LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2012-05 Notice of Service-Specific Prepayment Review: HCPCS Code E0260

Notice of Service-Specific Prepayment Review: HCPCS Code E0260
  • CGS, the Jurisdiction C DME MAC, will be implementing a service-specific Medical Review edit for Healthcare Common Procedure Coding System (HCPCS) codes E0260 ( HOSPITAL BED, SEMI-ELECTRIC [HEAD AND FOOT ADJUSTMENT], WITH ANY TYPE SIDE RAILS, WITH MATTRESS). This edit is the result of data demonstrating a high claims payment error rate for this HCPCS code. The national CERT error rate for HCPCS code E0260 was 88.5% in 2011 with $135,900,000 projected dollars paid in error.
  • Claims subjected to this edit will be developed for additional documentation. Suppliers receiving a development letter should follow the instructions in the letter for the specific documentation requested. Suppliers will be asked to submit documentation including, but not limited to:
    Preliminary dispensing order (if items were delivered prior to obtaining a detailed
    written order); Detailed written order;
    Relevant medical records confirming that the coverage criteria for a semi-electric hospital bed are met;
    Proof of delivery with name, address and signature of the beneficiary; the item(s) provided; date of delivery; and supplier identification;
    Any other pertinent information that would justify payment for the item(s) provided; and
    Advanced Beneficiary Notice (ABN) if one was obtained, this must be submitted with the above requested documentation.
  • Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify that the patient’s condition meets coverage criteria for a semi-electric hospital bed. The source of these records may be a physician’s office, hospital, nursing home, home health agency, etc. Evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.
  • The information must be received within 45 days of the date of the letter or the claim will be denied. Additional information on this and other documentation requirements for HCPCS codes E0260 may be found on the CGS Medical Review web site.