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December 12, 2013

Status Report for Quarter 3 - 2013 HCPCS Code E0260 Service-Specific DCR Prepayment Review

The Medical Review Department of CGS, the Jurisdiction C DME MAC, began a service-specific Documentation Compliance Review (DCR) of HCPCS code E0260 (Semi-Electric Hospital Bed) claims on May 29, 2012. DCRs are nonclinical, technical reviews that evaluate the presence or absence of particular pieces of documentation. This type of review is conducted when data analysis indicates there is a pattern of insufficient documentation in a product category.

A summary report for claims reviewed between July 1, 2013 and September 30, 2013 follows:

  Current Quarter Previous Quarter
Denial Rate 41% 46%
Allowed Dollars Error Rate 35% 36%
Error rate trend

Non-response Rate to Additional Documentation Requests – 17%

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

  1. The supplier did not provide medical records.
  2. The date of service on the claim did not match the date the beneficiary signed for delivery.
  3. The date of service under review was prior to the signature date on the detailed written order and the documentation did not include written confirmation of a preliminary dispensing order.
  4. A copy of the detailed written order was not received.
  5. Delivery documentation was not received or was incomplete.
  6. The claim was submitted before the supplier received a valid detailed written order from the treating practitioner.
  7. The medical records provided did not include an assessment/evaluation within 12 months prior to the date of service under review.
  8. The item(s) was delivered before the supplier obtained a detailed written order and the preliminary dispensing order was not valid because it was missing one or more required elements.
  9. The treating practitioner did not personally date his/her signature on the detailed written order.
  10. The detailed written order was missing one or more required elements.

Case Study

  • E.G. – 77 year old female
  • Diagnosis – Degenerative joint disease of the knee with left total knee replacement on 02/21/2013
  • Date of Service 03/08/2013
  • Documentation in the file included the following:
    • Telephone order from the treating physician to a hospital nurse for discharge planning to make arrangements for a CPM, rolling walker and bedside commode. The order is dated 03/05/13.
    • Detailed written order for a standard wheelchair with elevating legrests. The start date of the order is 03/08/13 and the doctor signed the order on 03/08/13.
    • Detailed written order for a semi-electric hospital bed with full side rails and a trapeze bar. The start date of the order is 03/08/13 and the doctor signed the order on 03/11/2013.
    • An operative report dated 02/21/2013.
    • A delivery slip signed by the beneficiary on 03/08/13. One of the items listed on this document is a semi-electric hospital bed.

Medical Review Decision – Deny the claim. A hospital bed was not included in the items on the 03/05/13 dispensing order. The detailed written order for the bed was not signed until 03/11/13 which was after the date of delivery. Therefore the supplier was not covered by a physician order when the hospital bed was delivered.

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