Urological Supplies Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for urological supplies HCPCS codes A4316, A4351, A4352, A4353, and A4355 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 22.75%. The top 10 reasons for claim denials are as follows:
Rank | Reason | Percent |
---|---|---|
1. | Records do not support payment of the amount billed. | 20.66% |
2. | The medical records from the treating practitioner do not document an impairment of urination. | 14.05% |
3. | The medical records do not document the medical necessity for a coude (curved) tip catheter. For example, an inability to catheterize with a straight tip catheter. | 14.05% |
4. | The medical records do not document that the beneficiary met one of the five additional coverage criteria for HCPCS code A4353. | 10.74% |
5. | We did not receive any medical record documentation. | 9.09% |
6. | There is not a valid handwritten or electronic signature by the author of the medical record. | 6.61% |
7. | Claim history shows that the supplier was already paid for all or a part of the medically necessary supplies for this time span. The excess units are denied. | 6.61% |
8. | The standard written order (SWO) is missing a description of the item. | 2.48% |
9. | The documentation does not have a valid SWO. | 2.48% |
10. | The medical record documentation has corrections/changes that do not follow accepted record keeping principles. | 2.48% |
*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:
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
- Urological Supplies: Intermittent Catheters Documentation Checklist
- Urological Supplies – Policy Article (A52521)
- Urological Supplies – LCD (L33803)
Updated: May 21, 2024