Surgical Dressings Quarterly Results of Targeted Probe and Educate Review - JA DME
Surgical Dressings 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) A6010, A6021, A6023, A6196, A6197, A6199, A6209, A6210, A6212, A6220 and A6252. The quarterly edit effectiveness results from April 2025 - June 2025 are as follows:
Based on dollars, the overall claim potential improper payment rate is 46%.
Top Medical Necessity Denial Reasons
- Medical record documentation does not contain current clinical information which supports the reasonableness and necessity of the type and quantity of surgical dressings provided.
- Medical record documentation does not support the use of specialty absorptive dressings when used on moderately or highly exudative full thickness (e.g., stage III or IV ulcers) wounds.
- Medical record documentation does not support the surgical dressings are required for the treatment of a wound caused by, or treated by, a surgical procedure; or that they are required after debridement of a wound.
Top Technical Denial Reasons
- Documentation was not received in response to the Additional Documentation Request (ADR) letter.
- Related item denied: Medical Necessity
- Claim was submitted without a required modifier. Refer to Medicare Claims Processing Manual 100-04, Chapter 20 & LCDs.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Surgical Dressings 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.
