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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 January 1 and March 31, 2024. The error rate for this quarter is 28.52%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. Records do not support payment of the amount billed. 30.53%
2. We did not receive any medical record documentation. 12.21%
3. The medical records do not document the medical necessity for a coude (curved) tip catheter. For example, an inability to catheterize with a straight tip catheter. 10.69%
4. The medical records from the treating practitioner do not document an impairment of urination. 8.40%
5. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 5.34%
6. The medical record documentation has corrections/changes that do not comply with accepted record keeping principles. 4.58%
7. The documentation does not have a valid Standard Written Order (SWO). 3.82%
8. The claim is billed for greater quantity than ordered. 3.82%
9. Claim history shows that the supplier was already paid for all or a part of the medically necessary supplies for this time span. The excess units are denied. 3.82%
10. The medical records do not document that the beneficiary met one of the five additional coverage criteria for HCPCS code A4353. 3.82%

*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 May 21, 2024

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