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Urological Supplies Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for urological supplies HCPCS codes A4316, A4351, A4352, A4353, and A4355 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 30.81%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. Records do not support payment of the amount billed. 38.30%
2. The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 14.89%
3. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF 10.64%
4. The submitted medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter.) 8.51%
5. The medical records from the treating practitioner do not document an impairment of urination. 6.38%
6. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 4.26%
7. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353. 4.26%
8. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4External PDF 2.13%
9. Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or a portion of the medically necessary supplies for this time span. 2.13%
10. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 2.13%

*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.

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Updated: February 2, 2024

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