Medicare Compliance & Reimbursement

Avoid denials with this official guidance.

If you're getting denied for osteoporosis drug injections, you aren't alone -- and the Centers for Medicare & Medicaid Services has taken note.

Problem: Many claims submitted for covered osteoporosis drugs don't provide a date of service that falls within the start and end dates of an existing prospective payment system (PPS) episode, according to a recent MLN Matters article.

Medicare outlines three criteria for covering injectable osteoporosis claims:

• Patients are eligible for home health services;

• Physicians certify that the individual sustained a bone fracture related to post-menopausal osteoporosis; and

• Physicians certify that the female patient can't selfadminister the drug and no caregivers are able to administer it for her.

That first criterion is where most agencies stumble, CMS says.

Crucial: Eligibility hinges on agencies providing the service during the health care episode -- for instance, if the claim contains HCPCS codes J0630, J3110, or J3490, or covered charges corresponding to those HCPCS codes.

When the date of service falls outside that range, the service becomes ineligible -- and your payment suffers.

Best: Make sure your dates of service for injectable osteoporosis drugs match up with the care episode, or you can expect to see MSN message 6.5, "Medicare cannot pay for this injection because one or more requirements for coverage were not met;" and claim adjustment reason code 177, "Patient has not met the required eligibility requirements," CMS warns.