Medicare’s Jurisdiction A DME MAC, NHIC Corp., has released the most recent results of its widespread prepayment review for Group 2 pressure-reducing support surfaces.
The products involved in the review have HCPCS code E0277, and in the news announcement, NHIC said the review “was initiated due to errors identified by the Comprehensive Error Rate Testing contractor.”
The charge denial rate for the second quarter of 2015 was 57 percent for claims dated April 1 through June 30 of this year.
For that period, the review examined 121 claims submitted by 57 different suppliers. NHIC did not receive responses to its Additional Documentation Requests for 33 percent of the claims being reviewed.
Of the 81 claims for which additional documentation was supplied, NHIC allowed 36 and denied 45.
The 57-percent charge denial rate was a significant drop from the January-through-March review period’s charge denial rate of 78.1 percent. Previous charge denial rates included 68.9 percent for July through September 2014, and 70.4 percent for October through December 2014.
The NHIC report said lack of adequate medical documentation was the most common reason for denials. The DME MAC said 28 percent of claims that were denied failed to meet one of three coverage criteria, including the beneficiary having multiple stage 2 pressure ulcers on the trunk or pelvis that haven’t improved in the last month; the beneficiary having large or stage 3 or 4 pressure ulcers on the trunk or pelvis; or the beneficiary having had flap or skin graft surgery for a pressure ulcer on the trunk or pelvis in the last 60 days, with the beneficiary also having used a group 2 or 3 support surface just before being discharged from a hospital or medical facility to go home.
Additionally, NHIC said 5 percent of claims didn’t include medical documentation at all, and 1 percent of claims had illegible medical documentation.
Other common reasons for denials included problems with the written order being done prior to delivery, and problems with proving the support surface had been delivered to the beneficiary.
NHIC said it was ending the prepayment review for the E0277 code, “but will continue to monitor billing patterns.”
