Results of Widespread Prepayment Review of Claims
(Continuous Positive Airway Pressure Devices) HCPCS Code E0601
Historical Review Results
This review was initiated due to errors identified by the Comprehensive Error Rate Testing (CERT) Contractor. The overall Charge Denial Rate (CDR) is the total denied allowance amount (dollar amount of services determined to be billed in error) divided by the total allowance amount (dollar amount of services medically reviewed). The previous quarterly findings covered claims reviewed from October 2015 through December 2015, and reported a CDR of 58.4%.
Current Review Results
The DME MAC JA has completed the widespread prepayment review of claims for Continuous Positive Airway Pressure Devices (HCPCS E0601). These findings include claims processed from January 2016 through March 2016. This review involved prepayment complex medical review of 1805 claims submitted by 369 suppliers. Responses to the Additional Documentation Request (ADR) were not received for 254 (14%) of the claims. Of the 1551 claims for which responses were received, 502 claims were allowed and 1049 were denied/partially denied. This resulted in a claim denial rate of 68%. The overall CDR was 61.3%.
Charge Denial Rate Historical Data
The following data depicts the Charge Denial rate from previous periods to current:
| Review Period | Charge Denial Rate |
| April 2015 - June 2015 | 54.8% |
| July 2015 - September 2015 | 57.7% |
| October 2015 - December 2015 | 58.4% |
| January 2016 - March 2016 | 61.3% |
Primary Reasons for Denial
Based on the review of the documentation received, the following are the primary reasons for denial. Note that the percentages below reflect the fact that a claim could have more than one missing/incomplete item:
Face-to-Face Clinical Evaluation Documentation Issues
- 17% of the denied claims had insufficient Face-to-Face clinical documentation to support medical necessity and consequently did not meet the coverage criteria outlined in the PAP LCD. The insufficient clinical documentation included:
- Missing Face-to-Face
- Untimely Face-to-Face
- Face-to-Face does not meet criteria based documentation submitted. Clinical documentation provided did not reflect the need for the care provided or no detailed narrative in the clinical documentation describing symptoms of sleep disordered breathing, daytime sleepiness/fatigue, observed apneas, and/or choking/gasping during sleep; duration of symptoms; or Epworth Sleepiness Scale scores.
- Face-to-Face is illegible due to poor fax quality or illegible handwriting
- Medical documentation not authenticated by the author.
Scenarios included:- Beneficiaries seeking initial coverage of a PAP device
- Beneficiaries seeking PAP replacement following the 5 year Reasonable Useful Lifetime (RUL)
- Beneficiaries seeking PAP replacement upon entering Fee-for-Service (FFS) Medicare
Detailed Written Order/Written Order Prior to Delivery Issues
- 30% of the denied claims had an incomplete Written Order Prior to Delivery (WOPD) for PAP device E0601.
Included in these results for incomplete WOPD were orders which were missing either: - Beneficiary's name
- The description of the E0601 PAP device ordered
- The prescribing practitioner's National Provider Identification (NPI)
- The signature of the prescribing practitioner
- The date of the order
- Signature date
- A date of receipt demonstrating supplier received the Detailed Written Order (DWO) on or before delivery
- DWO not submitted, illegible or is written before the Face-to-Face
- 85% of the claims had an incomplete DWO for PAP accessories.
Included in these for incomplete DWO were orders which were missing either: - Beneficiary's name
- Physician's name
- Date of the order
- Detailed description of item(s) ordered
- Items to be dispensed
- Physician signature and signature date
Also included in this calculation are orders which contain incompatible combinations: An example of this would be when the DWO lists multiple items that have the same purpose such as heated tubing and non heated tubing, or several different masks.
Sleep Study Documentation Issues
- 19% of the denied claims had insufficient Sleep Study documentation to support medical necessity and consequently did not meet the coverage criteria outlined in the PAP LCD. The insufficient clinical documentation included:
- No Sleep Study submitted
- Sleep test results did not meet Medicare coverage criteria
- Sleep Study interpretation per the PAP LCD
Training Documentation Issues
- 6% of the denied claims did not include evidence of training on the PAP device.
- 23% of the denied claims did not include evidence of beneficiary training (by entity conducting the test) on how to properly apply a portable sleep monitoring device prior to the home sleep test (HST). Per the PAP LCD, this can be accomplished either by a Face-to-Face demonstration, via video, or telephonic instruction and noted in the record.
Delivery Issues
- 3.2% of the denied claims were missing proof of delivery.
- 7% of the denied claims had proof of delivery which were missing either the beneficiary's name, delivery address, a sufficient description of the item(s) being delivered, quantity delivered, date delivered, or beneficiary's signature. *Refer to Article: Proof of Delivery Reminder.
Claim Examples
As an additional educational effort, the following are actual examples of claim denials. NHIC expects that these examples will assist suppliers in understanding the medical review process and the common documentation errors that may occur with PAP claims:
Example 1:
Received: A DWO/WOPD, a Sleep Test that meets the Medicare coverage criteria, evidence of training on the PAP device, proof of delivery containing replacement items, and Face-to-Face clinical evaluation by the treating physician.
Insufficient: DWO lists incompatible combinations. Some suppliers use preprinted forms for their DWOs that include a listing of many different items, not all of which may be needed by an individual beneficiary. The final document that is signed and dated by the physician must clearly identify the specific items that are being ordered for the beneficiary. *Refer to article Detailed Written Orders posted 4/8/10.
Example 2: (Initial coverage of PAP)
Received: Face-to-Face clinical evaluation, a DWO/WOPD, evidence of training on the PAP device and a diagnostic Sleep Test.
Incomplete/Insufficient: Proof of Delivery is missing a sufficient description of item(s) delivered.
Example 3:
Received: A DWO/WOPD, a Face-to-Face clinical evaluation by treating physician, Home Sleep Study, proof of delivery, and evidence of Training on the PAP device
Missing: Documentation submitted did not include information to support that the beneficiary received instruction for the application and use of a portable sleep monitoring device for a home sleep study either by Face-to-Face, video or telephonic instruction.
Next Step
Based on the results of this prepayment review, DME MAC JA will continue to review claims billed for Continuous 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.
DME MAC JA performs ongoing assessment of the effectiveness of its prepayment widespread reviews. 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 the 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 E0601 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:
