Immunosuppressive Drugs Quarterly Results of Targeted Probe and Educate Review - JA DME
Immunosuppressive Drugs 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) J5703, J7507, J7515, J7518 and J7527. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 27%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not indicate the transplant met Medicare coverage criteria in effect at the time as it does not indicate where the transplant occurred.
- Medical record documentation does indicate the transplant met Medicare coverage criteria in effect at the time as it does not indicate when the transplant occurred.
Top Technical Denial Reasons
- Beneficiary was in an acute care hospital or skilled nursing facility on this date of service. Refer to Medicare Claims Processing Manual 100-04, Chapter 20, Sections 210-212.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Immunosuppressive Drugs 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.
