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Continuous Airway Positive Pressure (CPAP) Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for CPAP HCPCS codes E0601, A7027 – A7034, and A7044 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 21.49%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. 19.46%
2. The Standard Written Order (SWO) is missing a description of the item. 17.07%
3. Documentation does not include a valid sleep study that meets all LCD requirements. 14.96%
4. The documentation does not have a valid SWO. 13.23%
5. Documentation does not include a valid in-person evaluation that meets all LCD requirements. 10.93%
6. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. 7.09%
7. The medical record documentation did not include an in-person evaluation conducted following Medicare eligibility or the evaluation did not confirm a diagnosis of obstructive sleep apnea and continued use of the positive airway pressure device. 4.12%
8. The claim is billed for greater quantity than the order indicates. 2.49%
9. There is not a valid handwritten or electronic signature by the author of the medical record. 1.82%
10. The supply or accessory is denied as the base equipment is denied. 1.25%

*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.


Updated: 07.08.24


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