptcy, Medicare can make an exception and start a new rental. Bankruptcy effectively renders the equipment lost. The payer will require proof of court documents to verify the bankruptcy claim.
By default, the payer will deny claims for new equipment as billed past the expected cap or same and similar to equipment in history. New suppliers are instructed to append the RA modifier on the first replacement claim. The narrative must clearly identify the equipment, invoke special consideration under the bankruptcy protocol, and confirm the type of bankruptcy as Chapter 11 (reorganization) or a Chapter 7 (liquidation).
Oxygen restart due to bankruptcy sample narrative (39 characters):
Oxygen Restart After Previous Supplier Exits the Program
Supplier abandonment is another exception that permits a restart of oxygen rentals prior to exhausting a useful lifetime. In some cases, suppliers must exit a business unexpectedly. Where possible, exiting suppliers are expected to find a competitor to take over the existing rentals (invoking a simple change in supplier where the existing rental cycle continues and does not restart). However, if the exiting supplier does not make these arrangements, the oxygen equipment is considered “lost” and it becomes eligible for early replacement.
By default, the payer will deny claims for new equipment as billed past the expected cap or same and similar to equipment in history. New suppliers are instructed to append the RA modifier on the first replacement claim. The narrative must clearly invoke special consideration through the supplier abandonment or voluntary exit protocol.
Oxygen restart after supplier exit sample narrative (39 characters):
Supplier abandonment is another exception that permits a restart of oxygen rentals prior to exhausting a useful lifetime. In some cases, suppliers must exit a business unexpectedly. Where possible, exiting suppliers are expected to find a competitor to take over the existing rentals (invoking a simple change in supplier where the existing rental cycle continues and does not restart). However, if the exiting supplier does not make these arrangements, the oxygen equipment is considered “lost” and it becomes eligible for early replacement.
By default, the payer will deny claims for new equipment as billed past the expected cap or same and similar to equipment in history. New suppliers are instructed to append the RA modifier on the first replacement claim. The narrative must clearly invoke special consideration through the supplier abandonment or voluntary exit protocol.
Oxygen restart after supplier exit sample narrative (39 characters):
Good narratives can go a long way in avoiding lost revenue and additional collection work. Just remember to use them … and keep them short so they fit … but use common abbreviations to avoid confusion in claims processing. And if you want to go back and read the other articles in this series, you can do that here and here.
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