CGS Administrators, Medicare’s DME MAC for jurisdictions B and C, will conduct widespread pre-pay service-specific medical record reviews for oxygen concentrators.
In a May 20 announcement, CGS said the review will focus on claims with the HCPCS code E1390 — Oxygen concentrator, single delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate — and associated codes with the N3 modifier (Group 3 oxygen coverage criteria met).
“The oxygen policy group ranks high in Comprehensive Error Rate Testing (CERT) errors for Jurisdiction B and Jurisdiction C,” CGS said in the announcement. “Data analysis also showed multiple suppliers using the N3 modifier more than expected.”
As a result, “CGS will review medical records for about 100 randomly chosen claims before payment. This review does not target any specific supplier or provider.”
For the selected claims, CGS will send Additional Documentation Requests (ADR) and urged recipients to respond to those ADR letters. Failure to provide the requested records “may result in a claim denial and referral to either or both the National Provider Enrollment contractor and UPIC [Unified Program Integrity Contractor].”
The ADR letters will request the treating practitioner’s written order; documentation to support statutory and reasonable and necessary criteria; other related documentation; and the Advance Beneficiary Notice (ABN), if one was used.
CGS included related resources on its webpage of the announcement.
