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.
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Published: November 5, 2024

