Wound Therapy Denials Soar 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.

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.