Ostomy Supplies Quarterly Results of Targeted Probe and Educate Review - JA DME
Ostomy Supplies 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) A4385, A4407, A4409, A4414 and A4419. The quarterly edit effectiveness results from October 2024 – December 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 23%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not support a covered diagnosis.
- Quantity billed exceeds the usual maximum quantity of supplies.
Top Technical Denial Reasons
- Standard written order (SWO) does not identify the item to be ordered. Refer to 42 CFR 410.38(d)(1) and Standard Documentation Requirements A55426.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Ostomy 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.
