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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 October 1 and December 31, 2023. The error rate for this quarter is 33.71%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The medical records from the treating practitioner do not document an impairment of urination. 26.19%
2. The submitted medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter) 19.05%
3. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 10.71%
4. The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353. 10.71%
5. Records do not support payment of the amount billed. 8.33%
6. The medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4External PDF 5.95%
7. No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8External PDF 4.76%
8. The standard written order (SWO) is missing a description of the item. Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.2External PDF and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)External Website. 2.38%
9. The medical record documentation contains corrections/changes that do not comply with accepted record keeping principles. 2.38%
10. Claim history shows that the supplier has already been paid for all or a portion of the medically necessary supplies for this time span. Therefore, the excess units are being denied. 2.38%

*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

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