Continuous Positive Airway Pressure & Supplies Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for CPAP & PAP Supplies HCPCS codes A7027-A7034, A7044 & E0601 reviewed July 1 – September 30, 2024. The error rate for this quarter is 17.41%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The order is missing a description of the item. | 19.95% |
2. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 16.80% |
3. | Documentation does not include a valid sleep study that meets all LCD requirements. | 12.16% |
4. | The medical record documentation did not include an in-person evaluation conducted following Medicare eligibility or the evaluation did not confirm a diagnosis of obstructive sleep apnea and continued use of the positive airway pressure device. | 10.52% |
5. | Documentation does not include a valid in-person evaluation that meets all LCD requirements. | 9.70% |
6. | The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. | 9.56% |
7. | The documentation does not have a valid standard written order. | 5.05% |
8. | The supplier billed for greater quantity than the order shows. | 4.10% |
9. | The medical record documentation does not have a clinical evaluation by the treating practitioner prior to the sleep test. | 3.96% |
10. | The supply or accessory is denied as the base equipment is denied. | 1.23% |
*The total percentage will be greater than 100% because some claims 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 be 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
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: November 1, 2024