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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:

Published: May 21, 2024

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