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 October 1 and December 31, 2023. The error rate for this quarter is 30.65%. The top reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) . |
26.03% |
| 2. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 |
23.29% |
| 3. | The medical record documentation does not support the beneficiary has obstructive pulmonary disease. Refer to Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466) |
15.07% |
| 4. | The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4 |
6.85% |
| 5. | The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
6.85% |
| 6. | The number of units listed on the claim is above the Local Coverage Determination (LCD) policy allowance. Refer to Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466) |
6.85% |
| 7. | The claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2, Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466) |
4.11% |
| 8. | The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
2.74% |
| 9. | 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 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) |
2.74% |
| 10. | 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 210-212 |
2.74% |
*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:
- Nebulizers and Inhalation Drugs Documentation Checklist
- Nebulizers – LCD (L33370)
- Nebulizers – Policy Article (A52466)
- Nebulizer Medical Review Resources
Updated: February 2, 2024
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