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Continuous Positive Airway Pressure (CPAP) Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for CPAP HCPCS codes E0601 reviewed between January 1 and January 31, 2024. The error rate for this quarter is 21.56%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The standard written order (SWO) is missing a description of the item. 17.67%
2. The documentation does not have a valid SWO. 15.80%
3. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 15.66%
4. Documentation does not include a valid sleep study that meets all LCD requirements. 15.09%
5. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. 7.76%
6. Documentation does not include a valid in-person evaluation that meets all LCD requirements. 7.61%
7. 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. 4.45%
8. There is not a valid handwritten or electronic signature by the author of the medical record. 3.59%
9. The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test. 2.44%
10. The claim is billed for greater quantity than the order indicates. 2.16%

*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:

Updated: May 21, 2024

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