Medical review of 314 CPAP claims produces 81 percent error rate

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department has completed a widespread prepayment Targeted Medical Review (TMR) of 314 random claims for continuous positive airway pressure (CPAP) devices, HCPCS code E0601KH. Only 61 claims were allowed as billed and 197 were denied—an error rate of 81 percent. A total of 134 claims were denied for insufficient or no medical record documentation of a face-to-face clinical evaluation for obstructive sleep apnea from the treating physician; 88 were denied for insufficient or no report of a Medicare covered sleep study; and 56 claims denied because the supplier did not respond to the additional documentation request (ADR).