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 July 1 – September 30, 2024. The error rate for this quarter is 18.36%. 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. | 29.73% |
2. | Records do not support payment of the amount billed. | 18.92% |
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. | 10.81% |
4. | The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353. | 8.11% |
5. | The order is missing a description of the item. | 5.41% |
6. | Claim history shows that the supplier has already been paid for all or part of the medically necessary supplies for this time span. Therefore, the excess units are being denied. | 5.41% |
7. | The medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter) | 5.41% |
8. | The documentation does not have a valid order. | 2.70% |
9. | Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or part of the medically necessary supplies for this time span. | 2.70% |
10. | The supplier billed for greater quantity than the order shows. | 2.70% |
*The total percentage will be greater than 100% because some claims 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 be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
- Urological Supplies: Intermittent Catheters Documentation Checklist
- Urological Supplies – Policy Article (A52521)
- Urological Supplies – LCD (L33803)
Updated November 1, 2024