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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 July 1 – September 30, 2024. The error rate for this quarter is 18.36%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records from the treating practitioner do not document an impairment of urination. 29.73%
2. Records do not support payment of the amount billed. 18.92%
3. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 10.81%
4. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353. 8.11%
5. The order is missing a description of the item. 5.41%
6. Claim history shows that the supplier has already been paid for all or part of the medically necessary supplies for this time span. Therefore, the excess units are being denied. 5.41%
7. The medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter) 5.41%
8. The documentation does not have a valid order. 2.70%
9. Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or part of the medically necessary supplies for this time span. 2.70%
10. The supplier billed for greater quantity than the order shows. 2.70%

*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 November 1, 2024

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