License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

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POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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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 A7027-A7034, A7044, and E0601 reviewed between April 1 and June 30, 2024. The error rate for this quarter is 18.42%. The top ten reasons for claim denials are as follows:

Rank	Reason	Percent
1.	The standard written order (SWO) is missing a description of the item.	20.03%
2.	Documentation does not include a valid sleep study that meets all LCD requirements.	19.23%
3.	Documentation does not include a valid in-person evaluation that meets all LCD requirements.	15.30%
4.	Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary.	13.36%
5.	The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary.	7.85%
6.	The documentation does not have a valid SWO.	6.52%
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.	6.41%
8.	The claim is billed for greater quantity than the order indicates.	3.18%
9.	There is not a valid handwritten or electronic signature by the author of the medical record.	2.31%
10.	The supply or accessory is denied as the base equipment is denied.	1.10%

*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:

Updated: July 30, 2024

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

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

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