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Hospital Beds Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for hospital beds HCPCS codes E0260, E0261, and E0303 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 10.20%. The top 5 reasons for claim denials are as follows:

Rank Reason Percent
1. 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 210-212External PDF. 75.00%
2. The documentation submitted is incomplete. 6.25%
3. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF 6.25%
4. The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 6.25%
5. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9External PDF 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.

Resources:

Updated: February 2, 2024

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