Nebulizer Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for nebulizer HCPCS codes J7605, J7606, J7613, J7620 and J7626 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 25.98%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | The number of units listed on the claim is above the Local Coverage Determination (LCD) policy allowance. | 34.85% |
2. | We did not receive any medical record documentation. | 22.73% |
3. | The claim is billed for greater quantity than the order shows. | 12.12% |
4. | The medical record documentation does not support the beneficiary has obstructive pulmonary disease. | 9.09% |
5. | The documentation does not have a valid Standard Written Order (SWO). | 7.58% |
6. | The records show the drug is not being administered with a nebulizer. Drugs that are not administered through Durable Medical Equipment (DME) are statutorily non-covered by the DME MACs but may be covered under other Medicare benefits (i.e., Medicare Part D). | 6.06% |
7. | The documentation is incomplete. | 3.03% |
8. | The SWO is illegible. | 1.52% |
9. | There is not a valid handwritten or electronic signature by the author of the medical record. | 1.52% |
10. | The SWO is missing a description of the item. | 1.52% |
*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:
- Nebulizers and Inhalation Drugs Documentation Checklist
- Nebulizers – LCD (L33370)
- Nebulizers – Policy Article (A52466)
- Nebulizer Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: May 21, 2024