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:
- Nebulizers and Inhalation Drugs Documentation Checklist
- Nebulizers – LCD (L33370)
- Nebulizers – Policy Article (A52466)
- Nebulizer Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
- Supplier Manual Chapter 3 – Supplier Documentation
Updated: November 5, 2024