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External Infusion Pump Drugs Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for external infusion pump drugs HCPCS codes J1559, J1569 and J1575 reviewed July 1 – September 30, 2024. The error rate for this quarter is 14.00 %. The top 5 reasons for claim denials are as follows:

Rank Reason Percent
1. The documentation is incomplete 35.71%
2. No medical record documentation was received. 28.57%
3. The claim is billed for greater quantity than the order shows. 14.29%
4. The medical records do not confirm a diagnosis of primary immune deficiency disorder or chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIg treatment. 14.29%
5. The external infusion medication is not covered when an external infusion pump is not being billed. 7.14%

*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:

Published: November 5, 2024

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