TriCenturion Posts Denial Rates for Negative Pressure Wound Therapy

COLUMBIA, S.C.–A fourth-quarter widespread prepay review of
negative pressure wound therapy claims turned up charge denial
rates of 90 percent in Jurisdiction A and 61 percent in
Jurisdiction B, according to TriCenturion, the DME PSC for those
regions.

In both instances, the reviews were sparked by high 2006 CDRs
for claims using HCPCS E2402, 75.5 percent in Jurisdiction A and
83.72 percent in Jurisdiction B.

Jurisdiction A saw an increase in the fourth quarter CDR from
the third quarter CDR of 85.06 percent. TriCenturion said 72
percent of the claims were denied because Medicare policy criteria
were not met, and 18 percent were denied for non-response.

In Jurisdiction B, the CDR decreased from 74.58 in the third
quarter to 61.01 percent in the fourth quarter. Of those denials,
51 percent of the claims did not meet policy criteria and 17
percent were denied for non-response. Eleven percent of the claims
reviewed were reopened, with a third overturned and paid, and
two-thirds affirmed as denied.

The DME PSC said its reviews will continue in both regions.
TriCenturion reminded providers that during a widespread review,
any claim billed with the appropriate HCPCS code might be selected
for review.