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 July 1 – September 30, 2024. The error rate for this quarter is 25.90 %. The top 10 reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | Records do not support payment of the amount billed. | 25.00% |
| 2. | The medical records do not document the medical necessity for a coude (curved) tip catheter. (Example: An inability to catheterize with a straight tip catheter) | 20.83% |
| 3. | The medical records from the treating practitioner do not document an impairment of urination. | 17.71% |
| 4. | The medical records received lack sufficient information concerning the beneficiary’s condition to determine if medical necessity coverage criteria were met. | 8.33% |
| 5. | The medical records do not document that the beneficiary met one of the 5 additional coverage criteria for HCPCS code A4353. | 7.29% |
| 6. | The documentation does not have a valid order. | 3.13% |
| 7. | The supplier billed for greater quantity than the order shows. | 3.13% |
| 8. | According to the medical records from the treating practitioner, the impairment of urination is expected to only be temporary (less than 3 months duration), or the records do not provide sufficient information to determine whether the impairment is temporary or permanent (duration of 3 months or more). | 3.13% |
| 9. | Multiple suppliers are billing for overlapping dates of service and payment has already been made for all or part of the medically necessary supplies for this time span. | 2.08% |
| 10. | Claim history shows that the supplier has already been paid for all or part of the medically necessary supplies for this time span. Therefore, the excess units are being denied. | 2.08% |
*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:
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

- Supplier Manual Chapter 3 – Supplier Documentation

- Urological Supplies: Intermittent Catheters Documentation Checklist

- Urological Supplies – Policy Article (A52521)

- Urological Supplies – LCD (L33803)

Updated: November 5, 2024

