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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 between January 1 and March 31, 2024. The error rate for this quarter is 13.54%. The top six 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 (LCD) policy allowance. 41.67%
2. We did not receive any medical record documentation. 33.33%
3. The medical record documentation does not support the beneficiary has obstructive pulmonary disease. 8.33%
4. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. 8.33%
5. There is not a valid handwritten or electronic signature by the author of the medical record. 4.17%
6. The standard written order (SWO) is missing a description of the item. 4.17%

*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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