Remark code M60 indicates that the claim has been processed but cannot be paid because it lacks a Certificate of Medical Necessity (CMN). The CMN is a document that Medicare requires for some Durable Medical Equipment (DME), which certifies that the equipment is medically necessary for the patient. The provider must submit this certificate to ensure reimbursement for the services or equipment provided.
Common causes of code M60 are:
1. Incomplete or missing documentation: The Certificate of Medical Necessity (CMN) may not have been submitted with the claim, or the necessary sections of the form were left blank.
2. Incorrect form submission: The CMN may have been submitted, but it was not the correct version or form type required by the payer for the specific service or equipment provided.
3. Timing issues: The CMN was not obtained within the required timeframe, either before the delivery of the service or equipment or within the payer's specified window post-delivery.
4. Provider signature missing or invalid: The CMN lacks a valid signature from the attending physician or the signature does not meet the payer's requirements (e.g., electronic signature when a handwritten signature is required).
5. Patient information errors: The patient's identifying information on the CMN does not match the information on the claim or the payer's records, leading to a rejection.
6. Lack of medical necessity evidence: The CMN does not adequately document the medical necessity of the service or equipment for the patient's condition, as required by the payer's guidelines.
7. Expiration of the CMN: The CMN is outdated, as some payers require a new CMN after a certain period or if there is a significant change in the patient's condition.
8. Incorrect coding: The diagnosis or procedure codes listed on the CMN do not correspond to the codes on the claim, or they do not support the medical necessity for the service or equipment provided.
9. Non-compliance with payer-specific guidelines: The CMN submission did not adhere to the specific instructions or guidelines of the payer, which can vary widely among different insurers.
Addressing these common causes can help healthcare providers reduce claim denials and streamline their revenue cycle management processes.
Ways to mitigate code M60 include implementing a robust documentation process that ensures all required certificates of medical necessity (CMNs) are obtained and attached to claims before submission. Train staff to identify which services and equipment require a CMN and establish a checklist for verification. Utilize electronic health record (EHR) systems with prompts or alerts that flag when a CMN is needed. Regularly audit claims to ensure compliance and address any gaps in the process. Engage in continuous education on documentation requirements to keep abreast of any changes in regulations.
The steps to address code M60 involve first reviewing the patient's medical records to confirm that a Certificate of Medical Necessity (CMN) is indeed required for the services billed. If the CMN is missing, promptly obtain the necessary documentation from the healthcare provider who ordered the services. Ensure that the CMN is fully completed, signed, and dated. Once the CMN is in hand, resubmit the claim with the CMN attached. If the CMN was previously submitted and may have been overlooked, contact the payer to verify receipt and ask for the claim to be reprocessed. Keep a record of all communications and submissions for tracking purposes and to prevent future occurrences.