Oxygen and Oxygen Equipment Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for oxygen HCPCS codes E0424, E0439, E1390 and E1391 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 25.86%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical record documentation does not support the treating practitioner has evaluated the results of a qualifying blood gas study performed. | 36.04% |
2. | The medical record documentation does not support any of the Group I criteria. Refer to National Coverage Determination 240.2 and Oxygen and Oxygen Equipment – LCD (L33797) | 12.18% |
3. | The medical record documentation does not support the blood gas study was obtained within two days prior to discharge from an inpatient hospital stay. Refer to National Coverage Determination 240.2 and Oxygen and Oxygen Equipment – LCD (L33797) | 6.09% |
4. | The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 5.58% |
5. | The medical record documentation does not support that the qualifying blood gas study was performed at the time of need. Refer to National Coverage Determination 240.2, Oxygen and Oxygen Equipment – LCD (L33797), and Oxygen and Oxygen Equipment – Policy Article (A52514) | 5.08% |
6. | 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. | 5.08% |
7. | 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 5.2.2 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) | 4.06% |
8. | The medical record documentation does not include a blood gas study. Refer the Refer to National Coverage Determination 240.2, Oxygen and Oxygen Equipment – LCD (L33797), and Oxygen and Oxygen Equipment – Policy Article (A52514) | 3.55% |
9. | 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 5.9. | 3.05% |
10. | The medical record documentation does not contain a qualifying blood gas study performed at rest (awake) or during exercise to support a portable oxygen system. Refer to National Coverage Determination 240.2 and Oxygen and Oxygen Equipment – LCD (L33797). | 2.03% |
*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:
- Medicare Minute MD℠ Oxygen and Oxygen Equipment
- Oxygen and Oxygen Equipment: Beneficiaries Meeting Group I & II Criteria – Documentation Checklist
- Oxygen and Oxygen Equipment – LCD (L33797)
- Oxygen and Oxygen Equipment – Policy Article (A52514)
- Oxygen Medical Review Resources
Updated: February 2, 2024