Columbia, S.C.
A pre-pay probe review of Jurisdiction A claims for negative
pressure wound therapy has resulted in more than three-quarters of
those claims being denied, according TriCenturion, the DME Program
Safeguard Contractor for regions A and B.
The review was triggered early last year by the addition of new
products to the NPWT policy group.
Because of the high rate of denials, the PSC will
“continue with a widespread pre-pay review of the new
suppliers billing claims with HCPCS E2402 in an effort to ensure
compliance with billing practices,” TriCenturion said in a
bulletin.
The overall charge denial rate was 75.55 percent. Statistics
also showed that 41 percent of the claims were denied because the
medical information submitted did not meet the policy criteria.
According to TriCenturion, the most common problems were:
supplier-created forms submitted as a substitute for requested
medical information; absence of medical information; incomplete
physician orders; lack of documentation of wound measurements;
unchanged wound measurements from previous month; unmet initial
coverage criteria; and therapy exceeding four months.
In addition, data showed that 30 percent of the claims were
denied because a request for documentation went unanswered.
To help reduce the error rate, TriCenturion offered the
following suggestions:
Review all documentation prior to responding to the Additional
Documentation Request letter to ensure all documentation is
present.
Implement a process to ensure that ADR letters are responded to
in a timely manner.
Consider obtaining information from the medical record to meet
reasonable and necessary criteria at the time the order is
received.
Review the information obtained from the medical record against
the local coverage determination and policy article to determine if
the reasonable and necessary coverage criteria are met.
Ensure that all appropriate employees are aware of discontinued
therapy to ensure that claims are not billed after NPWT therapy has
stopped.
