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 January 1 and March 31, 2024. The error rate for this quarter is 13.04%. The three top 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. | 77.78% |
2. | The documentation does not have a valid Standard Written Order (SWO). | 11.11% |
3. | There is not a valid handwritten or electronic signature by the author of the medical record. | 11.11% |
*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:
- External Infusion Pumps – LCD (L33794)
- External Infusion Pumps – Policy Article (A52507)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Published: May 21, 2024