DME MAC A Medical Review continues to review continuous positive airway pressure devices (E0601), based on the results of a previous probe review. The Charge Denial Rate for claims with paid dates, primarily from September 2010 through December 2010, was 49.3%, up from 39% from the period April 15, 2010, through June 20, 2010.
The latest review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The review involved prepayment complex medical review of 365 claims submitted by 213 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 86 (24%) of the claims. Of the 279 claims for which responses were received, 123 claims were allowed and 156 were denied resulting in a claim denial rate of 56%.
Primary reasons for denial were as follows:
• 65% of the denied claims did not have documentation verifying CPAP compliance either in a physician note or from a CPAP downloaded card.
• 58% of the denied claims did not have documentation of a physician re-evaluation assessing patient compliance and sleep improvement in a face-to-face visit.
• 42% of the denied claims did not have an initial face-to-face documenting the patient’s need for a sleep study.
• 22% of the denied claims did not have a valid delivery ticket.
Based on the results of this prepayment review, DME MAC A will continue to review claims for continuous positive airway pressure devices (E0601). Suppliers are reminded that repeated failure to respond to ADR requests could result in a referral to the Jurisdiction A Program Safeguard Contractor/Zone Program Integrity Contractor.
