Positive Airway Pressure (PAP) Devices Quarterly Results of Targeted Probe and Educate Review - JA DME
Positive Airway Pressure (PAP) Devices Quarterly Results of Targeted Probe and Educate Review
The Jurisdiction A, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0601. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 15%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not contain a sleep test. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
- Medical record documentation does not indicate the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events or the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
- Medical record documentation does not support hypopneas were calculated based on at least a 4 percent decrease in oxygen saturation. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
Top Technical Denial Reasons
- Standard written order (SWO) does not identify the item to be ordered. Refer to 42 CFR 410.38(d)(1) and Standard Documentation Requirements A55426.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Medical record documentation demonstrates the in-person visit was not conducted by the certifying physician.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the PAP webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.
See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.
