External Infusion Pump Drugs Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for knee orthoses HCPCS codes J1559, J1569 and J1575 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 6.11%. The top four reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The medical records do not confirm a diagnosis of primary immune deficiency disorder or chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIg treatment. | 55.55% |
2. | Infusion drugs started in a practitioner’s office cannot be billed to the DME MAC. | 22.22% |
3. | The medical record documentation is illegible. | 11.11% |
4. | The date on the medical record documentation is after the date of service. | 11.11% |
*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:
- External Infusion Pumps – LCD (L33794)
- External Infusion Pumps – Policy Article (A52507)
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Published: May 21, 2024