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Nebulizer Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for nebulizer HCPCS codes J7605, J7606, J7613, J7620 and J7626 reviewed July 1 – September 30, 2024. The error rate for this quarter is 31.76%. The top 5 reasons for claim denials are as follows:

Rank Reason Percent
1. The number of units listed on the claim is above the local coverage determination policy allowance. 78.26%
2. The medical record documentation does not support the beneficiary has obstructive pulmonary disease. 8.70%
3. No medical record documentation was received. 4.35%
4. The order is missing a description of the item. 4.35%
5. The claim is billed for greater quantity than the order shows. 4.35%

*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 be an overall error rate for the HCPCS code or policy under medical record review.

Resources:

Updated: November 1, 2024

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