Prepayment Review of CPAP Claims Shows 81% Error Rate

Prepayment Review of CPAP Claims Shows 81% Error Rate

National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department, reviewed 100 random claims for CPAP devices (HCPCS code E0601KJ) resulting in a claims error rate of 81%.

According to the contractor, only 19 of the claims reviewed were allowed as billed. Denials primarily resulted from:
• no documentation being received,
• no or insufficient medical record documentation of a face-to-face clinical evaluation for obstructive sleep apnea (OSA) by the treating physician prior to the sleep study,
• no or insufficient documentation of the clinical re-evaluation between the 31st and 91st day of therapy with documented improvement of signs and symptoms, and
• no or insufficient documentation of adherence to therapy/device usage for 4 or more hours for 70% of a consecutive 30 day period during the first 3 months of CPAP usage.

“Based on these findings, the Medical Review department will continue with prepayment review of HCPCS code E0601KJ,” according to a statement from the DME MAC.

Capped Rental Month Modifiers - KH, KI, KJ

If the wrong rental month modifier is applied to capped rental items, effective June 4, 2007 the claim will be denied as unprocessable and must be corrected and resubmitted.

To prevent delays in payment and assure accurate processing of capped rental items, it is important to use the modifier that indicates the correct rental month. The first three months of a capped rental item is calculated to limit the monthly rental to 10% of the allowed purchase price. Therefore, the KH modifier must be used on the first month and KI on the second and third months.

For each additional month, the allowance is reduced to 7.5% of the allowed purchase price. Therefore, the KJ modifier must be used for months four through thirteen.