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

Below is the analysis of claim denials for CPAP HCPCS codes A7027-A7034, A7044, and E0601 reviewed July 1 – September 30, 2024. The error rate for this quarter is 18.44%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The order is missing a description of the item. 18.63%
2. Documentation does not include a valid sleep study that meets all LCD requirements. 15.84%
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. 12.22%
4. Documentation does not include a valid in-person evaluation that meets all LCD requirements. 10.87%
5. 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. 10.14%
6. The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. 8.07 %
7. The documentation does not have a valid order. 7.04%
8. The claim is billed for greater quantity than the order shows. 6.11%
9. There is no documentation to support the provider of the CPAP device conducted education on the proper use and care of the device. 2.59%
10. The medical record documentation does not have a clinical evaluation by the treating practitioner prior to the sleep test. 1.97%

*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: November 5, 2024

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