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February 28, 2014

Status Report for Quarter 4 – 2013 - HCPCS Code E0601 Service-Specific Prepayment Review

The Medical Review Department of CGS, the Jurisdiction C DME MAC, continues its service-specific prepayment edit for HCPCS code E0601 (Continuous Airway Pressure [CPAP] Device). This edit is the result of data demonstrating a high claims payment error rate for this product category.

The claim review for October 1, 2013 – December 31, 2013 was only for the initial month of therapy (E0601RRKH). A summary report follows: 

 

Current Quarter
E0601RRKH

Previous Quarter
E0601RRKH

Denial Rate

48%

56%

Allowed Dollars Error Rate

53%

60%

Error Rate Trend

Non-response Rate to Additional Documentation Requests – 10%

An analysis of the claim denials showed that the top 10 reasons a determination was made not to pay the claim were:

RANK

REASON FOR DENIAL

PERCENT *

1

The documentation did not include a copy of a board certification document, screen print from a national certification agency, etc. that verifies that the physician who interpreted the sleep test met policy requirements.

30%

2

The medical records provided did not include documentation of a face-to-face clinical evaluation, conducted by the treating physician prior to the sleep study, which assessed the beneficiary for OSA.

24%

3

The author’s signature was missing or illegible on a key piece of medical documentation, so the information could not be authenticated.

11%

4

A copy of the sleep test interpretation was not provided.

11%

5

The claim was for a replacement PAP device due to the previous equipment reaching its reasonable useful lifetime (RUL) and the documentation either did not include a recent face-to-face evaluation or the evaluation did not confirm that the beneficiary continued to use and benefit from the PAP device.

9%

6

The sleep study was not interpreted by a physician with credentials meeting policy requirements or the proof of credentialing that was provided was not obtained from the website of a national certification agency or state medical board.

9%

7

The beneficiary or designee did not personally date his/her signature on the delivery slip.

6%

8

The supplier’s records did not document that the beneficiary and/or their caregiver received instruction in the proper care of the PAP device and accessories.

6%

9

The beneficiary began using PAP prior to Medicare eligibility and the documentation did not include a F2F evaluation conducted following enrollment in FFS Medicare or the note did not record that the beneficiary had a diagnosis of OSA and continued to use and benefit from PAP therapy.

6%

10

Proof of delivery was not provided or was incomplete.

5%

* Total percentage will be greater than 100% because some claims were denied for multiple reasons.

Online PAP Documentation Resources
http://www.cgsmedicare.com/jc/coverage/mr/pap.html

Webinar Information and Registration
http://www.cgsmedicare.com/jc/education/webinars.html

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