Immunosuppressive Drugs Quarterly Results of Targeted Probe and Educate Review - JA DME
Immunosuppressive Drugs 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) J7503, J7527, J7518, J7507, and J7515 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 1%.
Top Technical Denial Reasons
- No medical record documentation was received. Refer to Medicare Program Integrity Manual 3.2.3.8.
- Related Item Denied: Overutilization
- Standard Written Order (SWO) was not received.
Educational Resources
Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Immunosuppressive Drugs 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.
