Continuous Airway Positive Pressure (CPAP) Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for CPAP HCPCS codes E0601 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 25.88%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 22.34% |
2. | The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2, and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 12.64% |
3. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 12.09% |
4. | Documentation does not include a valid sleep study that meets all LCD requirements. | 6.78% |
5. | The claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2, Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686), and Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Article (A52457) | 6.41% |
6. | There is no documentation to support the provider of the CPAP device conducted education on the proper use and care of the device. Refer to National Coverage Determination 240.4 and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD (L33718). | 6.23% |
7. | The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test. Refer to National Coverage Determination 240.4 and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD (L33718) | 5.86% |
8. | The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. | 4.40% |
9. | The supply or accessory is denied as the base equipment is denied. Refer to Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686) and Ankle-Foot/Knee-Ankle-Foot Orthoses Policy Article (A52457) | 4.21% |
10. | For the PAP device being replaced following the 5 year reasonable useful lifetime, the documentation did not include an in-person evaluation, or the evaluation did not confirm that the beneficiary continues to use and beneficiary continues to use and benefit from the PAP device. | 4.03% |
*The total percentage will be greater than 100% because some claims were denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to represent an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Positive Airway Pressure (PAP) Devices for the Treatment of OSA Documentation Checklist
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD (L33718)
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article (A52467)
- Positive Airway Pressure (PAP) Medical Review Resources
February 2, 2024