Hospital Beds Quarterly Results of TPE Review - JD DME

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0260. The quarterly edit effectiveness results from January 2024 - March 2024 are as follows:

Based on dollars, the overall claim potential improper payment rate is 45%.

Top Medical Necessity Denial Reasons

• Medical record documentation does not support the beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed, requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, requires the head of the bed to be elevated more than 30 degrees, or requires traction equipment which can only be attached to a hospital bed.
• Medical record documentation does not support the beneficiary requires frequent changes in body position and/or has an immediate need for a change in body position.

Top Technical Denial Reasons

• Medical record documentation does not indicate the date of service or date of visit.
• Claim includes items which are not billable to the DME MAC.
• No medical record documentation was received.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Hospital Beds 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.