Oxygen Quarterly Results of Targeted Probe and Educate Review - JA DME
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) E0424, E0431, E1390 and E1392. The quarterly edit effectiveness results from July 2024 - September 2024 are as follows:
Based on dollars, the overall claim potential improper payment rate is 12%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not include a blood gas study. Refer the National Coverage Determination 240.2, Local Coverage Determination L33797, & Policy Article A52514.
- Medical record documentation does not support that the qualifying blood gas study was performed at the time of need. Refer to National Coverage Determination 240.2, Local Coverage Determination L33797, & Policy Article A52514.
- Medical record documentation does not support the treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed. Refer to National Coverage Determination 240.2, Local Coverage Determination L33797, & Policy Article A52514.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Documentation does not include a standard written order (SWO). Refer to 42 CFR 410.38(d)(1), Medicare Program Integrity Manual 100-08, Chapter 5, Section 5.2.1 & Standard Documentation Requirements A55426.
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 100-08, Chapter 3, Section 3.2.3.8.
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.
