External Infusion Pumps Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) J1559 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from October 2025 - December 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 13%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not support the beneficiary has a primary immune deficiency disorder or a diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) that has responded to IVIG treatment.

Top Technical Denial Reasons

  • Related item denied due to invalid order.
  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • The 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 External Infusion Pumps 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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