Oxygen 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) E0431, E1390, E1392, and K0738 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from July 2025 – September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 17%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support the blood gas study was obtained within two days of discharge from an inpatient hospital stay. Refer to National Coverage Determination 240.2 & Local Coverage Determination L33797.

Top Technical Denial Reasons

  • Standard Written Order (SWO) was not received.
  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Claim is billed for items which are not billable to the DME MAC.

Educational Resources

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

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