The DME MAC Jurisdiction A has completed a widespread prepayment review of claims for continuous positive airway pressure devices (HCPCS E0601). These findings include claims processed from July 2012 through December 2012. This review continues based upon the high charge denial rate (CDR) reported from the previous quarter.
This review involved prepayment complex medical review of 2,656 claims submitted by 555 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 314 (12%) of the claims. Of the 2,342 claims for which responses were received, 1,382 claims were allowed and 1,274 were denied/partially denied. This resulted in a claim denial rate of 54.3%. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed resulted in an overall CDR of 54.9%.
The primary reasons of denial included: face-to-face clinical evaluation documentation issues,
detailed written order issues, sleep study documentation issues, training documentation issues, and delivery issues.