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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 October 1 and October 31, 2023. The error rate for this quarter is 31.61%. The top 10 reasons for claim denials are as follows:

Rank	Reason	Percent
1.	The documentation does not contain a valid Standard Written Order (SWO). Refer to Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)	18.52%
2.	The number of units listed on the claim is above the Local Coverage Determination (LCD) policy allowance. Refer to Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466)	18.52%
3.	No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8	16.67%
4.	The claim is billed for greater quantity than the order indicates. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2, Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466)	14.81%
5.	The medical record documentation does not support the beneficiary has obstructive pulmonary disease. Refer to Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466)	12.96%
6.	The records indicate the drug is not being administered via 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). Refer to Nebulizers – LCD (L33370) and Nebulizers – Policy Article (A52466)	7.41%
7.	The treating practitioner's order, Certificate of Medical Necessity, supplier prepared statement, or the practitioner's attestation, by itself, does not provide sufficient documentation of medical necessity. Refer to Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.9	5.56%
8.	The standard written order (SWO) contains a treating practitioner's signature which does not comply with the Centers for Medicare & Medicaid Services signature requirements. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).	1.85%
9.	The medical record documentation is illegible.	1.85%
10.	The documentation submitted indicates the item(s) were returned by the beneficiary.	1.85%

*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:

Updated: February 2, 2024

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Nebulizer Pre-Pay Review Quarterly Status Report

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