Continuous Airway Positive Pressure (CPAP) Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for CPAP HCPCS codes E0601 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 21.49%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 19.46% |
2. | The Standard Written Order (SWO) is missing a description of the item. | 17.07% |
3. | Documentation does not include a valid sleep study that meets all LCD requirements. | 14.96% |
4. | The documentation does not have a valid SWO. | 13.23% |
5. | Documentation does not include a valid in-person evaluation that meets all LCD requirements. | 10.93% |
6. | The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. | 7.09% |
7. | The medical record documentation did not include an in-person evaluation conducted following Medicare eligibility or the evaluation did not confirm a diagnosis of obstructive sleep apnea and continued use of the positive airway pressure device. | 4.12% |
8. | The claim is billed for greater quantity than the order indicates. | 2.49% |
9. | There is not a valid handwritten or electronic signature by the author of the medical record. | 1.82% |
10. | The supply or accessory is denied as the base equipment is denied. | 1.25% |
*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:
- Positive Airway Pressure (PAP) Devices for the Treatment of OSA Documentation Checklist
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD (L33718)
- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article (A52467)
- Positive Airway Pressure (PAP) Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024