The DME MAC A Medical Review’s prepayment review of claims for continuous positive airway pressure devices, HCPCS E0601, shows a drop in denial rates from a 53.5% charge denial rate from November 2011 through January 2012 to a charge denial rate of 38.8% for claims processed January 2012 through March 2012.
The most recent review involved prepayment complex medical review of 616 claims submitted by 291 suppliers. Responses to the Additional Documentation Request were not received for 66 (10%) of the claims. Of the 616 claims for which responses were received, 351 claims were allowed and 199 were denied/partially denied. This resulted in a claim denial rate of 36%. 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 charge denial rate of 38.8%.
Issues with face-to-face clinical evaluation documentation was the primary reason for denial. Based on the results of this prepayment review, DME MAC A will continue to review claims billed for E0601.