Denials Soar for Wound Therapy Claims in Jurisdiction A

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.

“Data analysis identified significant increases in allowed
charges in Jurisdiction A,” TriCenturion officials said in a
bulletin.

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,” the bulletin said.

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 to providers:

• Review all documentation prior to responding to the Additional
  Documentation Request letter to ensure all documentation is present
  (CMN, order, etc.).
• 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.

To view the full bulletin, click here.