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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.

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Updated: May 21, 2024

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