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Nebulizer Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for nebulizer HCPCS codes J7605, J7606, J7613, J7620 and J7626 reviewed July 1 – September 30, 2024. The error rate for this quarter is 37.99 %. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. The number of units listed on the claim is above the policy allowance. 39.73%
2. The medical record documentation does not support the beneficiary has obstructive pulmonary disease. 19.18%
3. No medical record documentation was received. 13.70%
4. The supplier billed for greater quantity than the order shows.   9.59%
5. The order is missing a description of the item. 5.48%
6. The documentation does not have a valid standard written order. 5.48%
7. The order is illegible. 1.37%
8. There is not a valid handwritten or electronic signature by the author of the medical record. 1.37%
9. The documentation is incomplete. 1.37%
10. A treating practitioner's order, supplier prepared statement, or practitioner’s attestation, by itself, does not meet sufficient documentation of medical necessity.  1.37%

*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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