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DME MAC Conducts Prepayment Review of PAP Systems

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National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Medical Review Department, reported a claim error rate of 31.30% as a result of a prepayment targeted medical review of positive airway pressure devices.

The review of Healthcare Common Procedure Coding System (HCPCS) E0601 was conducted April 1, 2013 – June 30, 2013 and was based on claims from 16 suppliers.

According to the review, the top reasons for these claims being denied as not medically necessary were as follows:
• No face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for OSA,
• No documentation that the beneficiary and/or caregiver has received instruction from the supplier of the proper use and care of the equipment; and
• No proof of delivery.