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 April 2024 – June 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 10%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the 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
- Medical record documentation is not authenticated (handwritten or electronic) by the author. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.3.2.4.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
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.
