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2019 Quarterly Status Report – HCPCS Code A4253

A summary report for claims reviewed between July 1, 2019 and September 30, 2019 follows: 

An analysis of the claim denials from this review shows that the top 10 reasons a determination was made not to pay the claim were:

Rank Reason for Denial Percent*
1 No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8. 39.96%
2 The documentation does not contain a valid detailed written order. Refer to Medicare Program Integrity Manual 5.2.3. 20.39%
3 The medical record documentation does not document the specific reason for the additional testing materials for this particular beneficiary. Refer to L33822External Website. 18.65%
4 Documentation does not include a valid refill request. Refer to Medicare Program Integrity Manual 5.2.8. 16.50%
5 The medical record does not include documentation (e.g., a specific narrative statement that adequately documents the frequency at which the beneficiary is actually testing or a copy of the beneficiary's log) to indicate the beneficiary is actually testing at a frequency which corroborates the quantity of supplies that have been dispensed. Refer to L33822External Website. 15.37%
6 The KS modifier must not be used for a beneficiary who is being treated with insulin injections. Refer to L33822External Website. 5.58%
7 The medical record documentation does not establish that the treating physician saw the beneficiary and evaluated the beneficiary's diabetes control within 6 months before ordering the quantities of supplies exceeding utilization guidelines. Refer to L33822. 5.33%
8 The KX modifier must not be used for a beneficiary who is not treated with insulin injections. Refer to L33822External Website. 5.28%
9 Quantity of supplies ordered is above normal allowable amounts and no medical records were sent in to address the need for over-utilization. Medical records and a test log or narrative by the practitioner are required to support the requirements in the ‘high utilization' section of the LCD. Refer to L33822External Website. 4.35%
10 The claim is billed for greater quantity than the detailed written order indicates. Refer to Medicare Program Integrity Manual 5.9; L33822; L33370; L33824; L33831; L33803; L33794; L33826. 3.89%

* Total percentage will be greater than 100% because some claims were denied for multiple reasons.

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