CPAP denials are eating into HME revenues.
by Sarah Hanna

With the increase in sleep therapy over the past several years,
many providers' top revenue generator is the E0601 (CPAP). However,
analysis by RemitDATA shows that, on average, suppliers are
receiving a 15.6 percent denial rate on that HCPCS code. The
Jurisdiction A DME MAC (NHIC) recently completed a prepayment
review of CPAP claims with paid dates from April 15 through June
20. The review was initiated due to a high volume of claim errors
found by the Comprehensive Error Rate Testing (CERT)
contractor.

The prepayment complex medical review included 100 claims
submitted by 72 suppliers. Sixty-one claims were allowed and 39
were denied, resulting in a claim denial rate of 39 percent.

Based on the review of claims documentation, the DME MAC found
the following were the primary reasons for denial:

Service determined to be medically unnecessary (36%)

  • No initial face-to-face evaluation prior to sleep study or no
    face-to-face evaluations after 31st day
  • No signature and/or date on sleep study
  • No polysomnogram report
  • Prescription illegible, poor copy quality
  • Incorrect diagnosis

Duplicate submission (6%)

  • Service denied as duplicate, previously considered

Rental period exceeded (3%)

  • Service exceeded rental period, 15-month rental period met

Requested medical documentation not received (1%)

  • Service denied as requested documentation not received

A common problem in this review is missing or incomplete
records: no initial/follow-up face-to-face evaluations, no
signature/date and missing polysomnogram reports. Before you submit
your CPAP claims, check all requested documentation to make sure it
is complete and that it meets the required documentation
criteria.

Using this information to protect the integrity of the claims
you submit is imperative in the current environment with regard to
audits. It is the responsibility of the provider to prove the
medical necessity of the claims the company submits. Review of the
medical record for compliance is important to guarantee payment and
reduce the possibility of payment recoupment.

Based on analysis of 8,945,016 claims processed for RemitDATA
customers during the first quarter of 2010. Source: RemitDATA,
866/885-2974,
www.remitdata.com

Read more Working Down Denials
columns.

Sarah Hanna is a reimbursement consultant and vice president
of ECS Billing
& Consulting
, Tiffin, Ohio, and specializes in proper
billing protocols, Medicare coverage guidelines and billing office
procedures. You can reach her at 419/448-5332 or sarahhanna@bright.net.