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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 October 1 and December 31, 2023. The error rate for this quarter is 13.33%. The top 8 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. 50.00%
2. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF 6.25%
3. 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 6.25%
4. The medical record documentation is dated after the date of service. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website 6.25%
5. The external infusion medication is not covered when an external infusion pump is not being billed. 6.25%
6. 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 6.25%
7. Infusion drugs started in a practitioner's office cannot be billed to the DME MAC. 6.25%
8. 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 6.25%

*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:

Published: February 6, 2024

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