Remark code M11 indicates that durable medical equipment (DME), orthotics, and prosthetics claims should be submitted to the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) responsible for servicing the patient's geographic area, as determined by the patient's zip code. This ensures that the claim is processed by the correct carrier for reimbursement.
Common causes of code M11 are:
1. The billing address or service location for the DME, orthotics, or prosthetics is outside the service area of the patient's designated DME carrier.
2. The healthcare provider has incorrectly identified the DME carrier responsible for the patient's zip code, leading to a mismatch in the billing process.
3. There has been a recent change in the patient's insurance plan or DME carrier assignments that the provider was not aware of at the time of billing.
4. The claim was submitted to the general insurance carrier instead of the specific DME carrier that handles claims for the patient's geographic location.
5. The provider's billing system may have outdated or incorrect information regarding DME carrier coverage areas, resulting in claims being sent to the wrong carrier.
6. There may be a lack of coordination between the provider's billing department and the DME supplier, leading to confusion about which carrier to bill.
7. The patient may have multiple insurance plans, and the primary DME carrier was not billed first as required.
8. The claim form may have been completed with incorrect information, such as the wrong zip code or address for the service location, causing the claim to be routed incorrectly.
Ways to mitigate code M11 include ensuring that claims for durable medical equipment (DME), orthotics, and prosthetics are submitted to the correct Durable Medical Equipment Medicare Administrative Contractor (DME MAC) that corresponds with the patient's residential zip code. This can be achieved by:
- Maintaining an updated list of DME MACs and their corresponding service areas, including zip codes.
- Implementing a verification process within your billing system to automatically match the patient's zip code with the appropriate DME MAC before claim submission.
- Training your billing staff to recognize when a claim involves DME, orthotics, or prosthetics and to verify the correct DME MAC manually if necessary.
- Utilizing software solutions that include zip code validation features to prevent incorrect DME MAC submissions.
- Regularly reviewing and updating your billing procedures to accommodate any changes in DME MAC jurisdictions or policies.
By incorporating these strategies into your RCM processes, you can reduce the occurrence of code M11 and improve the accuracy of your DME-related claims submissions.
The steps to address code M11 involve verifying the patient's zip code and identifying the correct Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) that services the area. Once the appropriate DME MAC is determined, resubmit the claim for DME, orthotics, or prosthetics directly to that carrier. Ensure that all documentation, including the prescription and medical necessity, is accurate and complete to prevent further denials. It may also be necessary to contact the patient to confirm their current address if there is any discrepancy or recent change. Keep a record of the submission to the correct DME carrier for future reference and follow-up as needed to confirm the claim's acceptance and processing.