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Status Report for Quarter 4 – 2018: HCPCS Code J2260

A summary report for claims reviewed between October 1, 2018 and December 31, 2018 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 The medical records do not support the LCD requirements for the external infusion pump medications have been met. 66.13%
2 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. 45.16%
3 The detailed written order is missing the quantity to be dispensed. Refer to SDL A55426. 11.29%
4 The refill documentation is missing the description of each item that is being requested. Refer to A55426. 8.06%
5 There is no documentation showing the beneficiary has nearly exhausted their supplies. Refer to Medicare Program Integrity Manual 5.2.8. 6.45%
5 The refill documentation is missing information that the beneficiary's remaining supply is approaching exhaustion by the expected delivery date. Refer to Medicare Program Integrity Manual 5.2.8. 6.45%
5 The beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Claims Processing Manual. 6.45%
5 The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 3.3.2.4. 6.45%
9 The documentation does not include a detailed written order. Refer to Medicare Program Integrity Manual 5.2.3 & SDL A55426. 4.84%
10 The detailed written order is missing the number of refills. 3.23%

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

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