Results of Widespread Prepayment Review of Claims for
Oxygen and Oxygen Equipment
Historical Review Results
This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The total denied allowance amount (dollar amount of allowable charges for services determined to be billed in error) divided by the total allowance amount of services medically reviewed result is the Charge Denial Rate (CDR). The previous quarterly findings covered the period of July 01, 2015 through September 30, 2015 and resulted in a CDR of 58.8%.
Current Review Results
DME MAC JA has completed a widespread prepayment review of claims for Oxygen and Oxygen Equipment (HCPCS codes E1390, E0431, and E0439). These findings cover claim process dates primarily from October 01, 2015 through December 31, 2015.
The review involved prepayment complex medical review of 519 claims submitted by 120 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 221 (43%) of the claims. For the remaining 298 claims, 114 claims were allowed and 184 were denied/partially denied resulting in a claim denial rate of 62%, and a CDR of 59.7%.
Charge Denial Rate Historical Data
The following percentages depict the CDR from previous quarters to current:
| Review Period | Charge Denial Rate |
| 2015 Quarter 1 | 65% |
| 2015 Quarter 2 | 58.3% |
| 2015 Quarter 3 | 58.8% |
| 2015 Quarter 4 | 59.7% |
The Coverage Indications, Limitations and/or Medical Necessity section of the Oxygen and Oxygen supplies LCD states:
Home oxygen is covered only when both the reasonable and necessary criteria are met. Home oxygen therapy is reasonable and necessary only if all of the following conditions are met:
- The treating physician has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and
- The beneficiary's blood gas study meets the criteria stated in the LCD, and
- The qualifying blood gas study was performed by a physician or qualified provider or supplier of laboratory services, and
- The qualifying blood gas study was obtained under the following conditions:
- If the qualifying blood gas study is performed during an inpatient stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or
- If the qualifying blood gas study is not performed during an inpatient stay, the reported test must be performed while the beneficiary is in a chronic stable state - i.e. not during a period of acute illness or an exacerbation of their underlying disease, and
- Alternative treatment measures have been tried or considered and deemed clinically ineffective
Refer to the Oxygen and Oxygen Equipment Local Coverage Determination (LCD) L33797 and related Policy article for additional information.
Primary Reasons for Denial
The following are the primary reasons for denial.
Written Order Prior to Delivery Requirements Not Met (36%)
Documentation did not meet the written order prior to delivery requirements for items E0431 and E0439 outlined in LCD L33797 for dates of service on or after January 01, 2014 for the following reasons:- Detailed written order was signed after the date of delivery
- Detailed written order was received after the date of delivery
- No evidence, by date stamp or similar, that the supplier received the detailed written order prior to delivery
- Detailed written order was missing a detailed description of the DME item(s) ordered
- No detailed written order was submitted
- Detailed written order was missing the prescribing practitioner's NPI
- Correction was made to the detailed written order without the author's initials and the date of the correction
- Detailed written order was missing the prescribing practitioner's signature date
- Detailed written order was received by the supplier prior to the signature date
- Detailed written order was illegible
- Detailed written order was missing the prescribing practitioner's printed name
Missing Documentation (31%)
Missing required physician visit per Local Coverage Determination (LCD) L33797:- 14% - Missing treating physician visit dated within 30 days prior to the initial certification date
Missing qualifying blood gas study per LCD L33797:- 5% - No medical documentation to support the blood gas study reported on the CMN
Missing required Certificate of Medical Necessity (CMN) per LCD L33797:- 7% - Missing a valid initial CMN
- Initial CMN not submitted
- Initial CMN missing required information or required information was illegible
- Initial CMN contained corrections that did not include a single strikethrough, the author's initials and the date of the correction
Missing required Detailed Written Order per LCD L33797- 1% - Missing a detailed written order for item E1390
Missing valid proof of delivery per LCD L33797- 4% - Missing valid proof of delivery
- Proof of delivery not submitted
- Date of delivery did not match the initial date of service
- Proof of delivery missing a description of the items delivered
Clinical Documentation Issues (24%)
Clinical documentation did not support criteria of LCD L33797 for the following reasons:- 11% - Signature requirements were not met
- Medical records were not authenticated by the author
- Medical records contain an illegible signature and no signature log or attestation statement was submitted
- 10% - Documentation of a blood gas study performed during exercise did not meet testing criteria
- Missing beneficiary's saturation exercising with oxygen applied
- Missing beneficiary's saturation on room air at rest
- 4% - Documentation of a blood gas study performed during sleep did not meet testing criteria
- Oxygen saturation reported on the CMN was not the lowest value that occurred during the testing period
- No documentation of a titration polysomnogram for a beneficiary with obstructive sleep apnea
- 4% - Group I criteria was not met
- Exercise testing documentation did not support that the beneficiary's oxygen saturation was at or above 89 percent during the day while at rest
- Documentation did not support that the beneficiary's oxygen saturation was at or below 88%
- 3% - No indication in the medical documentation of the presence of a severe lung disease or hypoxia-related symptoms
- 1% - No documentation of testing on 4 LPM
Claim Examples
As an additional educational measure, the following are actual examples of claim denials. NHIC expects that these examples will assist suppliers in understanding the medical review process and the documentation errors that occur with oxygen therapy claims.
Example 1
DOS 4/18/15
Codes Billed: E1390, E0431
Documentation Received: Proof of delivery signed by the beneficiary on 4/18/12 (not a typo, this was the date on the proof of delivery received); initial CMN dated 4/17/15; detailed written order signed 5/15/15 and documented as received on 5/15/15; supplier forms; physician progress note dated 4/17/15 documenting the qualifying diagnosis and supporting the results of the blood gas study reported on the initial CMN
Missing: Detailed written order signed and received prior to delivery of the items ordered; physician's signature on the progress note dated 4/17/15, proof of delivery signed and dated 4/17/15
Example 2
DOS 7/29/15
Codes Billed: E1390
Documentation Received: Initial CMN dated 7/29/15; physician progress note dated 7/29/15 documenting the qualifying diagnosis and supporting the results of the blood gas study reported on the initial CMN; proof of delivery signed by the beneficiary on 7/29/15
Missing: Documentation of the beneficiary's oxygen saturation exercising with oxygen applied to meet the testing requirement for a blood gas study performed during exercise
Example 3
DOS 5/15/15
Codes Billed: E1390, E0431
Documentation Received: Dispensing order dated 5/13/15; physician progress notes dated 4/16/15 and 4/21/15 documenting the need for oxygen therapy; titration polysomnogram dated 5/6/15; proof of delivery signed by the beneficiary on 5/15/15; detailed written order signed 5/26/15
Missing: Detailed written order signed and documented as received by the supplier prior to the date of delivery; initial CMN
Next Steps
Based on the results of this prepayment review, DME MAC JA will continue to review claims billed with HCPCS codes E1390, E0431 and E0439.
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.
DME MAC JA performs ongoing assessment of the effectiveness of its prepayment widespread reviews. One assessment is the Compliance Improvement Program (CIP), which measures suppliers' performance with providing complete and accurate supporting documentation and their response rate to Additional Documentation Requests (ADRs). When a supplier achieves and maintains high quality accuracy and ADR response rate over three (3) quarterly periods, the supplier will be temporarily removed from that particular widespread review. The supplier's authorized official will be notified and provided details of this decision.
Questions and comments can be sent to the DME MAC JA Provider Compliance mailbox at: dme_mac_jurisdiction_a_provider_compliance@hpe.com
NHIC offers a self-service tool, Decision Desktop, which allows suppliers direct access to specific details about a claim decision for claims which have been selected for Complex Medical Review. This tool enables direct access to comprehensive information relating to the reason for denial along with saving time since it is no longer necessary to contact Customer Service for this information.
Decision Desktop can be accessed through the following link: http://www.medicarenhic.com/dme/mr.aspx
Educational References
NHIC provides extensive educational offerings related to the proper documentation requirements for E1390, E0431, and E0439 claims. Please ensure that the responsible supplier staff is aware of and references this educational material so that supporting documentation for your claims is compliant with all requirements. Suppliers are encouraged to review the following references:
