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 3.3.2.4 | 5.95% |
7. | No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8 | 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 5.2.2 and Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). | 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:
- Urological Supplies: Intermittent Catheters Documentation Checklist
- Urological Supplies – Policy Article (A52521)
- Urological Supplies – LCD (L33803)
Updated: February 2, 2024