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) | 14.89% |
3. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 | 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 3.3.2.4 | 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.
Resources:
- Urological Supplies: Intermittent Catheters Documentation Checklist
- Urological Supplies – Policy Article (A52521)
- Urological Supplies – LCD (L33803)
Updated: February 2, 2024