The DME MAC Jurisdiction A has completed the widespread prepayment review of claims for continuous positive airway pressure devices (HCPCS E0601). These findings include claims processed from November 2011 through January 2012.

This review involved prepayment complex medical review of 807 claims submitted by 311 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 322 (40%) of the claims. Of the 485 claims for which responses were received, 208 claims were allowed and 277 were denied/partially denied. This resulted in a claim denial rate of 57%. 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 53.5%.

The primary reasons for denial include issues with face to face clinical evaluation documentation, detailed written orders, sleep study documentation, training documentation, and advanced beneficiary notices.

Based on the results of this prepayment review, DME MAC A will continue to review claims billed for CPAP devices (E0601). Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.