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Commodes Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for commodes HCPCS codes E0163 and E0165 reviewed between October 1 and December 31, 2023. The error rate for this quarter is 43.03%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical record documentation does not support that one of the three criteria have been met for a commode. 62.27%
2. The medical records received lack sufficient information concerning the beneficiary's condition to determine if medical necessity coverage criteria were met. 11.37%
3. The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212External PDF. 10.34%
4. The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9External PDF. 5.43%
5. 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. 2.84%
6. 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 2.07%
7. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF. 1.55%
8. The documentation submitted is incomplete. 1.29%
9. This item or service is denied non-covered. 1.03%
10. The claim submitted is a duplicate to another claim billed. 0.52%

*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:

Updated: February 2, 2024

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