National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department, reviewed 100 random claims for CPAP devices (HCPCS code E0601KJ) resulting in a claims error rate of 81%.
According to the contractor, only 19 of the claims reviewed were allowed as billed. Denials primarily resulted from:
• no documentation being received,
• no or insufficient medical record documentation of a face-to-face clinical evaluation for obstructive sleep apnea (OSA) by the treating physician prior to the sleep study,
• no or insufficient documentation of the clinical re-evaluation between the 31st and 91st day of therapy with documented improvement of signs and symptoms, and
• no or insufficient documentation of adherence to therapy/device usage for 4 or more hours for 70% of a consecutive 30 day period during the first 3 months of CPAP usage.
“Based on these findings, the Medical Review department will continue with prepayment review of HCPCS code E0601KJ,” according to a statement from the DME MAC.