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Urological Supplies Pre-Pay Review Quarterly Status Report

Below is the analysis of claim denials for urological supplies HCPCS codes A4316, A4351, A4352, A4353, and A4355 reviewed between January 1 and March 31, 2024. The error rate for this quarter is 22.75%. The top 10 reasons for claim denials are as follows:

Rank Reason Percent
1. Records do not support payment of the amount billed. 20.66%
2. The medical records from the treating practitioner do not document an impairment of urination. 14.05%
3. The medical records do not document the medical necessity for a coude (curved) tip catheter. For example, an inability to catheterize with a straight tip catheter. 14.05%
4. The medical records do not document that the beneficiary met one of the five additional coverage criteria for HCPCS code A4353. 10.74%
5. We did not receive any medical record documentation. 9.09%
6. There is not a valid handwritten or electronic signature by the author of the medical record. 6.61%
7. Claim history shows that the supplier was already paid for all or a part of the medically necessary supplies for this time span. The excess units are denied. 6.61%
8. The standard written order (SWO) is missing a description of the item. 2.48%
9. The documentation does not have a valid SWO. 2.48%
10. The medical record documentation has corrections/changes that do not follow accepted record keeping principles. 2.48%

*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.


Updated: May 21, 2024


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