External Infusion Pump Drugs Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for knee orthoses HCPCS codes J1559, J1569 and J1575 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 13.33%. The top 8 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical records do not confirm a diagnosis of primary immune deficiency disorder or chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIg treatment. | 50.00% |
2. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 | 6.25% |
3. | The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4 | 6.25% |
4. | The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) | 6.25% |
5. | The external infusion medication is not covered when an external infusion pump is not being billed. | 6.25% |
6. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) | 6.25% |
7. | Infusion drugs started in a practitioner's office cannot be billed to the DME MAC. | 6.25% |
8. | The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212 | 6.25% |
*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.
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Published: February 6, 2024