External Infusion Pumps (HCPCS E0781, E0784) Final Edit Effectiveness Results of Documentation Compliance Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code E0781 and E0784. A Documentation Compliance Review (DCR) is a nonclinical, technical review verifying that submitted documentation meets payment requirements according to Local Coverage Determinations (LCD) for that DMEPOS item. The final edit effectiveness results from November 2016 through June 2017 are as follows:

The E0781 review involved 31 claims, of which 9 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 35%.

The E0784 review involved 16 claims, of which 4 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 22%.

Top Denial Reasons

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the External Infusion Pumps Local Coverage Determination L33794 and Policy Article A52507.

Suppliers can also review specific policy resources for External Infusion Pumps on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during Web-based workshops.

Suppliers can also review a specific policy Documentation Checklist for External Infusion Pumps on the Noridian website.

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.

Information about prepay reviews may be found in CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3.

Policy Education

Documentation was not received in response to the Additional Documentation Request (ADR) letter.

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).

Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian's website.


Last Updated Mon, 24 Feb 2020 11:20:59 +0000